**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to provide a Resident, a Resident's Representative, and the Office of the Long-term Care Ombudsman with an emergency discharge notice. This affected one resident (#91) out of three residents reviewed. The facility census was 68. Findings Include: Record review for Resident #91 revealed she was admitted to the facility on [DATE] and discharged to the hospital on [DATE] and was not permitted to return to the facility. The resident's diagnoses included dementia with behavioral disturbance, hyperlipidemia, major depressive disorder, anxiety disorder, symbolic dysfunction, and essential primary hypertension. Further record review revealed the facility failed to issue an emergency discharge notice to Resident #91, Resident #91's representative, or the Office of Long-term Care Ombudsman office in writing. Review of hospital notes dated 07/06/23 for Resident #91 and identified by the facility as part of their admission paperwork, revealed the resident was re-admitted to the hospital from another long-term care facility on 07/03/23 for a psychiatric admission related to inappropriate and sexually aggressive behaviors at her previous extended care facility (ECF). The resident was reported to have been grabbing people and being naked in bed with males. Notes indicated the ECF could no longer manage the resident. An assessment revealed the resident was calm, pleasant, confused and alert to person and alert to being in the hospital. Medications were reconciled and upon discharge, the hospital staff would seek alternative placement in new facility. Review of the discharge return not anticipated (DRNA) Minimum Data Set (MDS) assessment 3.0 for Resident #91, dated 07/11/23, revealed the resident had impaired cognition. The assessment revealed Resident # 91 displayed behaviors towards another person. Review of the progress note for Resident # 91, dated 07/11/23, revealed the Social Service Director (SSD) notified Resident #91's representative of their inability to provide the appropriate care for Resident #91 via phone call and the facility discharged Resident #91 to the hospital. Review of facility document titled Transfer/Discharge Report dated 07/11/23 and timed 5:48 P.M. revealed the resident was discharged to an acute hospital. Review of the hospital notes for Resident #91 dated 07/12/23, revealed the resident was seen in the emergency room for need of care coordination. The resident was at her baseline with no complaints and the resident was discharged back to the facility. When the transport serviced arrived at the facility, the facility refused to accept her, and the resident was returned to the emergency room. The Resident was very familiar to the psychiatric staff and hospital admitted the resident for history of dementia with continued management and investigation. Interview with Admissions Director (AD) # 133 on 09/06/23 at 10:48 A.M. confirmed the facility was aware of Resident #91's sexual behavior prior to admission to the facility; however, noted the facility was not aware of her exit seeking behaviors. Once the facility learned of the resident's exit seeking behaviors, the resident had to be moved from a mostly female populated nursing unit to the secured unit. AD #133 stated the secured unit consisted of both males and females and the facility was unable to ensure the safety of male residents related to the sexual behaviors of Resident #91. Therefore, the facility discharged Resident #91 to the hospital and refused to allow Resident #91 to return to the facility. AD #133 stated she did not complete the notifications and was not aware if anyone else completed the notifications. Interview Director of Clinical Services (DCS) #501 on 09/06/23 at 11:10 A.M. confirmed he spoke to the hospital regarding Resident #91's discharge to the hospital on [DATE]. DCS #501 stated the facility did not feel they were given all the required information prior to accepting Resident #91 to the facility on [DATE]. DCS #501 confirmed the Resident, Resident's representative or the Long-term Ombudsman's office were not notified in writing of Resident #91's emergency discharge notice. Review of the facility policy titled, Facility Initiated Discharge and Discharge Notification Policy, undated, revealed the facility will provide a thirty-day notice of discharge to Residents and Resident Representatives of an impending discharge. Further review of the policy revealed the timing of the notice is subject to change under specific circumstances. The policy states, under the following circumstances, the notice will be given as soon as practicable before the transfer or discharge: The safety of individuals in the facility would be endangered. The resident has not resided in the facility for thirty days. This deficiency represents non-compliance investigated under Complaint Number OH00145014

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, hospital records review, facility policy review, and staff interview, the facility failed to allow a resident to return to the facility following a hospital evaluation. This affected one resident (#91) out of three residents reviewed. The facility census was 68. Findings Include: Record review for Resident #91 revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE] and was not permitted to return to the facility. The