Based on medical record review, staff interview, facility document review, and review of the facility policy, the facility failed to ensure allegations of abuse were reported to the state survey agency (SSA). This affected two (Residents #156 and Resident #120) of three residents reviewed for abuse. Findings include:1. Review of the medical record for Resident #52 revealed an admission date of 12/26/2023 with diagnoses of schizophrenia and bipolar disorder. Review of the MDS for Resident #52 dated 05/21/25 revealed the resident had intact cognition. Review of the care plan for Resident #52 dated 04/16/24 revealed the resident had a history of behaviors which included wandering and making inappropriate comments to staff. Interventions included the following: direct staff to assist the resident to develop more appropriate methods of coping and interacting, encourage the resident to express feelings appropriately, offer tasks that divert the resident’s attention. Review of the medical record for Resident #156 revealed an admission date of 09/20/23 with a diagnosis of dementia with behavioral disturbances and a discharge date of 05/12/25. Review of the Minimum Data Set (MDS) assessment for Resident #156 dated 05/06/25 revealed the resident had severe cognitive impairment. Review of a progress note for Resident #156 dated 05/01/25 at 7:41 P.M. per Registered Nurse (RN) #14 revealed the the resident’s power of attorney (POA) expressed concern about an interaction they reportedly saw between Resident #156 and another resident and asked if the incident was documented. RN #14 told the POA that they could not release any information until they spoke to their supervisor to ensure there were no privacy violations. Review of the progress note for Resident #156 dated 05/02/25 at 12:05 PM revealed the facility held a care conference with a family member to discuss the resident’s escalated verbal and physical behaviors. The note did not address any resident-to-resident incidents. Review of the progress note for Resident #156 dated 05/12/25 at 1:21 P.M. revealed the facility held a care conference with the resident’s representative where they discussed the resident’s care. The note did not address any resident-to-resident incidents. Interview on 08/21/25 at 7:35 P.M. with Resident #156’s representative, Resident Representative (RR) #23 confirmed on 04/26/25 at approximately 7:00 P.M. Resident #156 was watching television when Resident #52 approached Resident #156’s room door with their pants down. RR #23 stated Resident #52’s belt was unbuckled, their pants were unbuttoned, the zipper was down, and the resident’s pants were down to the resident’s knees. RR #23 stated they intervened before Resident #52 pulled down their (Resident #52’s) brief. RR #23 stated they told Resident #52 to leave Resident #156’s room, and once Resident #52 left, RR #23 asked Resident #156 what happened. RR #23 stated that Resident #156 told them that Resident #52 was going to show the resident their genitalia. RR #23 stated they went to the nurses’ station at approximately 7:00 P.M. and notified the outgoing and incoming nurses of the interaction between Resident #156 and Resident #52. RR #23 stated staff told them they would keep an eye on the residents and would ensure they were separated. RR #23 stated they contacted the facility on 05/01/25 and spoke with an RN to ensure the facility administration was notified of the interaction. RR #23 stated that on 05/02/25 they called and notified a social worker who stated they would notify the Administrator. RR #23 stated on 05/02/25, they received a return call from the Administrator, the Director of Nursing (DON), and the Social Services Designee (SSD). RR #23 stated that during the phone call, they informed the facility staff of the incident and requested an in-person meeting. RR #23 stated that on 05/12/25 an in-person meeting was held with RR #23, the Administrator, the DON, the SSD, and the Assistant Director of Nursing (ADON), and RR #23 discussed the incident during the meeting. Interview on 08/22/25 at 10:53 A.M. with RN #14 confirmed RR #23 had mentioned an incident about Resident #52 exposing themself but stated he did not remember whether RR #23 had reported the incident to him. RN #14 further confirmed if RR #23 had reported something to him, he would have notified the Administrator immediately. Interview on 08/22/25 at 10:20 A.M. with RN #8, who was the former ADON, stated she was notified of the incident between Resident #52 and Resident #156 on 05/01/25. RN #8 stated RR #23 had wanted to speak with management regarding an incident between Resident #156 and Resident #52. RN #8 stated she spoke with RR #23 who stated Resident #156 was sitting on their bed watching television when RR #23 witnessed Resident #52 approaching the room with their pants down to their hips. RN #8 that RR #23 reportedly told Resident #52 that it was not their room, and the resident turned and left. Interview on 08/21/25 at 3:49 P.M. with the SSD confirmed during a meeting with RR #23, the Administrator, and the DON on 05/12/25, RR #23 alleged Resident #52 exposed themself to Resident #156. The SSD revealed the meeting was documented in a progress note, but the allegation of possible resident-to resident abuse was not documented. Interview on 08/21/25 at 4:00 P.M. with the DON confirmed she attended a meeting where RR #23 alleged Resident #52 attempted to expose their genitals to Resident #156. Interview on 08/21/25 at 5:14 P.M. with the Administrator confirmed he was the Abuse Coordinator for the facility and recalled a meeting was held regarding Resident #156’s behaviors. The Administrator confirmed during the meeting, RR #23 reported that Resident #52 attempted to expose themself to Resident #156 on 04/26/25. The Administrator confirmed the facility did not report the incident to the SSA. 2. Review of the medical record for Resident #120 revealed and admission date of 11/07/24 with diagnoses including chronic obstructive pulmonary disease, Alzheimer's disease, and major depressive disorder. Review of the MDS for Resident #120 date 06/04/25 revealed the resident had severe cognitive impairment and required supervision with activities of daily living (ADLs.) Review of the medical record for Resident #117 revealed and admission date of 03/22/25 with diagnoses including unspecified dementia without behavioral disturbance, adjustment disorder with anxiety, and hypertension. Review of the MDS assessment for Resident #117 dated 06/13/25 revealed the resident had severe cognitive and was ambulatory and wandered daily. Review of the care plan for Resident #117 undated revealed the resident had behavioral problems that included hitting others. Interventions included the following: provide a room change, intervene as necessary to protect the rights and safety of others, approach/speak to the resident in a calm manner, divert the resident's attention, take the resident to an alternate location as needed, monitor behavior episodes and attempt to determine the underlying cause, considering the location, time of day, persons involved, and situation, document the behavior and potential causes. Review of the progress note for Resident #120 dated 04/02/25 at 1:30 A.M. per Licensed Practical Nurse (LPN) #10 revealed staff heard the resident yelling and requesting staff get him/her off of me. LPN #10 observed Resident #120 lying in bed, and their roommate was standing over the resident hitting Resident #120 on the arm with a plastic cup. Resident #120 stated they had also been hit on the left arm and left leg. Review of the progress note for Resident #117 dated 04/02/25 at 1:31 A.M. per LPN #10 revealed Resident #117 was standing over their roommate hitting the roommate on the arm with a plastic medicine cup. LPN #10 asked Resident #117 why they were hitting their roommate and the resident stated they did not know. Review of the Interdisciplinary Team (IDT) note for Resident #117 dated 04/13/25 revealed a resident-to-resident incident occurred. Staff observed Resident #117 standing over their roommate and hitting them with a plastic cup. The note indicated the new behavioral intervention for the resident was a room change. Interview on 08/20/25 at 8:37 P.M. with LPN #10 confirmed on 04/02/25 she heard yelling out from a resident room and found Resident #117 standing at Resident #120's bedside hitting them with a plastic cup. LPN #10 stated she informed the charge nurse and the Director of Nursing (DON) of the resident-to resident incident. Interview on 08/22/25 at 11:00 A.M. with the DON confirmed the IDT met two times per week to review incidents. She stated that she deferred to the Administrator to decide which incidents should be reported to the SSA. Interview on 08/22/25 at 12:23 P.M. with LPN #9 confirmed she was a night shift team leader, and staff were to report all falls and incidents to her. LPN #9 confirmed she immediately notified the on-call person, the DON or Administrator of resident-to-resident altercations, which required two-hour reporting. She further stated the staff were to write witness statements about the incidents. LPN #9 stated that she did not recall an incident involving Resident #117 in an altercation with another resident Interview on 08/22/25 at 1:58 P.M. with RN #8 confirmed incidents were discussed during IDT meetings, and the Administrator made the decision on which incidents were to be reported to the SSA. She stated that resident-to-resident altercations were to be reported to the SSA within two hours of being notified of them. Interview on 08/22/25 at 3:06 P.M. with the Administrator confirmed the facility did not report the resident-to-resident incident between Resident #120 and #117 to the SSA. Review of the facility policy titled Abuse/Neglect/Misappropriation of Property revised September 2022 revealed the facility would report all allegations of abuse to the SSA. This deficiency represents noncompliance investigated under Complaint Number 1301484 (Complaint OH00165616.)

