**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to ensure documentation for medication administration was completed timely. This affected one resident (#10) out of three resident records reviewed for medication administration. The facility census was 38.Findings include:Review of the medical record for Resident #10 revealed an admission date of 03/13/25. Diagnoses included but were not limited to osteomyelitis of vertebra sacral and sacrococcygeal region, chronic osteomyelitis, injury at T7 - T12 thoracic spinal cord, sepsis, and paraplegia.Review of the quarterly MDS dated [DATE] revealed Resident #10 had intact cognition. Review of Resident #10's Medication Administration Record (MAR) in the electronic medical record for July 2025 revealed Cymbalta DR Particles 30 milligram (mg) give 1 capsule daily had blank spot not signed for (indicating the medication had not been received) for 7/16/25. Melatonin 3 mg give 1 tablet daily had a blank spot for 7/10/25 and 7/16/25. Bactrim Double Strength, (DS) 800-180 mg 1 tablet every 12 hours was not signed as being administered on 7/16/25. Ferrous Sulfate 325 mg 1 tablet two times a day (BID) was not signed as administered on 7/16/25. Glycolax powder give 17 gram BID was not signed as administered on 7/16/25. Omeprazole 20 mg give BID was not signed as administered on 7/16/25. Proheal liquid protein 30 milliliter (ml) BID was not signed as administered on 7/16/25. Baclofen 10 mg three times a day (TID) did not have the evening dose signed as administered, and Buprenorphine HCI-Naloxone HCI sublingual give 8-2 mg sublingually TID did not have the evening dose signed as administered. Review of Resident #10's printed MAR dated July 2025, provided by the facility, revealed the corresponding blank spaces identified in Resident #10's electronic medical record had manual initials written into the dates on which there were blank spaces. Review of Resident #10's MAR in the electronic medical record for August 2025 revealed Ceftazidime one gram (gm) intravenous every 8 hours had a blank space indicating the medication had not been administered on 08/04/25 or 08/06/25. Buprenorphine HCI-Naloxone HCI sublingual give 8-2 mg sublingually TID was not signed as administered on 08/04/25, 08/06/25, 08/13/25, 08/15/25, 08/23/25, and 08/27/25. Baclofen 10 mg TID was not signed as administered on 08/04/25, 08/06/25, 08/13/25, 08/15/25, 08/23/25, 08/24/25, or 08/27/25. Senna 8.6 mg give 1 tablet daily was not recorded as administered on 08/06/25, 08/23/25, or 08/24/25. Ascorbic Acid 500 mg 1 tablet daily was not recorded as administered on 08/06/25, 08/23/25, and 08/24/25. Glycolax powder give 17 gram BID was not recorded as administered on 08/06/25, 08/13/25, 08/23/25, and 08/24/25. Lactobacillus give 1 tablet daily was not recorded as administered on 08/06/25, 08/23/25, or 08/24/25. Ferrous Sulfate 325 mg give 1 tablet BID was not recorded as administered on 08/06/25, 08/13/25, 08/23/25, or 08/24/25. Folic Acid 1 mg give 1 mg was not recorded as administered on 08/06/25, 08/23/25, or 08/24/25. Multivitamin 1 tablet daily was not recorded as administered on 08/06/25, 08/23/25, or 08/24/25. Docusate Sodium 100 mg give one capsule daily was not recorded as administered on 08/13/25. Cymbalta DR 30 mg one capsule daily was not recorded as administered on 08/13/25. Review of the time stamped MARS for August 2025 for Resident #10 revealed the corresponding blank spaces identified in Resident #10's electronic medical record was electronically signed on 09/04/25. Interview on 09/04/25 at 12:05 P.M. with Assistant Director of Nursing (ADON) #100 confirmed medications are to be signed off immediately after they are administered to residents and are to be recorded in each resident's electronic medical record. ADON #100 confirmed Resident #10 had many blank spots where the nurse was to initial as given. Interview on 09/04/25 at 2:43 P.M. with Regional Nurse #200 revealed for Resident #10, she manually signed off the July 2025 MARS for the 3 staff after she called them and they reported they gave the medications to Resident #10 and forgot to sign the MARS off. Interview on 09/08/25 at 9:45 A.M. with the Director of Nursing (DON) revealed on 09/04/25 she, ADON #100, or Regional Nurse #200 checked with staff in the building or via phone to verify if medications had been administered to Resident #10 for the instances where the spaces were blank on the July 2025 and August 2025 MARs. The DON confirmed the staff reported they administered the medication but forgot to sign the administrations off on the corresponding MAR.Interview on 09/08/25 at 9:56 A.M. with Licensed Practical Nurse (LPN) #130 revealed she was approached by DON on 09/04/25 regarding not signing off medications. LPN #135 reported she gave the medications to Resident #10, but forgot to sign the medications off as administered. LPN #135 reported she was at work and signed them off electronically on 09/04/25. Interview on 09/08/25 at 10:05 A.M. with LPN #135 revealed she was approached by DON on 09/04/25 regarding not signing off medications. LPN #135 reported she gave the medications to Resident #10, but forgot to sign the medications off as administered. LPN #135 reported she was at work and signed them off electronically on 09/04/25.Review of the facility policy, Preparation and General Guidelines, revised December 2019, revealed the individual who administers the medication dose records the administration on the resident's EMR/eMar directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/eMAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. Review of facility policy, Documentation - Skilled Note', revised 01/06/25 revealed the policy will have documentation daily per the federal guidelines, and to accurately reflect the resident status on a daily basis for the interdisciplinary team to have available as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy the facility failed to ensure Resident #23's open area to the right inner heel was identified and treated timely and failed to ensure weekly skin assessments were completed as ordered. This affected one resident (Resident #23) out of three residents reviewed for wounds. The facility census was 43. Findings include: Review of Resident #23 medical record revealed an admission date of 04/19/22 and diagnoses included anoxic brain damage, benign intracranial hypertension, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Review of Resident #23's physician orders dated 03/15/24 revealed weekly C1 Health Documentation to be completed one time a day, every Friday for routine care. Review of Resident #23's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had severe cognitive impairment. Resident #23 had no impairment of the upper extremities and impairment on both sides of the lower extremities. Resident #23 used a wheelchair and was dependent for toileting and personal hygiene, dressing, bathing and putting on and taking off footwear. Resident #23 was always incontinent of urine and bowel. Review of Resident #23's care plan dated 04/29/24 included Resident #23 had the potential for alteration in skin integrity related to immobility, incontinence, generalized weakness and other diagnoses. Resident #23 would not develop skin breakdown through the review date. Interventions included braden score quarterly and as needed; transfer bar to bed