resident's diagnoses included dementia with behavioral disturbance, hyperlipidemia, major depressive disorder, anxiety disorder, symbolic dysfunction, and essential primary hypertension. Review of the Discharge Return Not Anticipated (DRNA) Minimum Data Set (MDS) assessment 3.0 dated 07/11/23 for Resident #91, revealed the resident had impaired cognition. The assessment revealed Resident # 91 displayed behaviors towards another person. Review of the progress note dated 07/11/23 for Resident #91, revealed the Social Service Director (SSD) notified Resident #91's representative of their inability to provide the appropriate care for Resident #91 via a phone call and then discharged Resident #91 to the hospital. Review of facility document titled Transfer/Discharge Report dated 07/11/23 and timed 5:48 P.M. revealed Resident #91 was discharged to an acute hospital. Review of the hospital notes for Resident #91 dated 07/12/23, revealed the resident was seen in the emergency room for need of care coordination. The resident was at her baseline with no complaints and the resident was discharged back to the facility. When the transport serviced arrived at the facility, the facility refused to accept her, and the resident was returned to the emergency room. Resident was admitted for continued management and investigation. Interview with Admissions Director (AD) # 133 on 09/06/23 at 10:48 A.M. confirmed the facility was aware of Resident #91's sexual behavior prior to admission to the facility; however, the facility was not aware of the residents exit seeking behaviors. Once the facility learned of her behaviors, the resident had to be moved from a mostly female populated nursing unit to the secured unit. AD #133 stated the secure unit consisted of both males and females and the facility was unable to ensure the safety of male residents related to the sexual behaviors of Resident #91. AD #133 verified the facility discharged Resident #91 to the hospital and refused to allow Resident #91 to return to the facility. Interview with Director of Clinical Services (DCS) #501 on 09/06/23 at 11:10 A.M. confirmed he spoke to the hospital regarding Resident #91's discharge to the hospital on [DATE]. DCS #501 stated the facility did not feel they were given all the required information prior to accepting Resident #91 to the facility on [DATE]. DCS #501 confirmed the facility did allow Resident #91 to return to the facility. This deficiency represents non-compliance investigated under Complaint Number OH00145014

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #48 revealed an admission date of 12/05/21. Diagnoses included dementia, Alzheimer's disease, hypertension, malignant neoplasm of breast, and bacterial pneumonia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #48 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. Resident #48 was assessed to require one-person extensive assistance with transfers, dressing, toileting, and bathing, and supervision with eating. Review of the care plan dated 09/08/22 revealed Resident #48 had impaired physical mobility related to right hip fracture. Interventions included call light in reach, assist with activities of daily living as needed, notify charge nurse of complaint of pain, non-compliance with weight bearing status, and any reddened areas noted. Observation on 09/19/22 at 1:58 P.M. revealed Resident #48 was in bed with call light not in reach. Call light was on the floor behind nightstand. Observation on 09/21/22 at 2:52 P.M. of call light on the floor behind nightstand and out of reach of Resident #48. Interview on 09/21/22 at 2:48 P.M. with the Administrator revealed Resident #48 was able to use call light properly. Interview on 09/21/22 at 3:04 P.M. with the LPN #51 verified Resident #48's call light was on the floor behind the nightstand and out of reach. Review of the facility policy, Call Light Policy & Procedure, dated November 2021 revealed residents will have a means of directly contacting staff when in their rooms and toilet and bathing facilities. All resident rooms, toilets, and bathing facilities will be equipped with call systems that sound at the nurse's station. Call lights will be answered in a timely manner. Based on observation, record review and staff interview, the facility failed to ensure resident call lights were in reach. This affected two Residents (#47 and #48) out of 24 residents reviewed for call lights. The facility census was 51. Findings include: 1. Review of the Resident #47's chart revealed Resident #47 admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, personal history of Coronavirus (COVID-19), insomnia, need for assistance with personal care, muscle weakness, type two diabetes mellitus, essential hypertension, hypothyroidism, delusional disorders, pain in left hip, pain in left shoulder, disease of pancreas and transient cerebral ischemic attack. Review of Resident #47's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #47 required extensive assistance with bed mobility, transfers, toileting, and dressing. Resident #47 also required supervision with eating and Resident #47 required limited assistance with personal hygiene. Review of Resident #47's call light care plan dated 03/02/22 revealed Resident #47 had a potential for falls with a history of falls. Interventions included encourage Resident #47 to use the