Based on medical record review, staff interview, facility document review, and review of the facility policy, the facility failed to thoroughly investigate allegations of resident abuse and ensure residents were protected from further potential abuse during the course of the investigation. This affected two (Residents #156 and Resident #120) of three residents reviewed for abuse. Findings include:1. Review of the medical record for Resident #52 revealed an admission date of 12/26/2023 with diagnoses of schizophrenia and bipolar disorder.Review of the MDS for Resident #52 dated 05/21/25 revealed the resident had intact cognition. Review of the care plan for Resident #52 dated 04/16/24 revealed the resident had a history of behaviors which included wandering and making inappropriate comments to staff. Interventions included the following: direct staff to assist the resident to develop more appropriate methods of coping and interacting, encourage the resident to express feelings appropriately, offer tasks that divert the resident's attention. Review of the medical record for Resident #156 revealed an admission date of 09/20/23 with a diagnosis of dementia with behavioral disturbances and a discharge date of 05/12/25. Review of the Minimum Data Set (MDS) assessment for Resident #156 dated 05/06/25 revealed the resident had severe cognitive impairment. Review of a progress note for Resident #156 dated 05/01/25 at 7:41 P.M. per Registered Nurse (RN) #14 revealed the the resident's power of attorney (POA) expressed concern about an interaction they reportedly saw between Resident #156 and another resident and asked if the incident was documented. RN #14 told the POA that they could not release any information until they spoke to their supervisor to ensure there were no privacy violations. Review of the progress note for Resident #156 dated 05/02/25 at 12:05 PM revealed the facility held a care conference with a family member to discuss the resident's escalated verbal and physical behaviors. The note did not address any resident-to-resident incidents. Review of the progress note for Resident #156 dated 05/12/25 at 1:21 P.M. revealed the facility held a care conference with the resident's representative where they discussed the resident's care. The note did not address any resident-to-resident incidents. Interview on 08/21/25 at 7:35 P.M. with Resident #156's representative, Resident Representative (RR) #23 confirmed on 04/26/25 at approximately 7:00 P.M. Resident #156 was watching television when Resident #52 approached Resident #156's room door with their pants down. RR #23 stated Resident #52's belt was unbuckled, their pants were unbuttoned, the zipper was down, and the resident's pants were down to the resident's knees. RR #23 stated they intervened before Resident #52 pulled down their (Resident #52's) brief. RR #23 stated they told Resident #52 to leave Resident #156's room, and once Resident #52 left, RR #23 asked Resident #156 what happened. RR #23 stated that Resident #156 told them that Resident #52 was going to show the resident their genitalia. RR #23 stated they went to the nurses' station at approximately 7:00 P.M. and notified the outgoing and incoming nurses of the interaction between Resident #156 and Resident #52. RR #23 stated staff told them they would keep an eye on the residents and would ensure they were separated. RR #23 stated they contacted the facility on 05/01/25 and spoke with an RN to ensure the facility administration was notified of the interaction. RR #23 stated that on 05/02/25 they called and notified a social worker who stated they would notify the Administrator. RR #23 stated on 05/02/25, they received a return call from the Administrator, the Director of Nursing (DON), and the Social Services Designee (SSD). RR #23 stated that during the phone call, they informed the facility staff of the incident and requested an in-person meeting. RR #23 stated that on 05/12/25 an in-person meeting was held with RR #23, the Administrator, the DON, the SSD, and the Assistant Director of Nursing (ADON), and RR #23 discussed the incident during the meeting. Interview on 08/22/25 at 10:53 A.M. with RN #14 confirmed RR #23 had mentioned an incident about Resident #52 exposing themself but stated he did not remember whether RR #23 had reported the incident to him. RN #14 further confirmed if RR #23 had reported something to him, he would have notified the Administrator immediately. Interview on 08/22/25 at 10:20 A.M. with RN #8, who was the former ADON, stated she was notified of the incident between Resident #52 and Resident #156 on 05/01/25. RN #8 stated RR #23 had wanted to speak with management regarding an incident between Resident #156 and Resident #52. RN #8 stated she spoke with RR #23 who stated Resident #156 was sitting on their bed watching television when RR #23 witnessed Resident #52 approaching the room with their pants down to their hips. RN #8 that RR #23 reportedly told Resident #52 that it was not their room, and the resident turned and left. Interview on 08/21/25 at 3:49 P.M. with the SSD confirmed during a meeting with RR #23, the Administrator, and the DON on 05/12/25, RR #23 alleged Resident #52 exposed themself to Resident #156. The SSD revealed the meeting was documented in a progress note, but the allegation of possible resident-to resident abuse was not documented.Interview on 08/21/25 at 4:00 P.M. with the DON confirmed she attended a meeting where RR #23 alleged Resident #52 attempted to expose their genitals to Resident #156. Interview on 08/21/25 at 5:14 P.M. with the Administrator confirmed he was the Abuse Coordinator for the facility and recalled a meeting was held regarding Resident #156's behaviors. The Administrator confirmed during the meeting, RR #23 reported that Resident #52 attempted to expose themself to Resident #156 on 04/26/25. The Administrator confirmed the facility did not report the incident to the SSA nor did the facility conduct a thorough investigation to include measures to protect residents during the course of the investigation. 2. Review of the medical record for Resident #120 revealed and admission date of 11/07/24 with diagnoses including chronic obstructive pulmonary disease, Alzheimer's disease, and major depressive disorder. Review of the MDS for Resident #120 date 06/04/25 revealed the resident had severe cognitive impairment and required supervision with activities of daily living (ADLs.) Review of the medical record for Resident #117 revealed and admission date of 03/22/25 with diagnoses including unspecified dementia without behavioral disturbance, adjustment disorder with anxiety, and hypertension. Review of the MDS assessment for Resident #117 dated 06/13/25 revealed the resident had severe cognitive and was ambulatory and wandered daily. Review of the care plan for Resident #117 undated revealed the resident had behavioral problems that included hitting others. Interventions included the following: provide a room change, intervene as necessary to protect the rights and safety of others, approach/speak to the resident in a calm manner, divert the resident's attention, take the resident to an alternate location as needed, monitor behavior episodes and attempt to determine the underlying cause, considering the location, time of day, persons involved, and situation, document the behavior and potential causes. Review of the progress note for Resident #120 dated 04/02/25 at 1:30 A.M. per Licensed Practical Nurse (LPN) #10 revealed staff heard the resident yelling and requesting staff get him/her off of me. LPN #10 observed Resident #120 lying in bed, and their roommate was standing over the resident hitting Resident #120 on the arm with a plastic cup. Resident #120 stated they had also been hit on the left arm and left leg. Review of the progress note for Resident #117 dated 04/02/25 at 1:31 A.M. per LPN #10 revealed Resident #117 was standing over their roommate hitting the roommate on the arm with a plastic medicine cup. LPN #10 asked Resident #117 why they were hitting their roommate and the resident stated they did not know. Review of the Interdisciplinary Team (IDT) note for Resident #117 dated 04/13/25 revealed a resident-to-resident incident occurred. Staff observed Resident #117 standing over their roommate and hitting them with a plastic cup. The note indicated the new behavioral intervention for the resident was a room change. Interview on 08/20/25 at 8:37 P.M. with LPN #10 confirmed on 04/02/25 she heard yelling out from a resident room and found Resident #117 standing at Resident #120's bedside hitting them with a plastic cup. LPN #10 stated she informed the charge nurse and the Director of Nursing (DON) of the resident-to resident incident. Interview on 08/22/25 at 11:00 A.M. with the DON confirmed the IDT met two times per week to review incidents. She stated that she deferred to the Administrator to decide which incidents should be reported to the SSA. Interview on 08/22/25 at 12:23 P.M. with LPN #9 confirmed she was a night shift team leader, and staff were to report all falls and incidents to her. LPN #9 confirmed she immediately notified the on-call person, the DON or Administrator of resident-to-resident altercations, which required two-hour reporting. She further stated the staff were to write witness statements about the incidents. LPN #9 stated that she did not recall an incident involving Resident #117 in an altercation with another resident Interview on 08/22/25 at 1:58 P.M. with RN #8 confirmed incidents were discussed during IDT meetings, and the Administrator made the decision on which incidents were to be reported to the SSA. She stated that resident-to-resident altercations were to be reported to the SSA within two hours of being notified of them. Interview on 08/22/25 at 3:06 P.M. with the Administrator confirmed the facility did not report the resident-to-resident incident between Resident #120 and #117 to the SSA nor did the facility conduct a thorough investigation to include measures to protect residents during the course of the investigation. Review of the facility policy titled Abuse/Neglect/Misappropriation of Property revised September 2022 revealed the facility would investigate all allegations of abuse and would ensure residents were protected from further potential abuse during the course of the investigation. This deficiency represents noncompliance investigated under Complaint Number 1301484 (Complaint OH00165616.)