to enable turning and repositioning and encourage Resident #23 to assist in turning and repositioning. Further review did not reveal an intervention for weekly skin assessments or reporting abnormalities to the physician. Review of Resident #23's C1 Health Documentation and progress notes revealed no evidence of the C1 Health Documentation assessment of the residents skin assessment. Review of Resident #23's C1 Health Documentation dated 05/09/25 revealed new skin issues were not identified. Review of Resident #23's Treatment Administration Record (TAR) dated 05/02/25 and 05/09/25 revealed there was a check mark for weekly C1 Health Documentation assessment to be completed every Friday indicating the assessment was completed. Review of Resident #23's C1 Health Documentation and progress notes revealed no evidence of the C1 Health Documentation assessment of the residents skin assessment. Review of Resident #23's C1 Health Documentation dated 05/09/25 revealed new skin issues were not identified. Review of Resident #23's shower sheets dated 05/04/25, 05/07/25 and 05/11/25 revealed there were no new areas noted. Observation on 05/14/25 at 10:20 A.M. of Resident #23 revealed Certified Nursing Assistant #336 was providing urinary incontinence care. During incontinence care an area to Resident #23's right inner foot was noted. The area was about a one inch by one inch square, the wound bed was dark reddish-brown and looked a little lumpy with clear tissue covering it. CNA #336 stated the area was not a new area, he had seen it before, but if it was new he would tell the nurse. CNA #336 stated the area looked older and he thought the nurses were aware Resident #23 had the open area on her right inner foot and he did not tell a nurse about it. Interview on 05/14/25 at 10:26 A.M. with Licensed Practical Nurse (LPN) #352 confirmed Resident #23 had an open area on the inner right foot. LPN #352 stated she was not sure about the area on Resident #23's foot, it looked old, like it had been there awhile, and walked out of the room and did not notify the nurse assigned to care for Resident #23 about the open area. Interview on 05/14/25 at 11:49 A.M. of LPN #339, LPN #252 and the Director of Nursing (DON) revealed LPN #339 and the DON were not aware Resident #23 had an open area on her right inner foot. LPN #339 was assigned to care for Resident #23 and stated no one told her about Resident #23's open area including CNA #336 and LPN #252. Observation with the DON and LPN #339 on 05/14/25 at 11:49 A.M. of Resident #23's right foot confirmed there was an open area and the wound bed was dark reddish-brown, looked a little lumpy and had a clear coating of tissue covering it. The DON asked Resident #23 how she got the open area and Resident #23 stated she scratched the area. Interview on 05/14/25 at 4:38 P.M. with the DON revealed Clinical Serviec Manager (CSM) #359 went with her to observe Resident #23's foot and Resident #23 was scratching her foot with a tissue and stated her foot itched. The DON stated a treatment was put in place. Observation on 05/15/25 at 9:59 A.M. of Resident #23's open area to the inner heel of the right foot with Wound Nurse Practitioner (WNP) #360 and Assistant Director of Nursing (ADON) #350 revealed WNP #360 stated the area looked like an abrasion. The area was open and the wound bed was reddish-pink. Resident #23 stated the area itched and WNP #360 stated Resident #23's skin definitely needed lotion. The area measured length 2.5 cm, width 3.0 cm and depth was less than 0.1 cm, was 100 percent granulation, with scant drainage. WNP #360 stated the area was a little macerated on the edges and the treatment would include xeroform every other day. Review of Resident #23's wound note dated 05/15/25 at 11:52 A.M. and written by WNP #360 included Resident #23 had a new area on the right medial foot. The wound was an abrasion, 100 percent granulation tissue to the wound bed with scant clear drainage. The periwound had mild maceration. No signs of infection. Plan was to cleanse the wound, pat dry, apply xeroform, cover with clean dry dressing every other day and as needed. Hydroxyzine 25 mg every six house as needed for 14 days for itching. Interview on 05/15/25 at 3:03 P.M. of the Administrator and CSM #359 revealed Resident #23's weekly skin documentation could be either a C1 Health Documentation assessment or a skilled note regarding skin written in the progress notes. Interview on 05/15/25 at 3:50 P.M. of the DON confirmed Resident #23's C1 Health Documentation assessment or a skilled progress note regarding skin assessment was not completed on 05/02/25 but Resident #23's shower sheets on 05/04/25, 05/07/25 and 05/11/25 did not have new areas on skin noted. Review of the facility policy titled Skin Care Management undated included Residents admitted to the facility would be assessed for potential risk of skin breakdown utilizing the Braden Scale. Based on the assessment a plan of care would be developed, Resident's skin would be visualized with care daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy the facility failed to ensure Resident #8 had comprehensive assessments of her dialysis access site post dialysis treatments. This affected one resident (Resident #8) of one resident reviewed for dialysis.Findings include:Review of Resident #8's medical record revealed an admission date of 02/06/25 and diagnoses included type two diabetes mellitus with diabetic neuropathy, paroxysmal atrial fibrillation, supraventicular tachycardia, and dependence on renal dialysis.Review of Resident #8's Dialysis Communication Forms dated 02/28/25 through 05/09/25 did not reveal evidence of immediate monitoring and documentation of the status of the Resident #8's access site upon return from the dialysis treatment to observe for bleeding or other complications. Review of Resident #8's care plan dated 02/13/25 included Resident #8 had renal failure related to ESRD (End Stage Renal Disease) with hemodialysis. Resident #8 would be kept comfortable in the presence of changing symptoms related to renal failure. Interventions included to notify the physician if Resident #8 presented with shunt problems including no bruit or thrill, bleeding, signs and symptoms of infection at port site. Review of Resident #8's physician orders dated 04/05/25 at 3:20 P.M. revealed Dialysis, complete and lock the LOA (leave of absence)/Dialysis Assessment and Dialysis Communication forms before and after dialysis. Print and send with patient to dialysis, one time a day every Monday, Wednesday and Friday. Further review revealed dialysis shunt assessment every shift, assess bruit, thrill and signs of infection, document abnormal findings, and report to dialysis center and the Nephrologist. If bleeding noted, apply pressure for 15 minutes, if bleeding continues, call 911 and notify the doctor. Review of Resident #8's physician orders dated 04/07/25 at 11:13 A.M. revealed Dialysis every Monday, Wednesday and Friday at 12:25 P.M. to 3:40 P.M. at a local Dialysis Center.Review of Resident #8's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact. Resident #8 had no impairment of her upper and lower extremities. Resident #8 used a wheelchair. Resident #8 required substantial to maximal assistance for toileting hygiene and bathing and partial to moderate assistance with dressing and personal hygiene.Interview