call light for assistance and keep the call light within reach. Observation of Resident #47 on 09/19/22 at 12:27 P.M. revealed Resident #47 was lying in bed. Resident #47's call light was curled up on the floor next to the privacy curtain. Resident #47's call light was not in reach. Observation of Resident #47 on 09/21/22 at 2:56 P.M. revealed Resident #47 was lying in bed. Resident #47's call light was curled up on the floor next to the privacy curtain. Resident #47's call light was not in reach. Interview on 09/21/22 at 4:31 P.M. with Licensed Practical Nurse (LPN) #70 verified Resident #47 was able to use a call light. Observation of Resident #47 on 09/22/22 at 8:16 A.M. revealed Resident #47 was lying in bed. Resident #47's call light was curled up on the floor next to the privacy curtain. Resident #47's call light was not in reach. Interview on 09/22/22 at 8:16 A.M. with LPN #51 verified Resident #47's was laying in her bed with her call light out of reach on the ground by the curtain. Review of the call lights policy dated November 2021 revealed the residents will have a means of directly contacting staffing when in their rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and policy review, the facility failed to complete a baseline care plan for pressure ulcers. This affected one Resident (#199) out of one resident reviewed for pressure ulcers. Facility census was 51. Findings include: Review of the medical record for Resident #199 revealed an admission date of 09/15/22. Diagnoses included Alzheimer's disease, hypertension, chronic kidney disease stage three, anxiety disorder, and malignant neoplasms prostate, bone, right lung, large intestine, and rectum. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 99. This resident was assessed to require supervision with transfers and toileting independent with dressing and eating, and one-person physical assistance with bathing. Review of the baseline care plan dated 09/15/22 revealed Resident #199 did not have a care plan in place for stage two pressure ulcer to the coccyx. Review of the progress note dated 09/15/22 at 5:38 P.M. revealed Resident #199 had an area to left buttock, which measured two centimeters (cm) length by one cm width and one and a half cm depth. Treatment included Medihoney to be applied to wound bed and covered with foam dressing every day and as needed. Review of the physician order dated 09/16/22 revealed Resident #199 was ordered to have left buttocks/coccyx cleansed with normal saline, Medihoney applied and covered with foam dressing every night. Observation on 09/21/22 at 2:17 P.M. of a treatment to the coccyx of Resident #199 completed by Director of Nursing (DON) and Licensed Practical Nurse (LPN) #42 revealed dressing change was completed per physician orders. Interview on 09/21/22 at 3:38 P.M. with DON verified Resident #199 did not have a baseline care plan for his pressure ulcer. DON stated interventions and treatments were initiated when Resident #199 entered the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #48 revealed an admission date of 12/05/21. Diagnoses included dementia, Alzheimer's disease, hypertension, malignant neoplasm of breast, and bacterial pneumonia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #48 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10. Resident #48 was assessed to require one-person extensive assistance with transfers, dressing, toileting, and bathing, and supervision with eating. Review of the care plan dated 09/08/22 revealed Resident #48 had impaired physical mobility related to right hip fracture. Interventions included call light in reach, assist with activities of daily living as needed, notify charge nurse of complaint of pain, non-compliance with weight bearing status, and any reddened areas noted. Observation on 09/19/22 at 1:58 P.M. revealed Resident #48 was in bed with call light not in reach. Call light was on the floor behind nightstand. Observation on 09/21/22 at 2:52 P.M. of call light on the floor behind nightstand and out of reach of Resident #48. Interview on 09/21/22 at 2:48 P.M. with the Administrator revealed Resident #48 was able to use call light properly. Interview on 09/21/22 at 3:04 P.M. with the LPN #51 verified Resident #48's call light was on the floor behind the nightstand and out of reach. LPN #51 verified call light was to be in reach of Resident #48 per care plan. Review of the facility policy titled, Care Planning - Interdisciplinary Team, dated 05/08/22 revealed a comprehensive care plan for each resident was developed within seven days of completion the resident assessment. The comprehensive care plan will be updated on an ongoing basis as changes in the resident's treatment plan and preferences can occur. To ensure care plan implementation, staff will be provided with access to the resident care plan interventions via the electronic medical record. Based on observation, record review and staff interview, the facility failed to ensure resident mobility and fall care plans were implemented. This affected two Residents (#47 and #48) out of 14 residents reviewed for care plans. The facility census was 51. Findings include: 1. Review of the Resident #47's chart revealed Resident #47 admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, personal history of Coronavirus (COVID-19), insomnia, need for assistance