Based on record review, interview, and facility policy review, the facility failed to prevent a significant medication error that placed 1 (Resident #132) of 1 resident reviewed for insulin administration at risk for hypoglycemia. Specifically, Resident #132 received short-acting insulin (Humalog) instead of long-acting insulin (Lantus) and required transfer to a hospital emergency department for observation.The findings included: Review of the medical record for Resident #132 revealed an admission date of 07/11/25 with diagnoses including myocardial infarction, chronic kidney disease, and type 2 diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #132 dated 07/17/25 revealed the resident had intact cognition. Review of the care plan for Resident #132 revealed the resident had diabetes mellitus with diabetic polyneuropathy. Interventions directed staff to administer diabetes medication as ordered by clinicians. Review of the physician's orders for Resident #132 revealed an order dated 07/11/25 for Lantus insulin subcutaneously 95 units at bedtime. Review of the physician's orders for Resident #132 revealed an order dated 07/24/25 for Humalog insulin 15 units with meals, hold if the blood sugar is below 150. Review of the progress note for Resident #132 dated 07/24/25 at 10:08 P.M. revealed Resident #132 was given 60 units of Humalog instead of 95 units of Lantus by mistake. Staff called the resident's physician and the resident showed no signs or symptoms of hypoglycemia. Review of the progress note for Resident #132 dated 07/24/25 at 11:00 P.M. revealed the physician gave an order to send the resident to the hospital for an evaluation. Review of the hospital after visit summary for Resident #132 dated 07/24/25 revealed the resident was seen for an accidental medication error. The hospital performed point of care glucose testing 10 times for Resident #132. Interview on 08/18/2025 at 2:27 P.M. with Resident Representative (RR) #6 confirmed she received a call from a facility nurse reporting Resident #132 had been given the wrong insulin and was being sent to the hospital for observation. Interview on 08/19/25 at 5:45 P.M. with Licensed Practical Nurse (LPN) #2 confirmed on 07/24/25 she mistakenly administered 60 units of Humalog insulin to Resident #132 instead of Lantus insulin. Interview on 08/20/25 at 9:43 A.M. with LPN #1 stated LPN #2 reported the medication error involving Resident #132 immediately and stayed with the resident until emergency medical services (EMS) transported the resident to the hospital. Interview on 08/20/25 at 10:27 A.M. with the Director of Nursing (DON) confirmed LPN #2 reported a medication error with Resident #132 on 07/24/25 in which the resident received Humalog insulin instead of Lantus insulin Interview on 08/21/25 at 3:59 P.M. with the Medical Director confirmed the facility notified him on 07/24/25 that Resident #132 received the wrong insulin. MD confirmed he gave an order for Resident #132 to be transferred to the emergency department for monitoring in a controlled environment. Review of the facility policy titled Medication Error dated May 2025 revealed medication errors would be prevented and reported. This deficiency represents noncompliance investigated under Complaint Number 2579530.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and review of the facility policy, the facility failed to maintain its environment in a sanitary manner on Health Care 2, one of the four halls where residents resided. This had the potential to affect the residents residing on Health Care 2. Findings include: Review of a work order dated 08/17/24 revealed there was mold on ceiling tiles in the Administrator's office. The work order indicated the ceiling tiles were replaced and the pipes were wrapped.Review of a work order dated 09/21/24 revealed there was a moldy hole in the ceiling of room [ROOM NUMBER]. The work order indicated the hole in the ceiling was being fixed.Review of a work order dated 09/12/24 revealed there was mold in the corner of the floor by the window in room [ROOM NUMBER]. Review of a work order dated 12/16/24 revealed there was mold/mildew in the bathroom of room [ROOM NUMBER]. The work order indicated there was no mold or mildew seen, but the bathroom had just been cleaned.Review of a work order dated 07/01/25 revealed a visitor saw and smelled mold in room [ROOM NUMBER]. The work order indicated that the air conditioning (A/C) unit was cleaned.Review of a work order dated 07/09/25 revealed there was mold on ceiling tiles in the administrator's office. The work order indicated the ceiling tiles were replaced.Review of a work order dated 07/20/25 revealed there was mold in room [ROOM NUMBER]. The work order indicated the mold was cleaned.Review of a work order dated 07/25/25 revealed there was a moldlike substance on the ceiling by the window of room [ROOM NUMBER]. The work order indicated the resident stated they had mold on their ceiling above the window, and the dry wall was cut out and replaced with new dry wall.Review of a work order dated 07/29/25 revealed there was mold on top of the ceiling of the bathroom in room [ROOM NUMBER]. The work order indicated the ceiling was treated.Review of a work order dated 07/30/25 revealed there was water damage and mold under the sink in room [ROOM NUMBER]. The work order indicated the room was getting a new vanity which had already been ordered. Review of a work order dated 08/01/25 revealed there was mold on the ceiling of dry storage in the kitchen. The work order indicated the area was treated and got rid of mold.Review of a work order dated 08/01/25 revealed there was mold on the ceiling in Health Care 1 medication room. The work order indicated the area was cleaned and treated. Review of a work order dated 08/13/25 revealed there was mold in the A/C unit of room [ROOM NUMBER]. The work order indicated the area was cleaned and treated.Review of a work order dated 08/14/25 revealed there was possible mold in the register of room [ROOM NUMBER]. The work order indicated the area was cleaned and treated.Observation on 08/18/25 at 1:21 P.M of resident room [ROOM NUMBER] located on HC2 revealed there was a black area on the left wall by the ceiling behind the resident's bed. Observation on 08/21/25 at 9:49 A.M. of room [ROOM NUMBER] located in hall HC2 revealed the black area at the top of the wall was no longer there. Observation on 08/21/25 at 10:00 A.M. revealed the ceiling tiles in the dining room adjacent to room [ROOM NUMBER] were stained brown and black. Interview on 08/21/2025 at 11:41 A.M. with Maintenance Director (MD) #16 stated that he was not aware of mold in the facility. He stated that there was a black substance that appeared on the walls and ceilings, but it was able to be wiped off easily. MD #16 confirmed Housekeeper #15 was able to wipe off the black area in room [ROOM NUMBER]. Interview on 08/21/25 at 1:52 P.M. with Housekeeper #15 confirmed she worked every other weekend on HC 2 located on the first floor, which included Rooms 151-181. Housekeeper #15 stated that there was a black stain in room [ROOM NUMBER] on the wall which she was able to remove. Interview on 08/21/25 at 1:58 P.M. with Environmental Services Supervisor (ESS) #17 stated that if a staff member saw a black substance and they wiped it off and put in a work order, she followed up. She stated she was not an expert but during high humidity days if residents did not have their air on, the black areas would appear, but the black areas would wipe off and not come back. Interview on 08/21/25 at 2:49 P.M. with MD #16 stated that he first became aware of the black substance in room [ROOM NUMBER] through work orders from the previous day. Interview on 08/22/25 at 2:11 P.M. with the Director of Nursing (DON) confirmed if staff saw mold they should report it to maintenance staff via work order. The DON stated she thought they would hire a contractor to come out and test or evaluate the situation. The DON stated that her expectation was that concerns with black areas be reported right away so that they could be addressed. Interview on 08/22/25 at 2:17 P.M. with the Administrator if staff saw a black substance in the environment which appeared to be mold it should be reported to the maintenance staff via work order so it could be addressed immediately. The Administrator stated the facility had not made any attempts to determine the origin of the black substances in the environment detailed on the work orders. Review of the facility policy titled Environmental Services-Homelike Environment dated January 2025 revealed the facility would maintain a high standard of cleanliness in all areas of the facility. The environmental service department worked diligently in conjunction with the other departments to maintain a comfortable homelike atmosphere that was clean and odor free for the residents.This deficiency represents noncompliance that was investigated under Complaint Number 2592171.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and policy review, the facility failed to ensure the residents were treated with dignity and respect at meal service. This affected one (Resident #120) of 11 residents whom were eating lunch in the dining room. The facility census was 148. Findings include: Record review for Resident #120 revealed Resident #120 was admitted on [DATE]. Diagnoses included congestive heart failure, diabetes mellitus, hypertension, obesity, chronic kidney disease, and anemia. Review of the five-day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #120 had no cognitive deficits and required supervision during eating. Observation of lunch service on 05/02/22 from 12:15 P.M. to 12:45 P.M. revealed State Tested Nursing Assistant (STNA) #46 brought Resident #120 into the dining room and placed Resident #120 at the table with Resident #20. Resident #20 was served her lunch at 12:15 P.M. and STNA #46 continued to serve the other nine residents (#14, #25, #31, #35, #41, #48, #59, #124, and #149) in the dining room and then started to set up room trays while Resident #120 was still waiting for her tray. Interview on 05/02/22 at 12:45 P.M. with STNA #46 verified Resident #120 had not been served her lunch and STNA #46 explained she had been forgotten. STNA #46 stated she went into the kitchenette and found Resident #120's meal ticket tucked under a tray and that was why she was forgotten. Review of the facility's Meal Service Policy, dated 05/2021, revealed the Registered Dietician/RD and nursing personnel will assist with the dining room seating charts for each unit. The charts will identify where the residents will be served and help ensure the delivery of the appropriate diet. It also assures that each resident at any given table is served before moving onto the next table, and all residents at one table will be served before moving to the next table. If a resident sits at a table where the tablemates are already eating, his/her tray will be obtained as quickly as possible. This deficiency substantiates Complaint Number OH00114887 and OH00113637.