on 05/13/25 at 2:27 P.M. of the Director of Nursing (DON) revealed Resident #8 rescheduled her dialysis for today. The DON stated the Dialysis Communication Form was completed by the nurses and sent with Resident #8 to dialysis, and when Resident #8 returned the Communication Form was placed in Resident #8's dialysis binder. Observation on 05/13/25 at 2:27 P.M. revealed Resident #8 was sitting in a wheelchair by the main entrance. Resident #8 stated she rescheduled her dialysis for today (Tuesday) because she was tired and not feeling well yesterday when it was scheduled.Interview on 05/13/25 at 3:26 P.M. of the DON and Clinical Service Manager (CSM) #359 confirmed Resident #8's Dialysis Communication Form included documentation before dialysis and during dialysis, but there was no documentation on the form immediately after Resident #8 returned to the facility including if there was bleeding or other complications from the dialysis access site. The DON stated the nurses were checking Resident #8's shunt sometime during the shift after she returned from dialysis, and that covered what they need to evaluate when Resident #8 returned to the facility. The DON indicated there was an order to check Resident #8's dialysis shunt every shift and assess bruit, thrill and signs of infection. The DON confirmed there was no evidence Resident #8's dialysis shunt was evaluated immediately upon her return to the facility from dialysis for bleeding and other complications.Interview on 05/13/25 at 4:35 P.M. of the Administrator confirmed there was no evidence of immediate monitoring and documentation of the status of the Resident #8's access site upon return from the dialysis treatment to observe for bleeding or other complications. Review of the facility policy titled Dialysis Communication undated included nursing would complete the Dialysis Communication Form each time the resident had dialysis. The Dialysis Communication Form would be completed via the Residents electronic record or in the Residents hard chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Resident #4 was free from significant medication error. This affected one resident (Resident #4) of one resident reviewed for significant medication administration. The facility census was 43. Findings include: Review of Resident #4's medical record revealed an admission date of 01/09/25 with diagnoses including paroxysmal atrial fibrillation, pneumonia and chronic diastolic (congestive) heart failure. Review of the physician's orders revealed the resident had an order for Flecainide Acetate 50 milligrams twice a day. Flecainide acetate, sold under the brand name Tambocor is an antiarrhythmic drug used to treat certain types of abnormal heart rhythms. Review of Resident #4's care plan dated 01/12/25 included Resident #4 was at risk for decreased cardiac output and abnormal lab values related to congestive heart failure (CHF), shortness of breath, myocardial infarction, history of vascular bypass and other diagnoses. The goal developed was for Resident #4 to be kept comfortable in the presence of cardiac symptoms. Interventions included to follow up with Resident #4's cardiologist with any change in condition; give medications per physician order; monitor for signs and symptoms of heart failure, dyspnea, shortness of breath, change in mental status, complaints of chest pain and increased edema. Review of Resident #4's Medication Administration Audit Report revealed Flecainide Acetate oral tablet 50 mg was due on 03/11/25 at 8:00 P.M. However, the medication was not administered. Review of Resident #4's On Call Nurse Practitioner Note dated 03/11/25 at 11:30 P.M. included Flecainide Acetate oral tablet 50 mg was not available the last two nights and the pharmacy was not called to find out why. Heart rate 68. The treatment plan was to call the pharmacy and check on Resident #4's medication and call back with an update (may need PA). Cardiology needed updated. The note indicated Resident #4 was treated in house. The note did not clarify or provide any additional information as to what treated in house meant. Review of Resident #4's late entry progress note dated 03/12/25 at 9:59 P.M. revealed on 03/11/25 at 9:58 P.M. Resident #4's medications could not be found. Resident #4's physician services were notified. Pharmacy was contacted and stated the medication was sent to the facility on [DATE] and a replacement card could be sent with prior payment. Resident #4's medication could not be reordered by this nurse, the supervisor was notified, and the nurse would continue to try and locate the medication. Review of Resident #4's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #4 was cognitively intact. Resident #4 used a walker and required partial to moderate staff assistance with lower body dressing and bathing and required supervision or touching assistance for toileting hygiene. Observation on 05/12/25 at 12:24 P.M. of Resident #4 revealed she was sitting in a chair by her bed. At the time of the observation, interview with Resident #4 revealed she had a heart attack and pneumonia when she was at a different facility and came to live at this facility in 01/2025. Resident #4 stated she went back to the hospital in 03/2025 because I had something wrong with my lungs. Resident #4 could not remember additional details of her hospital admission. Interview on 05/14/25 at 2:42 P.M. of LPN #328 revealed she remembered looking for Resident #4's Flecainide Acetate, could not find it in the medication cart and was unable to administer it to her. LPN #328 stated she did not administer the Flecainide Acetate to Resident #4 but could not remember what day(s) she was unable to administer it. LPN #328 stated she could not remember if she called Resident #4's cardiology service, but stated she probably called the resident's primary care physician but was not sure. LPN #328 stated Resident #4's Flecainide Acetate was eventually found in a really inconspicuous place in the med cart drawer. LPN #328 indicated she did not remember Resident #4 having any issues like chest pain, irregular heart rate as a result of the missed dose. Interview on 05/14/25 at 3:29 P.M. with Nurse Practitioner (NP) #400 confirmed Resident #4 had an order for Flecainide Acetate. The NP revealed it was an important medication and should be taken every 12 hours, two times a day but felt that missing one dose would be OK. If additional doses were missed, it could possibly cause chest pain and irregular heart rate. Interview on 05/15/25 at 9:19 A.M. with the Director of Nursing (DON) revealed the facility did not need to follow up with cardiology because the medication was found on 03/12/25. Interview on 05/15/25 at 10:36 A.M. with the DON and Administrator revealed they counted the doses given from the card and determined Resident #4 had missed a dose of Flecainide (as noted above on 03/11/25), they indicated the NP note was incorrect (reflecting two doses were missed). The medication was not administered as ordered on 03/11/25 on second shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy the facility failed to ensure appropriate infection control practices were implemented during Resident #10's medication administration and Resident #23's incontinence care. This affected one resident (Resident #10) of five residents reviewed for medication administration and one resident (Resident #23) of one resident reviewed for incontinence care. Findings include: 1. Review of Resident #10's medical record revealed an admission date of organ-limited amyloidosis, vascular dementia, and acute kidney failure. Observation on 05/14/25 at 8:02 A.M. of Licensed Practical Nurse (LPN) #339 revealed she prepared Resident #10's medications, placed them in a small plastic cup, and walked into his room to administer the medications to him. Resident #10 was sitting on the edge of his bed, LPN #339 handed him the plastic cup and a cup of water and as Resident #10 was putting the pills in his mouth he dropped two of the pills on the floor. LPN #339 picked the two medications off the floor with her bare hands, discarded the pills in a container hanging on the side of the medication cart, and opened the medication cart drawer to find Resident #10's medications and replace the dropped pills. LPN #339 did not wash her hands or use hand sanitizer after picking the pills off the floor and discarding them. LPN #339 did not wash her hands or use hand sanitizer before opening the medication cart drawer to find the replacement pills. LPN #339 administered the replacement pills to Resident #10 and did not use hand sanitizer or wash her hands before administering Resident #10 the medications. Interview on 05/14/25 at 8:05 A.M. of LPN #339 confirmed she did not wash her hands or use hand sanitizer after she picked Resident #10's pills off the floor and discarded them. LPN #339 confirmed she did not wash her hands or use hand sanitizer before opening the medication cart and preparing Resident #10's replacement medications, or before administering the medications to Resident #10. 2. Review of Resident #23 medical record revealed an admission date of 04/19/22 and diagnoses included anoxic brain damage, benign intracranial hypertension, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Review of Resident #23's care plan dated 04/29/24 included Resident #23 had the potential for alteration in skin integrity related to immobility, incontinence, generalized weakness and other diagnoses. Resident #23 would not develop skin breakdown through the review date. Interventions included braden score quarterly and as needed; transfer bar to bed to enable turning and repositioning and encourage Resident #23 to assist in turning and repositioning. Further review did not reveal an intervention for weekly skin assessments or reporting abnormalities to the physician. Review of Resident #23's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 had severe cognitive impairment. Resident #23 had no impairment of the upper extremities and impairment on both sides of the lower extremities. Resident #23 used a wheelchair and was dependent for toileting and personal hygiene, dressing, bathing and putting on and taking off footwear. Resident #23 was always incontinent of urine and bowel. Observation on 05/14/25 at 10:20 A.M. of Resident #23 revealed Certified Nursing Assistant (CNA) #336 was providing incontinence care. CNA #336 threw Resident #23's soiled bed linens, towels, and urine saturated incontinence brief directly on the floor. CNA #336 did not place the soiled items in a plastic bag or appropriate container, but left them lying on the floor during the incontinence care. Interview on 05/14/25 at 10:20 A.M. of CNA #336 confirmed he threw Resident #23's soiled bed linens, towels and her urine soaked incontinence brief on the floor without using a proper container. CNA #336 stated he should not have done that because it could cause cross contamination. Review of the facility policy titled Handwashing-Hand Hygiene undated included all personnel should be trained on the importance of hand hygiene in preventing the transmission of healthcare-associated infection. Hand hygiene was done including before or after direct resident contact, before preparing or handling medications, after handling soiled or used linens, supplies, equipment or utensils.

Based on observation, interview, record review and review of the facility policy the facility failed to ensure a sanitary kitchen. This had the potential to affect all 43 of 43 residents who resided in the facility and received meals. Findings include: Observation on 05/12/25 at 8:05 A.M. of the soap dispenser with Dietary Manager #360 and Dietary Aide #306 revealed it was located above the hand washing station and it did not have soap in it. Dietary Aide #306 stated she would let housekeeping know the soap dispenser needed refilled. Observation on 05/12/25 at 8:07 A.M. of the facility kitchen revealed the floor had dried food bits and multiple dried, dark brown and clear, sticky fluid spills. Observation of metal counters, metal meal carts, metal shelves, doors and sides to the freezer, cooler, and oven revealed they were covered with whitish colored drip marks and what appeared to be dried food and liquid smudges. All the surfaces appeared grubby. Interview on 05/12/25 at 8:07 A.M. of Dietary Aide (DA) #306 and Dietary Manager (DM) #360 confirmed the floor had dried food bits and dried liquid spill marks, the metal counters, doors and sides to the freezer, cooler, and oven revealed they were covered with whitish colored drip marks and what appeared to be dried food and liquid smudges. DA #306 confirmed the surfaces looked grubby, she just arrived for work and could tell no one yesterday did any cleaning. DA #306 stated the staff were young and needed education about cleaning. DM #360 stated he just started working for the facility six days ago and he was trying to get the kitchen in order. DM #360 confirmed the kitchen was not clean, he did not work yesterday and would make sure it was cleaned today. Review of the facility policy titled Food Preparation and Storage undated included the kitchen would be kept neat and orderly, the kitchen surfaces and equipment would be cleaned and sanitized as appropriate.

Based on medical record review, observation, and staff interview, the facility failed to ensure care plans were updated to include new interventions for falls. This affected two (Residents #1 and #29) of three residents reviewed for falls. The facility census was 41 residents. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 10/24/24 with diagnoses including kidney failure, congestive heart failure (CHF), insomnia, muscle weakness and history of stroke. Review of the care plan for Resident #1 dated 10/26/24 revealed the resident was at risk for falls due to an unstable health condition. Interventions included assistance with all transfers and mobility, bed in a low position, call light within reach, and commonly used articles within reach. Review of the Minimum Data Set (MDS) assessment for Resident #1 dated 11/01/24 revealed the resident was moderately cognitively impaired and required setup help for eating, and substantial or maximum assistance for oral hygiene, toileting and personal hygiene. Review of the nurses' note for Resident #1 dated 11/07/24 timed at 2:15 A.M. revealed the resident had an unwitnessed fall from bed at 1:30 A.M. The aide notified the nurse Resident #1 was on the floor with both legs bent on the right side. Resident #1 denied hitting his head and had no complaints of pain. Review of the fall review for Resident #1 dated 11/07/24 revealed new interventions to prevent further falls included placing a mattress to the floor in the resident's room and 30-minute safety checks. Review of the fall care plan for Resident #1 revealed the new fall prevention interventions were not added to the resident's care plan. Observation on 12/16/24 at 8:45 A.M. revealed there was no mattress to the floor in Resident #1's room. Interview on 12/16/24 at 9:49 A.M. with the Director of Nursing (DON) confirmed there was no mattress to the floor of Resident #1's room and the facility had not updated the resident's care to include the mattress to the floor and 30-minute safety checks as recommended by the facility fall review. 