with personal care, muscle weakness, type two diabetes mellitus, essential hypertension, hypothyroidism, delusional disorders, pain in left hip, pain in left shoulder, disease of pancreas and transient cerebral ischemic attack. Review of Resident #47's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #47 required extensive assistance with bed mobility, transfers, toileting, and dressing. Resident #47 also required supervision with eating and Resident #47 required limited assistance with personal hygiene. Review of Resident #47's call light care plan dated 03/02/22 revealed Resident #47 had a potential for falls with a history of falls. Interventions included encourage Resident #47 to use the call light for assistance and keep the call light within reach. Observation of Resident #47 on 09/19/22 at 12:27 P.M. revealed Resident #47 was lying in bed. Resident #47's call light was curled up on the floor next to the privacy curtain. Resident #47's call light was not in reach. Observation of Resident #47 on 09/21/22 at 2:56 P.M. revealed Resident #47 was lying in bed. Resident #47's call light was curled up on the floor next to the privacy curtain. Resident #47's call light was not in reach. Interview on 09/21/22 at 4:31 P.M. with Licensed Practical Nurse (LPN) #70 verified Resident #47 was able to use a call light. Observation of Resident #47 on 09/22/22 at 8:16 A.M. revealed Resident #47 was lying in bed. Resident #47's call light was curled up on the floor next to the privacy curtain. Resident #47's call light was not in reach. Interview on 09/22/22 at 8:16 A.M. with LPN #51 verified Resident #47's was laying in her bed with her call light out of reach on the ground by the curtain. Review of the call lights policy dated November 2021 revealed the residents will have a means of directly contacting staffing when in their rooms. Review of the facility policy titled, Care Planning - Interdisciplinary Team, dated 05/08/22 revealed the facility will be responsible for the development of an individualized comprehensive care plan for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #3 revealed an admission date of 12/27/21. Diagnoses included melas syndrome, cortical blindness, type one diabetes mellitus, seizures, epilepsy, major depressive disorder, and generalized anxiety disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #3 had impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 99. Resident #3 was assessed to require two-person extensive assistance with transfers and toileting, one-person extensive assistance with dressing and eating, one-person total dependence with bathing. Review of the care plan dated 08/12/22 revealed Resident #3 had potential of adverse medication side effects related to refusal of medications. Interventions included medications as ordered, monitor for side effects/effectiveness of medications and notify physician as needed. Staff to monitor lab results and report to physician as ordered. Staff to report to change nurse change in condition, lethargy, complain of blurred vision, and headaches. Review of the physician order dated 12/27/21 revealed Resident #3 was ordered Pristiq (anti-depressant) extended release (ER) 24-hour 100 milligrams (mg), give 100 mg by mouth one time a day related to major depressive disorder. Review of the physician order dated 01/15/22 revealed Resident #3 was ordered Remeron (anti-depressant) 7.5 mg, give 7.5 mg by mouth at bedtime for appetite stimulant. Review of the physician order dated 08/25/22 revealed Resident #3 was ordered Seroquel (anti-psychotic) 100 mg, give 100 mg by mouth two times a day related to Melas Syndrome. Review of the pharmacy medication recommendation dated 05/22/22 revealed Resident #3 was currently prescribed Pristiq 100 mg by mouth daily and Seroquel 75 mg by mouth twice a day. Recommendation was to evaluate for a dose reduction to determine the lowest effective dose. The facility responded on 06/17/22 that Resident #3 was well-controlled with current medication and will continue to monitor. Interview on 09/22/22 12:38 PM with the Administrator confirmed pharmacy recommendation was not addressed in a timely manner. Review of the facility policy titled, Consulting Pharmacist Monthly Drug Regimen Review, dated 11/11/21 revealed the consulting pharmacist must conduct a monthly drug regime review and report any identified medication irregularities in accordance with this policy. The written report shall be completed and sent to the resident's attending physician. the Director of Nursing (DON), and the Medical Director within seven days of the review (unless the irregularity requires urgent action.) Based on record review and staff interview, the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner. This affected three Residents (#3, #17 and #47) out of six residents reviewed for unnecessary medications. The facility census was 51. Findings include: 1. Review of the Resident #17's chart revealed Resident #17 admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, thyroid disorders, personal history of Coronavirus (COVID-19), dysphagia, anxiety disorder, hypokalemia, acute recurrent sinusitis, dizziness and giddiness, and benign neoplasm of prostate. Review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and Resident #17 required limited assistance with bed mobility, and toileting. Resident #17 required supervision with transfers, dressing, eating, and personal hygiene. Review of Resident #17's pharmacy recommendation dated 04/24/22 revealed Resident #17 had an order for Vistaril (anxiety) 25 milligrams (mg) every six hours as needed (PRN) for anxiety and agitation. The pharmacy recommendation stated a duration or rational needed to be added to the order. Further review of the pharmacy recommendation revealed Physician #400 addressed the pharmacy recommendation on 06/17/22 and reported this medication was required for more than 14 days due to chronic anxiety and agitation. The medication was effective and will be continued indefinitely. The physician will review medications with visits and attempt a gradual dose reduction at least annual unless contraindicated. 