2. Observation on 05/02/22 at 12:45 P.M. revealed the residents were being served their afternoon meal. The residents were receiving hamburgers on bun with condiments and toppings consisting of lettuce, tomatoes, mayonnaise and mustard in individual packs. STNA #5 was assisting Resident #29 with meal set up. STNA#5 asked Resident #29 what they wanted on their hamburger. STNA# 5 then picked up the lettuce and tomatoes with her bare hand and placed them on the hamburger, used her bare hand to smash the sandwich down, and then cut it with the knife. During an interview with STNA #5, she verified she touched Resident #29's food with her bare hands. She stated she sanitized her hands but stated she should have applied gloves to touch the food. Review of the facility's policy titled Meal Service dated 05/2021 revealed staff is to serve meals using proper hand techniques. No direct contact with food. Based on observation, staff interview, and policy review, the facility failed to ensure the resident's foods were handled in a manner to prevent the potential spread of food borne illness. This affected three residents (Residents #7, #29, and #60) observed during the afternoon meal. The facility census was 148. Findings include: 1. Observations on 05/02/22 at 12:48 P.M. revealed the residents were being served their afternoon meal. The residents were receiving hamburgers on bun with condiments and toppings consisting of lettuce, tomatoes, mayonnaise and mustard in individual packs. State Tested Nursing Assistant (STNA) #63 was assisting Resident #60 with meal set up. STNA#60 asked Resident #60 what they wanted on their hamburger. The STNA opened the packs of mayonnaise and mustard put on the top bun. STNA# 63 then picked up the lettuce, and tomatoes with her bare hand and placed them on the hamburger, the STNA then wiped her hands on her scrub top and picked up the top bun placed it on the hamburger, used her bare hand to smash the sandwich down and then cut it with the knife. During the same observation on 05/02/22 at 12:50 P.M., STNA #124 was assisting Resident #7 with adding condiments to the resident's hamburger. STNA#124 put mustard and ketchup from individual packets on the sandwich and then placed the top bun on the hamburger with her bare hand then held the sandwich with one bare hand while using the knife to cut the sandwich in half. STNA #124 picked up half the sandwich with her bare hand and handed it to Resident #7. Interview with STNA #124 on 05/02/22 at 1:00 P.M. verified she did touch Resident #7's food with her bare handed and she should have used the resident's eating utensils to apply and cut the food. Interview on 05/02/22 at 1:05 P. M. with STNA #63 verified she applied the condiments with her bare hand and she should have used gloves or utensils when setting Resident #60's meal tray.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to provide a copy of the transfer or discharge notification to the Ombudsman for discharges from the facility. This affected two (#24 and #114) of nine residents reviewed for discharge notification. The facility census was 167. Findings include: 1. Record review revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses include epilepsy, apraxia, weakness, pain, unspecified convulsions, abnormal findings of blood chemistry, non toxic multinodular goiter, muscle weakness, anemia, peripheral vascular disease, acquired absence of left leg below knee, essential hypertension, anxiety disorder, atrial fibrillation, type two diabetes mellitus with hyperglycemia and hyperlipidemia. Review of Resident #24's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to be cognitively impaired and require limited assistance with personal hygiene. Resident #24 also required supervision with eating and extensive assistance with bed mobility, transfers, dressing and toileting on 04/17/19. Review of Resident #24's chart revealed resident discharged to the hospital on [DATE] with seizures and returned to the facility on [DATE]. Further review of Resident #24's chart revealed no evidence of Ombudsman notification for resident's hospitalization on 03/28/19 was located in the chart. Interview with Business Office Coordinator #76 on 07/24/19 at 12:39 P.M. verified there was not evidence of the Ombudsman being notified of Resident #24's discharge to the hospital on [DATE]. 2. Record review revealed Resident #114 was admitted to the facility on [DATE]. Diagnoses include heart failure, type two diabetes mellitus with diabetic neuropathy, difficulty in walking, anemia, atrial fibrillation, dysphagia, repeated falls, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, seizure, gastro esophageal reflux disease, chronic obstructive pulmonary disease, major depressive disorder, type two diabetes mellitus and essential hypertension. Review of Resident #114's significant change MDS assessment dated [DATE] revealed the resident to be cognitively impaired and require extensive assistance with bed mobility, transfers, toileting, dressing, eating and personal hygiene. Review of Resident #114's chart revealed resident discharged to the hospital on [DATE] with cerebrovascular accident and returned to the facility on [DATE]. Resident #114 also discharged to the hospital on [DATE] with anemia and returned to the facility on [DATE]. Further review of Resident #114's chart revealed no evidence of Ombudsman notification for resident's hospitalizations on 02/26/19 and 03/29/19 were located in the chart. Interview with Business Office Coordinator #76 on 07/24/19 at 12:39 P.M. verified there was no evidence of the Ombudsman being notified of Resident #114's discharges to the hospital on [DATE] and 03/29/19. Review of the facility Resident Transfer and Discharge Rights from the Facility policy dated November 2016 revealed the facility must send a copy of the notice of transfer or discharge to the representative of the Office of the State Long Term Care Ombudsman by certified mail or electric email.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure a nurse provided the correct pressure ulcer dressing for a resident in accordance with a physician order. This affected one (#84) out of four residents reviewed for pressure wounds. The facility census was 167. Findings include: Review of Resident #84's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include degeneration of brain, gastrointestinal hemorrhage, dysphagia, hyperlipidemia, electrolyte/fluid balance disorders, diabetes, chronic kidney disease, vitamin D, peripheral vascular disease, anxiety, hypertension, hypokalemia, transient ischemic attack, hemiplegia, anxiety, chronic obstructive pulmonary disease, osteoporosis, and dementia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 has severe cognitive deficits, and requires extensive assist to total dependence for activities of daily living, is frequently incontinent of bladder, and always incontinent of bowel. Review of care plan latest revision date of 08/07/18 revealed Resident #84 has the potential for skin impairment related to impaired mobility, incontinence, diabetes, history of skin breakdown, hemiplegia, and peripheral vascular disease. Continued review of care plan with latest revision date of 07/22/19 revealed Resident #84 has has a pressure ulcer to sacrum related to impaired mobility, incontinence, diabetes, fragile scar tissue related to history of pressure ulcer to sacrum, cerebral vascular accident, hemiparesis, peripheral vascular disease, hypertensive chronic kidney disease, dementia, and unaware of needs. Resident #84 has wound healing compromised by terminal prognosis, receiving hospice services. Reviewed of wound care note dated 01/23/17 revealed the sacrum wound was acquired on 11/13/16 and healed on 01/23/17. Further review of wound care notes dated 03/05/19 revealed the old wound opened again and healed and reopened again on 03/05/19 and is in the process of healing at this time measuring 0.3 centimeters (cm) long by 0.1 cm wide by 0.2 cm in depth on 07/22/19. Review of physician order dated 07/12/19 revealed to cleanse sacral wound with normal saline and pat dry. Apply max-absorb extra AG wound dressing and cover with gauze pad four inches by four inches and secure with tape. Change daily and as needed. Observation on 07/24/19 from 2:30 P.M. to 3:00 P.M. with two Registered Nurses (RN) #52 and #173 providing wound care to Resident #84. During the observation, RN #52 removed the old dressing, removed his/her soiled gloves, washed his/her hands, donned new gloves, changed his/her gloves and measured the wound. RN #52 then removed his/her soiled gloves, washed his/her hands, donned new gloves, cleansed wound with normal saline, removed his/her soiled gloves, washed his/her hands and donned new gloves. RN #52 then applied max-absorb to the wound on the sacral area, then placed the tape on the dressing and did not place a gauze pad four inches by four inches prior to securing with tape. Interview on 07/24/19 at 2:54 P.M. during observation RN #52 verified she did not place the gauze pad four inches by four inches over the max-absorb prior to securing with tape and stated he/she would redo the dressing. Review of the Infection Control-Dressings, Dry/Clean Policy dated 04/2017 revealed to apply the ordered treatment, dressing, and secure with tape.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a still shot picture and staff and resident interview, the facility failed to provide care in a dignified manner when a staff member did not assist and/or seek timely assistance for a resident who expressed a need to use the toilet in the early morning and subsequently had an incontinence episode, causing the resident to be upset. This affected one Resident (#363) out of six sampled for respect and dignity. The facility census was 159. Findings include: Review of a medical record revealed Resident #363 revealed the resident was admitted on [DATE] with diagnosis including chronic pain, shortness of breath, hypertension, urinary tract infection, acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, and type 2 diabetes. Review of the Medicare- five day Minimum Data Set (MDS) dated [DATE] revealed Resident #363 was cognitively intact, required extensive assist with activities of daily living (ADL), was frequently incontinent of bladder and frequently incontinent of bowels. Review of medical record revealed Resident #362 revealed the resident was admitted on [DATE] with diagnosis including heart failure, hypertension, diabetes, thyroid disorder, depression, anxiety, and gastroesophageal reflux disease. Review of the MDS dated [DATE] revealed Resident #362 was cognitively intact, required limited assist with activities of daily living, was continent of bowel and bladder. Interview on 06/26/18 at 11:30 A.M. with Resident #362 reported her roommate, Resident #363 pulled the call light on 06/26/18 around 4:30 A.M. to be assisted to the bathroom. Registered Nurse (RN) #135 turned the call light off and told her he will send someone in. Resident #362 reported Resident #363 started to cry and ended up urinating on herself. Resident #362 reported RN #135 returned to the room around 6:30 A.M. to give them their medications and Resident #363 told him that she had urinated on herself. RN #135 stated he will send someone and no one came until first shift rounds. Resident #362 stated she was upset because she could not help Resident #363 but she reported the incident to State Tested Nursing Assistant (STNA) #167. Interview on 06/26/18 at 1:05 P.M. with Resident #363 reported she pulled her call light for assistance to go to the bathroom around 4:30 A.M. RN #135 answered the call and told her he would send someone in. Resident #363 stated RN #135 came back to room around 6:30 A.M. to pass out medications and she told him that she had urinated on herself. Resident #363 stated RN #135 told her he would get someone. Resident #363 was tearful and said that no one came until around 7:30 A.M. Resident #363 stated I was cold and I could not believe he did that to me. Who wants to lay in a wet and cold bed for hours? Since they took the bars off the bed I cannot get out of bed. I used to get out of bed and wheel myself over to the bedside commode. Resident #363 stated she