2. Review of the medical record for Resident #29 revealed an admission date of 09/16/22 with diagnoses including breast cancer, diabetes, abnormalities in mobility, muscle weakness and history of falling. Review of the physician's orders for Resident #29 revealed an order dated 10/20/23 for non-skid strips to the open side of the resident's bed. Review of the MDS assessment for Resident #29 dated 09/15/24 revealed the resident was cognitively intact and was independent in eating and oral hygiene, required partial to moderate assistance for toileting, and required supervision or touch assistance for showering, dressing and personal hygiene. Review of the care plan for Resident #29 dated 09/15/24 revealed the resident was at risk for falls due to a history of falls, poor safety awareness and unstable health conditions. Interventions included the bed in the lowest position, a sign to remember to call for assistance with transfers, the call light within reach, non-skid socks, assistance with toileting upon rising, after meals at night and as needed, a night light and ensuring commonly used items, such as a walker, were in reach. Review of the nurses' notes for Resident #29 dated 09/19/24 through 12/12/24 revealed documentation of multiple refusals from the resident to wear non-skid socks or to use her call light for assistance. Review of the nurses' note for Resident #29 dated 11/16/24 at 5:39 A.M. revealed the resident had an unwitnessed fall and was found sitting on the floor in her room, at the foot of the bed. Resident #29 said she fell coming out of the bathroom by herself. Review of the fall review for Resident #29 dated 11/16/24 revealed the resident had an unwitnessed fall and was found sitting on the floor in her room, at the foot of the bed. The facility recommended new intervention of adding a tab alarm while in bed. Review of the fall care plan for Resident #29 revealed it was not updated regarding the resident's refusal to wear nonskid socks and to use her call light or with the new interventions of adding a tab alarm while in bed. Interview on 12/16/24 at 8:41 A.M. with the Administrator confirmed the facility had not updated Resident #29's care plan regarding the resident's refusal to use the call light or wear nonskid socks and the use of a bed alarm while in bed. Review of the facility policy titled Comprehensive Care Plans dated 06/08/22 revealed the facility would update resident care plans as needed. Review of the facility policy titled Falls - Clinical Protocol dated 11/30/23 revealed the facility would evaluate and document falls including information related to when and where they happened, and review and revise the care plan as appropriate. This deficiency represents noncompliance investigated under Complaint Number OH00159960.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure fall prevention interventions were implemented. This affected two (Residents #1 and #29) of three reviewed for falls. The facility census was 41 residents. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 10/24/24 with diagnoses including kidney failure, congestive heart failure (CHF), insomnia, muscle weakness and history of stroke. Review of the care plan for Resident #1 dated 10/26/24 revealed the resident was at risk for falls due to an unstable health condition. Interventions included assistance with all transfers and mobility, bed in a low position, call light within reach, and commonly used articles within reach. Review of the Minimum Data Set (MDS) assessment for Resident #1 dated 11/01/24 revealed the resident was moderately cognitively impaired and required setup help for eating, and substantial or maximum assistance for oral hygiene, toileting and personal hygiene. Review of the nurses' note for Resident #1 dated 11/07/24 timed at 2:15 A.M. revealed the resident had an unwitnessed fall from bed at 1:30 A.M. The aide notified the nurse Resident #1 was on the floor with both legs bent on the right side. Resident #1 denied hitting his head and had no complaints of pain. Review of the fall review for Resident #1 dated 11/07/24 revealed new interventions to prevent further falls included placing a mattress to the floor in the resident's room and 30-minute safety checks. Review of the fall care plan for Resident #1 revealed the new fall prevention interventions were not added to the resident's care plan. Observation on 12/16/24 at 8:45 A.M. revealed there was no mattress to the floor in Resident #1's room. Interview on 12/16/24 at 9:49 A.M. with the Director of Nursing (DON) confirmed there was no mattress to the floor of Resident #1's room and the facility had not updated the resident's care plan to include the mattress to the floor and 30-minute safety checks as recommended by the facility fall review. 2. Review of the medical record for Resident #29 revealed an admission date of 09/16/22 with diagnoses including breast cancer, diabetes, abnormalities in mobility, muscle weakness and history of falling. Review of the physician's orders for Resident #29 revealed an order dated 10/20/23 for non-skid strips to the floor to the open side of the resident's bed. Review of the quarterly MDS assessment for Resident #29 dated 09/15/24 revealed the resident was cognitively intact and was independent in eating and oral hygiene, required partial to moderate assistance for toileting, and supervision or touch assistance for showering, dressing and personal hygiene. Review of the care plan dated for Resident #29 dated 09/15/24 revealed the resident was at risk for falls due to a history of falls, poor safety awareness and unstable health conditions. Interventions included the bed in the lowest position, a sign to remember to call for assistance with transfers, the call light within reach, non-skid socks, assistance with toileting upon rising, after meals at night and as needed, a night light and ensuring commonly used items, such as a walker, were in reach. Review of the quarterly fall risk assessment for Resident #29 dated 09/18/24 revealed the resident was at high risk for falls. Observation on 12/12/24 at 11:06 A.M. revealed Resident #29 did not have non-skips strips on the floor to the open side of her bed as ordered by the physician on 10/20/23. Interview on 12/12/24 at 11:07 A.M. with Licensed Practical Nurse (LPN) #200 confirmed Resident #29 was ordered to have non-skid strips to the floor of her room to the open side of the bed, but the strips were not in place. Observation on 12/16/24 at 10:02 A.M. revealed Resident #29 was lying in bed, and her walker was under the television, in the middle of the room and out of the resident's reach. Interview on 12/16/24 at 10:03 A.M. with the Administrator confirmed Resident #29 should have her walker within reach to prevent falls. The Administrator confirmed Resident #29's walker was not within reach. Review of the facility policy titled Falls - Clinical Protocol dated 11/30/23 revealed the facility would evaluate and document falls including information related to when and where they happened. Falls would be identified as a witnessed or unwitnessed events. The facility would attempt to define possible causes and review and revise the care plan as appropriate and implement interventions to prevent further falls. This deficiency represents noncompliance investigated under Complaint Number OH00159960.