2. Review of the Resident #47's chart revealed Resident #47 admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, personal history of COVID-19, insomnia, need for assistance with personal care, muscle weakness, type two diabetes mellitus, essential hypertension, hypothyroidism, delusional disorders, pain in left hip, pain in left shoulder, disease of pancreas and transient cerebral ischemic attack. Review of Resident #47's quarterly MDS assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #47 required extensive assistance with bed mobility, transfers, toileting, and dressing. Resident #47 also required supervision with eating and Resident #47 required limited assistance with personal hygiene. Review of Resident #47's pharmacy recommendation dated 04/24/22 revealed the resident was currently receiving Levothyroxine (thyroid replacement). Please consider adding thyroid stimulating hormone (TSH) level to the next laboratory (lab) day and periodically thereafter to monitor the thyroid levels. Further review of the pharmacy recommendation revealed Physician #400 addressed the pharmacy recommendation on 06/17/22 and agreed with the commendation. Interview with the Director of Nursing (DON) on 09/21/22 at 8:37 A.M. revealed Resident #17 and Resident #47's pharmacy reviews dated 04/24/22 were not addressed until 06/17/22. The DON stated the physician had 30 days to address pharmacy recommendations at the facility. Review of the consulting pharmacist monthly drug regimen review dated 11/21/21 revealed the resident's attending physician will review the irregularity report on the next patient visit and will document in the medical record that the identified irregularity had been reviewed and what action has been taken to address it. If there was to be no change, the attending physician should document his or her rationale in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident that received psychotropic medications had an appropriate diagnosis and indications for use. This affected one Resident (#104) out of six residents reviewed for unnecessary medications. The facility census was 51. Findings include: Review of the Resident #104's chart revealed Resident #104 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with late onset, need for assistance with personal care, chronic kidney disease stage three, dementia in other diseases classified elsewhere, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified convulsions, and anemia in chronic kidney disease. Review of Resident #104's Minimum Data Set (MDS) assessment was not completed due to Resident #104 being newly admitted to the facility. Review of Resident #104's admission assessment dated [DATE] revealed Resident #104 was severely cognitively impaired, and Resident #104 required limited assistance with bed mobility. Resident #104 also required supervision with transfers, and eating and extensive assistance with dressing, toileting, and personal hygiene. Review of Resident #104's care plan dated 09/21/22 revealed Resident #104 received psychotropic medication. Interventions included administer medications as ordered, monitor and record occurrences of targeted behavior symptoms, encourage residents to attend activities, provide psychological care if symptoms become worse and medication is ineffective with family's permission and staff to be aware of increased risk for falls while on the medication. Review of Resident #104's physician order dated 09/18/22 revealed Resident #104 was ordered to give Seroquel (anti-psychotic) 12.5 milligrams (mg) by mouth two times a day related to Alzheimer's disease with late onset. Review of the Seroquel manufacture prescribing information dated April 2008 revealed Warning: increased mortality in elderly patients with dementia. Warning: increased mortality in elderly patients with dementia related psychosis. Interview with the Director of Nursing (DON) on 09/21/22 at 4:03 P.M. verified Resident #104 was prescribed Seroquel for Alzheimer's disease. Interview with the Administrator on 09/22/22 at 12:38 P.M. verified Resident #104 was prescribed Seroquel for Alzheimer's disease. The Administrator also confirmed Seroquel had a warning stating that the use of Seroquel in elderly patients with dementia could cause increased mortality. The Administrator reported Resident #104's diagnosis on his Seroquel was changed on 09/22/22. Review of the facility's psychotropic drugs policy dated 11/20/21 revealed the facility will ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Residents who use psychotropic drugs receive behavioral interventions.