was in disbelief and Resident #362, verbalized her concerns to morning shift STNA #167. Resident #363 stated no one came to her room to talk to her about the incident. Interview on 06/26/18 at 2:00 P. M. with STNA #167 reported Resident #363 was crying, distraught and upset. STNA #167 reported Resident #363's sheet on her bed had a dry brown ring from her feet to half way up her back. STNA #167 reported Resident #363's sheet, top sheet, two blankets and her pants were wet. STNA #167 reported initially Resident #363 was reluctant to get out of bed because she was cold. STNA #167 cleaned the resident up around 7:30 A.M. and reported it to RN #144. Interview on 06/27/18 at 4:20 P. M. with RN #144 reported Resident #363 was wet and upset. RN #144 stated that Resident #363 reported to her that she asked to go to be changed and was not changed in a timely manner. RN #144 reported the incident to her Licensed Practical Nurse Unit Manager (LPN #78). Interview 06/27/18 at 2:10 P. M. with LPN #78 reported she did an investigation and interviewed staff at 5:30 A.M. and pulled reports that everything was in place. LPN #78 reported STNA #166 or STNA #176 were the person/staff who took care of Resident #363 at 5:30 A.M. LPN #78 did not give STNA's last name. LPN #78 reported therapy had reported Resident #363 was confused at times. LPN #78 reported Resident #362 is bipolar and has some significant mood issues. LPN #78 stated RN #135 works the night shift and would be available if the surveyor came in on 06/28/18. Further review of Resident #363's activities of daily living (ADL) sheet on 06/27/18 at 2:45 P.M. revealed STNA #191 took care of Resident #363 on 06/26/18 at 5:30 A.M. There were no initials of STNA #166 or STNA #176. Interview on 06/27/18 at 3:45 P.M. with LPN #78 to inform of the findings on Resident's #363 ADL sheets. LPN #78 did not confirm or deny the ADL sheet. Requested to look at the camera on the unit to clear up any discrepancies. LPN #78 directed the surveyor to the Administrator. Interview on 06/27/18 at 4:00 P.M. with Administrator who reported she was not allowed to have surveyor review the video but Administrator showed a picture of a STNA coming out of a room with a bag in her hand. The picture was not clear and unable to see an identifiable room number; therefore, the picture was unable to validate if the STNA was coming out of Resident's #363 room. The individual in the picture was also unidentifiable. On 06/28/18 at 7:50 A.M. RN #135 was not available to be interviewed. The surveyor requested RN #135, STNA #166 and STNA #176 contact information from the facility and this information was not provided to the surveyor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of self-reported incidents (SRI's), resident, staff, physician, physician assistant and resident's friend interview, and review of the facility abuse policy and procedure, the facility failed to implement their abuse/neglect policy to ensure they reported allegations of neglect to the state agency. This affected two Resident (#363 and #510) out of six sampled for neglect. The facility census was 159. Findings include: 1. Review of a medical record revealed Resident #363 was admitted on [DATE] with diagnosis including chronic pain, shortness of breath, hypertension, urinary tract infection, acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, and type 2 diabetes. Review of the Medicare-five day Minimum Data Set (MDS) dated [DATE] revealed Resident #363 was cognitively intact, required extensive assist with activities of daily living (ADL), was frequently incontinent of bladder and frequently incontinent of bowels. Review of medical record revealed Resident #362 was admitted on [DATE] with diagnosis including heart failure, hypertension, diabetes, thyroid disorder, depression, anxiety, and gastroesophageal reflux disease. Review of MDS dated [DATE] revealed Resident #362 was cognitively intact, required limited assist with activities of daily living, was continent of bowel and bladder. Interview on 06/26/18 at 11:30 A.M. with Resident #362 reported her roommate, Resident #363 pulled the call light on 06/26/18 around 4:30 A.M. to be assisted to the bathroom. Registered Nurse (RN) #135 turned the call light off and told her he will send someone in. Resident #362 reported Resident #363 started to cry and ended up urinating on herself. Resident #362 reported RN #135 returned to the room around 6:30 A.M. to give them their medications and Resident #363 told him that she had urinated on herself. RN #135 stated he will send someone and no one came until first shift rounds. Resident #362 stated she was upset because she could not help Resident #363 but she reported the incident to State Tested Nursing Assistant (STNA) #167. Interview on 06/26/18 at 1:05 P.M. with Resident #363 reported she pulled her call light for assistance to go to the bathroom around 4:30 A.M. RN #135 answered the call and told her he would send someone in. Resident #363 stated RN #135 came back to room around 6:30 A.M. to pass out medications and she told him that she had urinated on herself. Resident #363 stated RN #135 told her he would get someone. Resident #363 was tearful and said that no one came until around 7:30 A.M. I was cold and I could not believe he did that to me. Who wants to lay in a wet and cold bed for hours? Since they took the bars off the bed I cannot get out of bed. I used to get out of bed and wheel myself over to the bedside commode. Resident #363 stated she was in disbelief and Resident #362, verbalized her concerns to morning shift STNA #167. Resident #363 stated no one came to her room to talk to her about the incident. Interview on 06/26/18 at 2:00 P.M. with STNA #167 reported Resident #363 was crying, distraught and upset. STNA #167 stated Resident #363's sheet on her bed had a dry brown ring from her feet to half way up her back and all two covers were wet along with the top and bottom sheet. STNA #167 reported the incident to RN #144. Interview on 06/27/18 at 4:20 P.M. with RN #144 reported Resident #363 was wet and upset. RN #144 stated that Resident #363 reported to her that she asked to go to be changed and was not changed in a timely manner. RN #144 reported the incident to her Licensed Practical Nurse Unit Manager (LPN #78). Interview 06/27/18 at 2:10 P.M. with LPN #78 reported she did an investigation and interviewed staff at 5:30 A.M. and pulled reports that everything was in place. LPN #78 stated she reported the incident to the Administrator. LPN #78 stated RN #35 works the night shift and would be available if the surveyor came in on 06/28/18. Interview on 06/27/18 at 4:00 P.M. with Administrator who reported she was aware of the situation and a time line was created to show that there was no negligence on the facility. On 06/28/18 at 7:50 A.M. RN #35 was not available to be interviewed. The surveyor requested RN #35, STNA #166 and STNA #176 contact information from the facility and this information was not provided to the surveyor. Review of the facility's SRI on 06/27/18 at 6:00 P.M., revealed there was no incident involving Resident #363's allegation. 2. Clinical record review revealed Resident #510 was admitted to the facility on [DATE]. Diagnoses included encounter orthopedic aftercare, displaced trimalleolar fracture of the left lower leg, nicotine dependent, presence of left artificial joint and chronic obstructive pulmonary disease (COPD). Review of the nursing admission assessment dated [DATE] revealed Resident #510 had a surgical incision with redness surrounding the incision and a 0.4 centimeter (cm) open area. He had a deep tissue injury (DTI), to the left heel at this time. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 06/07/18, revealed the resident had intact cognition. It was important for him to have close friends and family involved with his care. He required extensive assistance of one to two staff for care. He was frequently incontinent of urine and always continent of bowel. He had no infection. He had an unstageable pressure area upon admission and a surgical wound but did not identify infection. Review of the labs dated from 06/02/18 documented a 11.9 thousand per cubic millimeter (K/cmm) white blood cell count which was listed at high (H) where normal was 4.5 to 10.8 K/cmm the next lab drawn on 06/04/18 the white blood count was 12.1 K/cmm. Review of the plan of care dated 06/03/18 revealed the resident had a surgical site to left lateral and left medial ankle due to a recent fracture. The incision will show signs of healing an remain free from infection. Interventions included administer treatments as ordered and monitor for effectiveness, evaluate incision for size, depth, wound edges document progress on an ongoing basis, notify physician as indicated, keep responsible party updated of status, monitor for signs of infection, observe for redness and obtain and monitor laboratory values. Review of physician orders from 05/31/18 to 06/13/18 identified orders for skin prep to heels bilaterally and to swab surgical incision with betadine 10 percent every night shift apply gauze and ace wrap. Surgical boot when up and out of bed. A follow up appointment with the orthopedic specialist on 06/13/18. Review of the treatment administration record (TAR) dated for May 2018 and June 2018 documented the treatment had been completed as ordered except for 06/04/18 and 06/06/18 it was documented as the treatment was refused. Review of the skin observation charting dated from 06/06/18 to 06/09/18 did not thoroughly document the assessment of the surgical incision daily. The charting revealed the treatment was completed or continue treatment. Review of the weekly skin round dated 06/03/18 documented surgical incision present, reddened areas present with dehiscence noted. Left medial ankle area scabbed with no drainage, reddened peri wound, left lateral incision with opened area measured 0.4 cm in center of incision. The assessment obtained on 06/10/18 measured 9.0 cm by 0.1 cm by 0.1 cm. Clarification added on 06/18/18 of location of the wound documented a surgical incision with dehiscence noted at distal end of wound. Length of opened area is 0.4 cm by 0.5 cm by 0.1 cm. The wound bed was documented as yellow and pink with small yellow drainage it also documented the physician was notified. Review of the skin observation charting dated from 06/11/18 to 06/13/18 revealed the assessment did not describe the incision, the open area or the surrounding tissue, it only documented continued treatment. Review of the nurses notes dated 06/13/18 at 2:16 P.M., Unit Manager (UM) #78 called the local hospital to inquire about the orthopedic follow up appointment and was made aware Resident #510 was going to have a revision of the left ankle post open reduction and internal fixation (ORIF) on 06/14/18. Note on 06/14/18 confirmed UM #78 called back to the local hospital and the resident did have surgery on left ankle and was admitted to the surgical intensive care unit (ICU). Interview on 06/27/18 at 8:06 A.M., the wound nurse Registered Nurse (RN) #143 stated she completed the weekly wound rounds and she saw the wound on 06/10/18 and it had an open area but she did not see any hardware sticking out. Interview on 06/27/18 at 8:26 A.M., UM #78 said she had received a phone call from someone claiming to be the residents daughter and said there were issues about care and had said the surgeon had some neglect concerns, she then retracted and said she did not use the word neglect but said the surgeon was concerned of how the incision deteriorated and questioned the care he had received and she should look into neglect. She said the Assistant Director Of Nursing (ADON) #31 was also on the phone call and heard what she heard. She then said she went and completed calls to the surgeon to find out what was going on and she found he was to have an antibiotic started on 05/28/18 but this was not started at the previous facility and there was no mention of this on the transfer. She said she could not speak to the incision because she never saw it because the treatment was on night shift and he had a surgical boot on it. Interview on 06/27/18 at 11:12 A.M., RN #144 and Licensed Practical Nurse (LPN) #123 