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure oxygen tubing was changed as ordered. This affected one (Resident #1) of three residents reviewed for oxygen administration. The facility identified three (Residents #1, #7 and #25) who received oxygen. The facility census was 41 residents. Findings include: Review of the medical record for Resident #1 revealed an admission date of 10/24/24 with diagnoses including kidney failure, congestive heart failure (CHF), and history of stroke. Review of the Minimum Data Set (MDS) assessment for Resident #1 dated 11/01/24 revealed the resident was moderately cognitively impaired and required setup help for eating, and substantial or maximum assistance for oral hygiene, toileting and personal hygiene. Review of the care plan for Resident #1 dated 10/26/24 revealed the resident had an ineffective breathing patterns as a result of shortness of breath. Interventions included administering medications and respiratory treatments as ordered, administering oxygen per physician's order and monitoring for signs of shortness of breath. Review of the physician's orders for Resident #1 revealed an order dated 11/20/24 to change oxygen tubing and clean the filter every week. Observation on 12/12/24 at 10:56 A.M. of Resident #1 revealed the oxygen tubing in use was dated 11/21/24. Interview on 12/12/24 at 10:57 A.M. with Registered Nurse (RN) #201 confirmed Resident #1's oxygen tubing was dated 11/21/24. RN #201 confirmed the resident's oxygen tubing should be changed weekly. Review of the facility policy titled Oxygen Administration dated 11/30/23 revealed oxygen would be administered, and tubing, nasal cannulas, and humidifiers would be changed according to the physician's orders. This deficiency is a recite to the survey dated 11/14/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy, the facility did not notify the physician and/or designee regarding Resident #13's change in condition. This affected one resident (#13) out of six residents reviewed for change in condition. The facility census was 40. Findings include: Review of the medical record for Resident #13 revealed an admission date of 10/24/24 with diagnoses including chronic obstructive pulmonary disease (COPD), hypertension, congestive heart failure (CHF), and oxygen dependence. Review of the blood pressures dated from 10/24/24 to 11/07/24 revealed Resident #13's blood pressures included: 10/25/24 it was 130/76, 10/26/24 it was 138/78, 10/27/24 it was 134/76, 10/29/24 it was 106/54, 11/05/24 it was 110/76, and 11/06/24 it was 134/58. There was no documented evidence since admission, 10/24/24, that Resident #13's systolic blood pressure had been below 100. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had impaired cognition. Review of the November 2024 physician orders revealed Resident #13 was to receive the following medications in the morning including: amiodarone hydrochloride (HCL) 200 milligram (mg) tablet by mouth for hypertension, Lasix 20 mg tablet by mouth as a diuretic, Lasix 40 mg tablet by mouth, hydralazine HCL 100 mg tablet by mouth for hypertension, and metoprolol succinate extended release (ER) 50 mg tablet by mouth due to hypertension. There were no parameters listed for any of the above medications to be held. Observation on 11/07/24 at 9:07 A.M. revealed Licensed Practical Nurse (LPN) #604 obtained Resident #13's blood pressure, and it was 72/55. She repositioned Resident #13 and re-took the blood pressure which was 96/56, and his heart rate was 56. She then proceeded to prepare Resident #13's morning medications which included: amiodarone HCL 200 mg tablet, Lasix 20 mg tablet, Lasix 40 mg tablet, hydralazine HCL 100 mg tablet, and metoprolol succinate ER 50 mg tablet. Interview on 11/07/24 at 10:07 A.M. with LPN #604 as she walked into Resident #13's room to administer his medications regarding the amount of blood pressure medications and his current blood pressure; LPN #604 stated she would only hold if his systolic blood pressure was below 90. She revealed his blood pressure was within his normal range, proceeded into his room and administered his medications. Interview on 11/07/24 at 11:44 A.M. with Nurse Practitioner (NP) #661 revealed she had been coming to the facility for approximately three years and was at the facility twice a week. She revealed she was familiar with Resident #13. This surveyor reviewed the above blood pressures and medication regimen with NP #661, and she stated Resident #13's blood pressure was quite low. She would have expected LPN #604 to have contacted the physician and/or herself regarding the low blood pressure, especially with the number and the dosage of medications that he takes that not only can affect his blood pressure but his heart rate as well. She revealed she would have ordered some lab work and orthostatic blood pressures to make sure Resident #13 was not dehydrated. She also revealed she would have ordered to hold his metoprolol succinate ER 50 mg tablet and his hydralazine HCL 100 mg tablet. She would have also requested the nurse complete a full assessment including checking if the resident had complaints of dizziness. Interview on 11/07/24 at 12:57 P.M. with the Director of Nursing (DON) after review of Resident #13's morning blood pressures, history of blood pressures, and medication regimen, she verified LPN #604 should have contacted the physician and/or nurse practitioner prior to administering Resident #13's morning medications, especially due to the number of cardiac medications he was ordered. Review of the facility policy labeled, Change in a Resident's Condition, dated 11/30/23, revealed the facility shall notify the physician of a change in a resident's medical/mental condition. There were no other details in the policy regarding when to notify the physician and/ or what constitutes a change in condition. This deficiency represents non-compliance investigated under Master Complaint Number OH00159487.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of the facility self-report incident (SRI) tracking number (#)253244 and investigation, and review of the facility abuse policy, the facility failed to promptly report an allegation of staff-to-resident sexual abuse to the Ohio Department of Health (ODH), local police department, and physician from 10/04/24 until 10/23/24. This affected one resident (#28) out of six residents reviewed for abuse. The facility census was 40. Findings include: Review of the medical record for Resident #28 revealed an admission date of 08/22/24 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, and spinal stenosis. There was no documentation in the nursing notes from 10/04/24 to 10/23/24 regarding any allegation of staff-to-resident abuse. Review of the care plan dated 08/30/24 revealed Resident #28 had a self-care performance deficit related to fatigue, COPD, and weakness. Interventions included extensive assistance with toileting needs, monitoring for fatigue, and providing rest periods as needed. Review of the witness statement dated 10/04/24 and signed by CNA #602 revealed he was providing incontinence care to Resident #28, and she had a bowel movement and in the process of cleaning her up, she asked CNA #602 to stop as he was not cleaning her correctly. CNA #602 revealed he stopped giving her care, repositioned her in bed and went and got CNA #662. The statement revealed after CNA #662 came into the room, CNA #602 left out of the room and went to provide care to another resident. CNA #602 revealed Resident #28 had never stated she had any issues. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had intact cognition and was dependent on staff assistance with rolling left and right in bed, toileting, hygiene, and transfers. She was always incontinent with urine and bowel. She had no behaviors that were identified. Review of the nursing note dated 10/23/24 at 3:47 P.M. and authored by the Director of Nursing (DON) revealed Resident #28 was interviewed, her chart was reviewed, and Resident #28 denied any psychological and/or psychosocial effects related to the allegation of receiving improper incontinence care. She was joyful and in a pleasant mood and stated she felt safe in the facility. A skin assessment was completed without any findings. Nurse Practitioner (NP) #661 was notified. Review of SRI #253244 dated 10/23/24 revealed the facility filed an allegation of neglect as Former CNA #662 reported that Resident #28 informed her that CNA #602 did not adequately clean her peri area during incontinence care after having a bowel movement. The facility initiated an investigation, and CNA #602 was suspended pending the outcome of the investigation. The SRI revealed Resident #28 denied allegations and that she felt safe and appropriately cared for by the facility. The facility unsubstantiated the allegation. Review of the facility timeline of events dated 10/23/24 and labeled, Timeline of Events- Resident #28- Allegation of Sexual Assault completed by the Administrator revealed on 10/03/24 at approximately 5:00 P.M. (which after clarification with Administrator should have been 10/04/24) Former CNA #662 informed the DON that Resident #28 had stated CNA #602, had used his fingers to wipe her in the front and in the back during incontinence care. The DON notified the Administrator, and they interviewed Resident #28 who stated CNA #602 did not do anything wrong, he just did not clean her up how she liked to be cleaned. Resident #28 asked him to stop and get a female aide. Resident #28 denied sexual abuse, and the facility educated CNA #602 on female hygiene including incontinence care. On 10/23/24, the Administrator was contacted by Regional Director of Operations #667 that Former CNA #662 alleged that a resident was sexually assaulted (resident or perpetrator was not identified) as a male aide stuck his finger in her butt. The timeline revealed an SRI was filed and an investigation was initiated. CNA #602 was suspended pending the investigation. The police were notified on 10/23/24 but due to high call volume, it was unsure when an officer could come. The timeline revealed on 10/25/24 the police arrived and interviewed Resident #28 and CNA #602 with no report filed. Review of the undated Cleveland Division of Police service number 2024-313919 revealed Officer #663 responded. Officer #663 did not file an official report. Interview on 11/07/24 at 10:51 A.M. with Resident #28 revealed a guy (CNA #602) entered her room to clean her up and took his finger and swiped her as she demonstrated by taking her index finger in front of her in a slow manner. She revealed he took his finger across her buttock. She revealed she felt CNA #602's mind was on someone else during the incident as she was not sure what he was thinking. She revealed it was not right how he was doing it as she stated maybe he got into it with his girlfriend or something. She denied that the incident was abusive but stated again, it was not right the way he changed me. She revealed she had reported it because she did not want the same thing to happen to someone else. She had previous male caregivers, and that was not the issue, it was the way he did it. She remained focused during the interview regarding the way he took his finger and swiped her up and down her butt. Interview on 11/07/24 at 3:15 P.M. and 11/13/24 at 11:47 A.M. with Former CNA #662 revealed from 10/03/24 to 10/04/24 she worked 11:00 P.M. to 7:00 A.M. with CNA #602 and CNA #644. During that shift, she had not provided any care for Resident #28, and Resident #28 had not voiced any concerns. She denied that CNA #602 ever came and asked her to provide incontinence care for Resident #28 during that shift. Former CNA #662 revealed she then came back to work on second shift on 10/04/24 and at approximately 3:40 P.M., she had entered Resident #28's room, and Resident #28 asked who the guy was with the yellow hoodie last night. Former CNA #662 asked her what she meant, and Resident #28 stated he took his finger and inserted his finger in her butt and removed it and did it again. Former CNA #662 stated that Resident #28 stated the towel was dry and had no water and he did it twice and when Resident #28 was describing the concern, she held up her middle finger indicating he had used his middle finger. Former CNA #662 revealed Resident #28 stated she had a lot of pressure; it was hurting, and she did not want CNA #602 to take care of her again. Former CNA #662 revealed she immediately reported it to the Administrator and DON and verified she reported exactly what Resident #28 stated word for word. Former CNA #662 revealed she felt it was abuse. She stated that the Administrator and DON did go into Resident #28's room, but she did not feel the incident was thoroughly investigated as CNA #602 was never suspended, and when the Administrator left for the day, she had commented understand some people are miserable. She revealed she was terminated from the facility, and she felt it was a result of reporting the incident because CNA #602 was a relative of the Administrator. She revealed that Former Scheduler/ CNA #664 had also stated Resident #28 reported the incident to her, and she reported the incident. Interview on 11/07/24 at 12:36 P.M. with the Administrator revealed that Former CNA #662 came into the DON's office where she and the DON were present and stated that CNA #602 had not cleaned Resident #28 properly. She revealed that Former CNA #662, DON and herself went into Resident #28's room and believed it was more a concern that CNA #602 was a new aide, and Resident #28 was concerned he did not clean her properly by getting into every, nook and cranny as well as CNA #602 did not feel comfortable cleaning a woman's anatomy. She denied at any time that Resident #28 or Former CNA #662 had communicated any allegation of potential sexual abuse. She revealed Former CNA #662 had never said anything regarding sexual abuse until she was terminated and contacted the corporate office on 10/23/24 stating Resident #28 was sexually assaulted by CNA #602. She revealed she then filed an SRI regarding the allegation that was made on 10/23/24. She verified she had not filed an SRI on 10/04/24 