stated they had never seen the incision he had a surgical boot on it and the treatment was done on night shift. Interview on 06/27/18 at 11:24 A.M., Medical Doctor (MD) #436 and Physician Assistant (PA) #437 stated neither one of them had seen the incision so they could not speak to the deterioration the surgeon was speaking of. MD #436 stated she reviewed the laboratory values and his white blood cell (WBC) count was elevated but she would not have started antibiotics due to the neutrophils were within a normal range. She also said this could have masked symptoms if something was going on inside the incision it would have healed on the outside and not on the inside. Had staff notified them of any concerns she would have consulted the surgeon prior to starting any antibiotic, however she would have considered it if the WBC count was over 20 thousand. Interview on 06/27/18 at 3:06 P.M., the Director of Nursing (DON) and ADON #31 stated the residents representative called and had questions about what had happened to the surgical incision. She said the surgeon wanted to know how the wound got so big and the way it looked. She had concerns with lack of care. The DON stated she never said the word neglect, but when asked if she was on the conference call she replied she was not on the phone call and did not actually hear what was reported. She further said they did not report the incident. Telephone interview on 06/27/18 5:00 P.M., the friend of Resident #510 stated she really did not know the extent of the wound until she arrived to the hospital and was made aware by Surgeon #439 at the hospital and the social worker (SW) #440. She was informed the plate was sticking out of the incision and how anyone who was visualizing the incision could not identify this was unacceptable. She also said she called the ADON #31 and the Unit Manager (UM) #78 and questioned how the wound got in such terrible shape if the staff were monitoring and looking at this wound. She said he had a scab going on the right lower leg which was scabbed over and then he had a cast on the left leg and when they removed the cast the plate was sticking out of his leg. She said she told them the surgeon said this would have been very noticeable to anyone who was looking at it. She also told her to obtain a lawyer who dealt with neglect and told the facility this wound was not properly taken care of. Telephone interviews on 06/27/18 at 5:30 P.M., a message was left with Surgeon #439 and local hospital SW #440. Interview on 06/28/18 at 7:05 A.M., attempted an interview with the third shift nurse RN #138 who had seen the wound the three nights in a row prior to having his orthopedic follow up appointment on 06/13/18 and UM #78 stated he was able to go home because they had an extra nurse, the phone number was requested at this time. Telephone interview on 06/28/18 at 10:50 A.M., the wound nurse RN #142 stated she went into the note and clarified the description of the dehisced area and she knew it did not look good to go in and change a note but she thought her first documentation looked like the whole wound was open. She said she did not notify the physician or family and was unsure why those boxes were checked. Telephone interview on 06/28/18 at 10:54 A.M., Nurse #138 stated he did not really remember what the incision looked like and he completed treatments right after his evening medication pass or he would complete them with the early morning medication pass just so residents could sleep. He could not remember if he documented a description of the incision when he documented. Interview on 06/28/18 at 6:50 P.M., the Corporate Clinician (CC) #438 and the Administrator stated there was never an allegation of neglect, just some care issues which we investigated as a team and reviewed everything. CC #438 and the Administrator stated this was why we did not report the incident. She further said maybe the surgeon was trying to cover up his mistakes too. Review of the SRI's dated from 06/13/18 to 06/28/18 revealed there was no report made to the state agency of the alleged neglect. Review of the policy titled Abuse, Neglect, Misappropriation of Property revised 11/2016 documented the facility will investigate all allegations of neglect. Facility staff should immediately report all such allegations to the Administrator and to the state agency. Neglect was defined as the failure or the facility, its employees, or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. The Administrator or designee will notify the STATE AGENCY of all alleged violations involving abuse, neglect, mistreatment of a resident, exploitation or misappropriation of resident property as soon as possible but no later than 24 hours from the time the incident/allegation was made known to a staff member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of self-reported incidents (SRI's), resident, staff, physician, physician assistant and resident's friend interview and review of the facility abuse policy and procedure, the facility failed to report allegations of neglect to the state agency. This affected two Resident (#363 and #510) out of six sampled for neglect. The facility census was 159. Findings include: 1. Review of a medical record revealed Resident #363 was admitted on [DATE] with diagnosis including chronic pain, shortness of breath, hypertension, urinary tract infection, acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, and type 2 diabetes. Review of the Medicare-five day Minimum Data Set (MDS) dated [DATE] revealed Resident #363 was cognitively intact, required extensive assist with activities of daily living (ADL), was frequently incontinent of bladder and frequently incontinent of bowels. Review of medical record revealed Resident #362 was admitted on [DATE] with diagnosis including heart failure, hypertension, diabetes, thyroid disorder, depression, anxiety, and gastroesophageal reflux disease. Review of MDS dated [DATE] revealed Resident #362 was cognitively intact, required limited assist with activities of daily living, was continent of bowel and bladder. Interview on 06/26/18 at 11:30 A.M. with Resident #362 reported her roommate, Resident #363 pulled the call light on 06/26/18 around 4:30 A.M. to be assisted to the bathroom. Registered Nurse (RN) #135 turned the call light off and told her he will send someone in. Resident #362 reported Resident #363 started to cry and ended up urinating on herself. Resident #362 reported RN #135 returned to the room around 6:30 A.M. to give them their medications and Resident #363 told him that she had urinated on herself. RN #135 stated he will send someone and no one came until first shift rounds. Resident #362 stated she was upset because she could not help Resident #363 but she reported the incident to State Tested Nursing Assistant (STNA) #167. Interview on 06/26/18 at 1:05 P.M. with Resident #363 reported she pulled her call light for assistance to go to the bathroom around 4:30 A.M. RN #135 answered the call and told her he would send someone in. Resident #363 stated RN #135 came back to room around 6:30 A.M. to pass out medications and she told him that she had urinated on herself. Resident #363 stated RN #135 told her he would get someone. Resident #363 was tearful and said that no one came until around 7:30 A.M. I was cold and I could not believe he did that to me. Who wants to lay in a wet and cold bed for hours? Since they took the bars off the bed I cannot get out of bed. I used to get out of bed and wheel myself over to the bedside commode. Resident #363 stated she was in disbelief and Resident #362, verbalized her concerns to morning shift STNA #167. Resident #363 stated no one came to her room to talk to her about the incident. Interview on 06/26/18 at 2:00 P.M. with STNA #167 reported Resident #363 was crying, distraught and upset. STNA #167 stated Resident #363's sheet on her bed had a dry brown ring from her feet to half way up her back and all two covers were wet along with the top and bottom sheet. STNA #167 reported the incident to RN #144. Interview on 06/27/18 at 4:20 P.M. with RN #144 reported Resident #363 was wet and upset. RN #144 stated that Resident #363 reported to her that she asked to go to be changed and was not changed in a timely manner. RN #144 reported the incident to her Licensed Practical Nurse Unit Manager (LPN #78). Interview 06/27/18 at 2:10 P.M. with LPN #78 reported she did an investigation and interviewed staff at 5:30 A.M. and pulled reports that everything was in place. LPN #78 stated she reported the incident to the Administrator. LPN #78 stated RN #35 works the night shift and would be available if the surveyor came in on 06/28/18. Interview on 06/27/18 at 4:00 P.M. with Administrator who reported she was aware of the situation and a time line was created to show that there was no negligence on the facility. On 06/28/18 at 7:50 A.M. RN #35 was not available to be interviewed. The surveyor requested RN #35, STNA #166 and STNA #176 contact information from the facility and this information was not provided to the surveyor. Review of the facility's SRI on 06/27/18 at 6:00 P.M., revealed there was no incident involving Resident #363's allegation. 2. Clinical record review revealed Resident #510 was admitted to the facility on [DATE]. Diagnoses included encounter orthopedic aftercare, displaced trimalleolar fracture of the left lower leg, nicotine dependent, presence of left artificial joint and chronic obstructive pulmonary disease (COPD). Review of the nursing admission assessment dated [DATE] revealed Resident #510 had a surgical incision with redness surrounding the incision and a 0.4 centimeter (cm) open area. He had a deep tissue injury (DTI), to the left heel at this time. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 06/07/18, revealed the resident had intact cognition. It was important for him to have close friends and family involved with his care. He required extensive assistance of one to two staff for care. He was frequently incontinent of urine and always continent of bowel. He had no infection. He had an unstageable pressure area upon admission and a surgical wound but did not identify infection. Review of the labs dated from 06/02/18 documented a 11.9 thousand per cubic millimeter (K/cmm) white blood cell count which was listed at high (H) where normal was 4.5 to 10.8 K/cmm the next lab drawn on 06/04/18 the white blood count was 12.1 K/cmm. Review of the plan of care dated 06/03/18 revealed the resident had a surgical site to left lateral and left medial ankle due to a recent fracture. The incision will show signs of healing an remain free from infection. Interventions included administer treatments as ordered and monitor for effectiveness, evaluate incision for size, depth, wound edges document progress on an ongoing basis, notify physician as indicated, keep responsible party updated of status, monitor for signs of infection, observe for redness and obtain and monitor laboratory values. Review of physician orders from 05/31/18 to 06/13/18 identified orders for skin prep to heels bilaterally and to swab surgical incision with betadine 10 percent every night shift apply gauze and ace wrap. Surgical boot when up and out of bed. A follow up appointment with the orthopedic specialist on 06/13/18. Review of the treatment administration record (TAR) dated for May 2018 and June 2018 documented the treatment had been completed as ordered except for 06/04/18 and 06/06/18 it was documented as the treatment was refused. Review of the skin observation charting dated from 06/06/18 to 06/09/18 did not thoroughly document the assessment of the surgical incision daily. The charting revealed the treatment was completed or continue treatment. Review of the weekly skin round dated 06/03/18 documented surgical incision present, reddened areas present with dehiscence noted. Left medial ankle area scabbed with no drainage, reddened peri wound, left lateral incision with opened area measured 0.4 cm in center of incision. The assessment obtained on 06/10/18 measured 9.0 cm by 0.1 cm by 0.1 cm. Clarification added on 06/18/18 of location of the wound documented a surgical incision with dehiscence noted at distal end of wound. Length of opened area is 0.4 cm by 0.5 cm by 0.1 cm. The wound bed was documented as yellow and pink with small yellow drainage it also documented the physician was notified. Review of the skin observation charting dated from 06/11/18 to 06/13/18 revealed the assessment did not describe the incision, the open area or the surrounding tissue, it only documented continued treatment. Review of the nurses notes dated 06/13/18 at 2:16 P.M., Unit Manager (UM) #78 called the local hospital to inquire about the orthopedic follow up appointment and was made aware Resident #510 was going to have a revision of the left ankle post open reduction and internal fixation (ORIF) on 06/14/18. Note on 06/14/18 confirmed UM #78 called back to the local hospital and the resident did have surgery on left ankle and was admitted to the surgical intensive care unit (ICU). Interview on 06/27/18 at 8:06 A.M., the wound nurse Registered Nurse (RN) #143 stated she completed the weekly wound rounds and she saw the wound on 06/10/18 and it had an open area but she did not see any hardware sticking out. Interview on 06/27/18 at 8:26 A.M., UM #78 said she had received a phone call from someone claiming to be the residents daughter and said there were issues about care and had said the surgeon had some neglect concerns, she then retracted and said she did not use the word neglect but said the surgeon was concerned of how the incision deteriorated and questioned the care he had received and she should look into neglect. She said the Assistant Director Of Nursing (ADON) #31 was also on the phone call and heard what she heard. She then said she went and completed calls to the surgeon to find out what was going on and she found he was to have an antibiotic started on 05/28/18 but this was not started at the previous facility and there was no mention of this on the transfer. She said she could not speak to the incision because she never saw it because the treatment was on night shift and he had a surgical boot on it. Interview on 06/27/18 at 11:12 A.M., RN #144 and Licensed Practical Nurse (LPN) #123 stated they had never seen the incision he had a surgical boot on it and the treatment was done on night shift. Interview on 06/27/18 at 11:24 A.M., Medical Doctor (MD) #436 and Physician Assistant (PA) #437 stated neither one of them had seen the incision so they could not speak to the deterioration the surgeon was speaking of. MD #436 stated she reviewed the laboratory values and his white blood cell (WBC) count was elevated but she would not have started antibiotics due to the neutrophils were within a normal range. She also said this could have masked symptoms if something was going on inside the incision it would have healed on the outside and not on the inside. Had staff notified them of any concerns she would have consulted the surgeon prior to starting any antibiotic, however she would have considered it if the WBC count was over 20 thousand. Interview on 06/27/18 at 3:06 P.M., the Director of Nursing (DON) and ADON #31 stated the residents representative called and had questions about what had happened to the surgical incision. She said the surgeon wanted to know how the wound got so big and the way it looked. She had concerns with lack of care. The DON stated she never said the word neglect, but when asked if she was on the conference call she replied she was not on the phone call and did not actually hear what was reported. She further said they did not report the incident. Telephone interview on 06/27/18 5:00 P.M., the friend of Resident #510 stated she really did not know the extent of the wound until she arrived to the hospital and was made aware by Surgeon #439 at the hospital and the social worker (SW) #440. She was informed the plate was sticking out of the incision and how anyone who was visualizing the incision could not identify this was unacceptable. She also said she called the ADON #31 and the Unit Manager (UM) #78 and questioned how the wound got in such terrible shape if the staff were monitoring and looking at this wound. She said he had a scab going on the right lower leg which was scabbed over and then he had a cast on the left leg and when they removed the cast the plate was sticking out of his leg. She said she told them the surgeon said this would have been very noticeable to anyone who was looking at it. She also told her to obtain a lawyer who dealt with neglect and told the facility this wound was not properly taken care of. Telephone interviews on 06/27/18 at 5:30 P.M., a message was left with Surgeon #439 and local hospital SW #440. Interview on 06/28/18 at 7:05 A.M., attempted an interview with the third shift nurse RN #138 who had seen the wound the three nights in a row prior to having his orthopedic follow up appointment on 06/13/18 and UM #78 stated he was able to go home because they had an extra nurse, the phone number was requested at this time. Telephone interview on 06/28/18 at 10:50 A.M., the wound nurse RN #142 stated she went into the note and clarified the description of the dehisced area and she knew it did not look good to go in and change a note but she thought her first documentation looked like the whole wound was open. She said she did not notify the physician or family and was unsure why those boxes were checked. Telephone interview on 06/28/18 at 10:54 A.M., Nurse #138 stated he did not really remember what the incision looked like and he completed treatments right after his evening medication pass or he would complete them with the early morning medication pass just so residents could sleep. He could not remember if he documented a description of the incision when he documented. Interview on 06/28/18 at 6:50 P.M., the Corporate Clinician (CC) #438 and the Administrator stated there was never an allegation of neglect, just some care issues which we investigated as a team and reviewed everything. CC #438 and the Administrator stated this was why we did not report the incident. She further said maybe the surgeon was trying to cover up his mistakes too. Review of the SRI's dated from 06/13/18 to 06/28/18 revealed there was no report made to the state agency of the alleged neglect. Review of the policy titled Abuse, Neglect, Misappropriation of Property revised 11/2016 documented the facility will investigate all allegations of neglect. Facility staff should immediately report all such allegations to the Administrator and to the state agency. Neglect was defined as the failure or the facility, its employees, or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. The Administrator or designee will notify the STATE AGENCY of all alleged violations involving abuse, neglect, mistreatment of a resident, exploitation or misappropriation of resident property as soon as possible but no later than 24 hours from the time the incident/allegation was made known to a staff member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, medical record review and review of facility policy, the facility failed to provide audiology services to a resident. This affected one (#6) out of two residents reviewed for hearing/vision services. The facility census was 159. Findings include: Review of medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including dementia, pseudobulbar affect, cataracts, asthma, and bilateral hearing loss. Review of the Minimum Data Set(MDS) completed 06/15/18 revealed Resident #6 is moderately cognitively impaired, has minimal difficulty hearing loss, and requires extensive assistance with bed mobility, dressing, eating, toileting, limited assistance with personal hygiene, and is totally dependent with locomotion and bathing. Review of MDS mood scale revealed Resident #6 has mild depression. Review of the medical record was silent of verification Resident #6 had been seen by audiology services since admission. Further review of medical record revealed a physician order dated 01/10/18 stating Resident #6 may be seen by ancillary services including audiologist. Observation on 06/25/18 at 11:00 A.M. staff was observed yelling in the ear of Resident #6 in order for him to hear her. Interview conducted on 06/27/18 at 7:52 A.M. Registered Nurse Supervisor (RN) #427 stated she was able to find verification in the medical record where Resident #6 declined seeing the dentist, however she was unable to find any verification were Resident #6 was offered or seen audiology services since admission. RN #427 stated there were no consults noted in either the hard chart or electronic health record. RN #427 stated Resident #6 does not have any hearing aids that she is aware of. Observation and interview conducted on 06/27/18 at 2:30 P.M. Resident #6 was observed sitting in wheelchair in lounge room. During interview Resident #6 did not have hearing aids noted, and surveyor had to speak to resident at elevated voice for him to understand. Resident #6 stated he had hearing aides 20 years ago and they continuously buzzed in his ears, so he couldn't wear them. Resident #6 stated he has not had hearing aides since then, and no one in the facility has offered for him to see an audiologist to get hearing aids. Resident states he is not interested in seeing the dentist, however he would like to see about hearing aides if they are not going to charge him a lot of money, and he is sure the hearing aids have improved a lot in the last 20 years since he had them. Review of the facility policy Ancillary Services Coordinator revised on 11/2017 revealed the nursing staff will speak to the resident and/or their family as needed for approval after obtaining a physician order for ancillary services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a staff statement and resident, physician assistant and staff interview, the facility failed to ensure a resident received the appropriate amount of assistance to prevent a fall and that a fall was thoroughly investigated. This affected two Residents (#42 and #102) out of seven Residents reviewed for falls. The facility census was 159. Findings included: 1. Record review revealed Resident #102 was admitted to the facility on [DATE]. Her diagnoses included intellectual disabilities, muscle weakness, malaise, diaphragmatic hernia, abdominal pain, pain in the knee, insomnia, hyperlipidemia, major depressive disorder, constipation, urinary incontinence, obstructive sleep apnea, gastro-esophageal reflux disease, heart failure, epilepsy, hypothyroidism, anemia, psoriasis, psychosis, and osteoarthritis. She had a modification of the annual Minimum Data Set (MDS) assessment completed on 04/04/18. She had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating she had moderate cognitive impairment. She needed extensive assist of two staff for bed mobility, transfer, and toilet use. She did not walk. She needed extensive assist of one staff for locomotion, dressing, eating and bathing. She needed supervision and set up for personal hygiene. She had not had any falls since the prior assessment. She had a care plan addressing her risk for falls related to side effects of medications, poor communication/comprehension, seizure disorder, osteoarthritis, and incontinence. On 04/28/18 she had a fall risk assessment completed. She was assessed to be at increased risk for falls. Her score was 18 (a resident who scored 10 or higher was at risk). She had a post fall assessment and scored 21 on 05/20/18. Record review revealed on 05/20/18 there was an occurrence progress note for falls. It indicated on 05/20/18 at 5:00 A.M. a State Tested Nursing Assistant (STNA) notified nursing that Resident #10 had fallen to the ground during incontinence care. The STNA stated the resident pulled on the curtain during repositioning leading her to fall onto the ground. The resident was found to be lying on her right side. The STNA stated she fell on her side and did not hit head. The STNA was educated that the resident was a two person assist on the [NAME]. On 06/27/18 at 4:20 P.M. an interview was conducted with the Director of Nursing (DON). She indicated on 05/20/18 the STNA notified the nurse that the resident had fallen. The STNA was repositioning her in the bed and she pulled on the curtain and rolled off the bed landing on her right side. The STNA said she landed on her right side but did not hit her head. The nurse assessed her and she had some right shoulder pain. She was assisted back to bed via Hoyer lift. The doctor was called and a stat (immediate) x-ray of the shoulder was ordered and was negative. Her vital signs were stable and her range of motion was in normal limits. The new intervention was staff education to use a two person assist all the time. She indicated the resident was a one to two person assist for bed mobility. A statement was obtained from STNA #450 on 05/20/18. It indicated he had the resident roll from her left side to right side. When she rolled to her right side, she grabbed the curtain and pulled herself off the bed and the resident fell on to her right side. The resident did not hit her head. The resident landed on her shoulder and complained of shoulder pain. He indicated he ran and got the nurse who assessed the resident, did vitals, and then was hoyered up by himself, and five other staff. She was then put into bed. 2. Clinical record review revealed Resident #42 was admitted to the facility on [DATE] diagnosis included orthopedic care follow up after left below knee amputation (BKA), diabetes, dialysis, anxiety, major depression and end stage kidney disease. Review of the minimum data set (MDS) quarterly assessment dated [DATE] revealed Resident #42 required extensive assistance of two plus staff for toilet and transfer. Review of the comprehensive MDS assessment dated [DATE] revealed he had intact cognition, does not reject care, required extensive assistance of one staff for transfer and toileting. Review of the nurse notes dated 05/21/18 documented Licensed Practical Nurse (LPN) #116 was placing the stocking onto the residents left stump when he became impatient and wanted to use the urinal before the nurse was completed with placing his cast on. Interrupting her and moving away from the cast he stood up on his right leg and stated he needed to urinate while standing and demanded LPN #116 give him his urinal. While he was balancing himself on his right leg and his left stump balancing on his locked wheelchair resident was very unsteady while she stood next to him. Resident suddenly leaned backwards and plopped himself onto the bed. His buttocks and back were completely on the bed. Looking at his left stump she noticed he was bleeding through the stockings which were placed on his left stump. When she pulled the stocking off his wound incision had dehisced. She immediately put pressure to stop the bleeding, placed steri-strips to close the incision, placed adaptic and gauze to cover the wound taped closed and Called the doctor. Review of the Interdisciplinary team (IDT) note dated 05/21/18 revealed Resident #42 had a witnessed fall and lost his balance in the presence of the nurse. Interview on 06/25/18 at 4:42 P.M., Resident #42 stated he had fallen and had to be sent out to have his stump wound closed again. He said LPN #116 was putting his stocking on his stump when he asked her to go to the bathroom. He said LPN #116 said he could wait and he could not wait so he stood up to use the urinal and lost his balance and fell to the floor. He said no one ever asked him what happened and he knew LPN #116 said he did not even fall, he only fell back to his wheelchair. He said his wound opened up in the process and she was not even holding on to me. Interview on 06/27/18 at 12:15 P.M., the Physician Assistant (PA) #437 said Resident #42 was very non compliant with care but she was unsure of what had happened with his stump incision when it had re-opened but she knew it involved LPN #116. Interview on 06/27/18 at 3:44 P.M., LPN #116 stated he kept telling everyone he fell, she was there and she had a hold of his arm, she had the stocking half way on and the resident asked her to use the urinal and she said okay and she was standing right next to him. She said he placed his stump on the wheelchair and he slipped while she was standing right by him onto the bed. She said State Tested Nursing Assistant (STNA) #178 was behind the curtain taking care of his roommate and she heard the sound and came over and she stated again the resident never fell. Interview on 06/27/18 at 4:21 P.M., the Director of Nursing (DON) was looking for a fall investigation and she said the IDT considered this a fall, but they had not interviewed anyone due to it being a witnessed fall. Interview on 06/27/18 at 5:41 P.M., the DON stated she had just talked with LPN #116 today and she said Resident #42 never hit the floor or his stump and she also said STNA #178 was in the room. She also said she only had the IDT note as the facilities investigation. Interview on 06/28/18 at 6:50 P.M., the Corporate Clinician #438 and the Administrator stated the IDT note is the investigation they did not need to interview anyone else because it was a witnessed fall.

Based on record review and staff interviews, the facility failed to maintain resident fund accounts free of charges to the accounts. This affected 14 (#95, #102, #58, #142, #5, #364, #97, #107, #11, #37, #73, #143, #76 and #30) of 14 resident fund accounts managed by the facility. Facility census was 159. Findings include: 1. Review of resident fund account for Resident # 95, revealed a charge of $6.36 dated 09/13/17 for Safeguard Check Reorder. 2. Review of resident fund account for Resident # 102, revealed a charge of $6.36 dated 09/13/17 for Safeguard Check Reorder. 3. Review of resident fund account for Resident # 58, revealed a charge of $6.36 dated 09/13/17 for Safeguard Check Reorder. 4. Review of resident fund account for Resident #142, revealed a charge of $6.36 dated 09/13/17 for Safeguard Check Reorder. 5. Review of resident fund account for Resident #5, revealed a charge of $6.36 dated 09/13/17 for Safeguard Check Reorder. 6. Review of resident fund account for Resident #364, revealed a charge of $6.36 dated 09/13/17 for Safeguard Check Reorder. 7. Review of resident fund account for Resident #97, revealed a charge of $6.36 dated 09/13/17 for Safeguard Check Reorder. 8. Review of resident fund account for Resident #107, revealed a charge of $6.36 dated 09/13/17 for Safeguard Check Reorder. 9. Review of resident fund account for Resident #11, revealed a charge of $6.36 dated 09/13/17 for Safeguard Check Reorder. 10. Review of resident fund account for Resident #37, revealed a charge of $6.36 dated 09/13/17 for Safeguard Check Reorder. 11. Review of resident fund account for Resident #73, revealed a charge of $6.36 dated 09/13/17 for Safeguard Check Reorder. 12. Review of resident fund account for Resident #143, revealed a charge of $6.36 dated 09/13/17 for Safeguard Check Reorder. 13. Review of resident fund account for Resident #76, revealed a charge of $6.37 dated 09/13/17 for Safeguard Check Reorder. 14. Review of resident fund account for Resident #30, revealed a charge of $6.36 dated 09/13/17 for Safeguard Check Reorder. On 06/28/18 at 2:45 P.M., an interview with Business Office Coordinator #32 confirmed checks were ordered to pay resident personal liability to the facility and the charge was divided between the resident fund accounts. It was revealed $6.36 was charged to each account and $6.37 was charged to Resident #76's fund account.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure medication was maintained in locked storage area. This had the potential to affect four cognitively impaired mobile Residents (#11, #16, #91 and #135) residing in the 200 hall. The facility census was 157. Findings include: 1. Review of medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including dementia, hypertension, an osteoarthritis. Review of the Minimum Data Set(MDS) completed 04/02/18 revealed Resident #11 is moderately cognitively impaired and uses a walker or wheelchair for mobility. 2. Review of medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including dementia, altered mental status, and heart failure. Review of the MDS completed 04/04/18 revealed Resident #16 is moderately cognitively impaired and uses a walker for mobility. 3. Review of the medical record revealed Resident #91 was admitted to the facility on [DATE] with diagnose including metabolic encephalopathy, altered mental status, Alzheimer's, hypertension. Review of the MDS completed 06/12/18 revealed Resident #16 is severely cognitively impaired and uses wheelchair for mobility. 4. Review of the medical record revealed Resident #135 was admitted to the facility on [DATE] with diagnoses including type two diabetes, age related cognitive decline, and hypertension. Review of the MDS dated [DATE] revealed Resident #135 is moderately cognitively impaired and uses a cane for mobility. Observation at 10:10 A.M. while walking down 200 hall surveyor observed storage room door was not fully not closed. Surveyor then opened storage room and revealed multiple medications including, but not limited to, vitamins (B-6, C, B-12, D, E, and B 1), multivitamins, magnesium, aspirin, antacids, Ibuprofen, Mucinex, gas ban, hemorrhoid cream, folic acid, Melatonin, iron, and Miramax. Also noted was antifungal creams noted for external use only, and numerous syringes, in different sizes. Interview conducted on 06/27/18 at 10:10 A.M. Licensed Practical Nurse (LPN) #110 verified the door was unattended and open to storage room containing medications and syringes. LPN #110 verified door should be locked at all times. The facility confirmed Resident #11, #16, #91 and #135 are cognitively impaired and independently mobile and could potentially be affected by the unattended medication storage concern. Review of the facility policy Medication Storage dated 01/18 revealed medications and biological's are to be securely stored in locked medication rooms that is inaccessible by residents and visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based medical record review, observation, and staff interview the facility failed to provide wound care treatment in a in a sanitary manner affecting one (#37) out of the five residents reviewed for pressure ulcers during the survey. The facility census was 159. Findings include:1. Review of medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including Parkinson's, seizures, heart failure, and type two diabetes. Review of the Minimum Data Set(MDS) completed 04/12/18 revealed Resident #37 is cognitively intact with no behaviors noted. Resident #37 requires extensive assistance with bed mobility, transfer, dressing, toileting, personal hygiene, and limited assistance with eating. MDS revealed Resident #37 has one noted stage two pressure ulcer noted from 04/02/18 with epithelial tissue affected, documented at Moisture associated skin damage no dressing or wounds to feet noted. Interview conducted on 06/25/18 at 1:21 P.M. Resident #37 stated she has a pressure area noted on her coccyx, and left heel. Resident #37 stated the staff put medicine on them and wrap them. During observation and interview conducted on 6/28/18 at 10:15 A.M. Licensed Practical Nurse's(LPN) #76 and #78 were observed providing wound care and dressing changes for Resident #37. During observation LPN #78 was observed pulling a pair of scissors out her scrubs pocket, noted to also contain tape and pens, handing them to LPN #76 whom cut an old gauze dressing off of Resident #37's left heal area. LPN #76 was then noted putting the dirty scissors on the table with the clean dressings. The old dressing was noted to contain scant amounts of dried serosanguinous fluids, was disposed of in the trash bag located next to the residents. LPN #76 was noted then performing hand hygiene and donning new gloves, picking up the clean puracol plus wound dressing, measuring it for size around the heal wound, and then grabbing the dirty scissors off the table and cutting the clean dressing to fit the wound. LPN #76 was then attempting to put the dressing on Resident #37's heel, when the surveyor asked the staff members of breach in infection control. LPN #78 then stated she had cleaned the scissors prior to putting them in her pocket. LPN #78 was then noted going out to the hall and obtaining new dressings, performing hand hygiene, and appropriately cleaning scissors and table area. LPN #76 then completed the dressing change, wrapped and dated the new clean dressing.