as she did not see it as abuse after speaking with Resident #28. She also verified she had not obtained a witness statement from Former CNA #662 or from Resident #28 except for what was placed in the timeline which was completed on 10/23/24. She did verify CNA #602 was a relative of hers. Interview on 11/07/24 at 12:57 P.M. with the DON revealed on 10/04/24 Former CNA #662 came to her office and said that she was the only one in the office. She verified the Administrator was not in the office at the time Former CNA #662 came to her office. The DON revealed Former CNA #662 stated CNA #602 had used his finger to wipe her: swiping up her buttock and down but stated she could not remember exactly what Former CNA #662 said. The DON revealed she immediately went to speak with Resident #28 because the way it was described by Former CNA #662 it was vulgar but again stated she could not remember the exact wording, but that it sounded off. She revealed Former CNA #662 and herself were in Resident #28's room, and Resident #28 stated he took his finger and stuck it up her butt but when she clarified by asking if she felt sexually assaulted, or violated she denied and instead revealed CNA #602 had not cleaned her properly as he did not get in her butt cheeks. She revealed Resident #28's daughter came in as well, and she got the Administrator, especially because of the verbiage Resident #28 was using and they interviewed her again. She revealed it did not sound good how Resident #28 was describing it as he was swiping his finger up and down her butt but again, she denied abuse and instead it sounded as CNA #602 had not provided proper incontinence care. They provided education to CNA #602. She verified she had not filed an SRI, contacted the police or notified the physician on 10/04/24 as she did not see it as abuse after speaking with Resident #28. She also verified she had not obtained a witness statement from Former CNA #662 or from Resident #28 except what was placed in the timeline, which was completed on 10/23/24. Interview on 11/07/24 at 2:54 P.M. with CNA #602 revealed on 10/04/24 he removed Resident #28's brief, and he completed one wipe using a washcloth across the front of her waistline above her genital area as she was wet from urine. CNA #602 revealed he could not remember if she was incontinent of bowel movement as he had just seen the front of Resident #28. He revealed he never rolled her over or provided any incontinence care to her rectal/buttock area as again he stated he had just wiped one time in the front. He revealed Resident #28 stated she would feel better with a female aide, so he went and got Former CNA #662 who completed the rest of her care. He denied at any time that he was sexually inappropriate or abusive. He revealed he was suspended for two or three days (could not remember the exact dates) as he stated the Administrator stated another aide had made an allegation, but that Resident #28 denied it. He did verify he was related to the Administrator. Interview on 11/07/24 at 3:37 P.M. with Resident #28's daughter revealed she talked with her mother on the morning of 10/04/24, and she said that a gentleman had cleaned her up the previous night. She revealed Resident #28 stated he wiped her kind of weird and she thought it was concerning as she said he wiped her by using two fingers up across her buttocks as she said, he swiped his fingers. She revealed she felt her mother may have used the wrong terminology as when she asked her mother if she felt it was sexual, she stated no, but it felt uncomfortable. She verified she was in the room when the Administrator and DON were questioning her mother, and she shared the same thing that she had on the phone that she did not feel it was sexual, but she did state, I felt it was uncomfortable how he wiped me. Interview on 11/07/24 at 5:00 P.M. with the Administrator and DON verified they had not reported the incident including filing an SRI, contacted the police or notified the physician on 10/04/24 regarding the incident as they stated they did not see it as abuse after speaking with Resident #28. They verified the facility abuse policy revealed the facility was to report all allegations of abuse to ODH and then investigate the allegation. Interview on 11/13/24 at 8:40 A.M. with Former Human Resources (HR)/Payroll #665 revealed she was not directly involved but heard from Former Scheduler/ CNA #664 that Former CNA #662 was upset that she reported an allegation of sexual abuse involving CNA #602 and Resident #28, and it was not investigated because the Administrator was related to CNA #602. She revealed she asked the DON about the incident, and the DON stated, oh we did a soft file on it as they had talked with Resident #28, and CNA #602 had not cleaned her up properly. She revealed in her conversation with Former Scheduler/ CNA #664 it sounded more like an allegation of sexual abuse, and the facility did not report it until Former CNA #662 contacted corporate regarding the allegation. She revealed that was one of the main reasons she resigned, as she felt she should be privy to that information especially when staff feel the situation was being swept under the rug due to CNA #602 being a relative to the Administrator. Interview on 11/13/24 at 9:01 A.M. with Former Scheduler/CNA #664 revealed the morning of 10/04/24 she was working on the floor as there was a staffing shortage, and she was helping out. She revealed on 10/04/24 between 8:30 A.M. and 10:00 A.M. (she could not remember exact time), she was in Resident #28's room, and Resident #28 seemed upset and stated, she never wanted that man to take care of her again. Resident #28 stated CNA #602 rolled her over and took his finger and wiped up her butt crack and then rolled her back over and used his finger up and down the crack of her buttocks. Former Scheduler/CNA #664 revealed Resident #28 stated I am no damn fool; I know the difference between a finger and a towel as she repeated it was something skinny which was how she knew it was his finger. She immediately stopped the resident and went and got the DON. Resident #28 then communicated the same facts to the DON, and the DON questioned Resident #28 to see if she felt harmed or abused, and Resident #28 stated no. Resident #28 told the DON several times that she felt uncomfortable during the incident, and she stated. It ain't right, and I am not dumb. Former Scheduler/CNA #664 revealed she did not feel Resident #28 was conveying to the DON that it was a hygiene issue, but instead felt Resident #28 was reporting how uncomfortable she felt because he used his finger during her care, and that it was not right. Former Scheduler/CNA #664 revealed believed it was possible sexual abuse by the way Resident #28 described it. She heard other staff state Resident #28 shared the same story with them, and she was worried as it felt like the facility did not investigate the incident. She revealed since she was the scheduler, she knew CNA #602 had not been removed from the schedule after she had reported the incident on 10/04/24. She also verified she had not filled out a witness statement regarding the incident that she reported on 10/04/24. Review of the facility policy labeled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated 02/08/24, revealed the facility would immediately report all allegations to the administrator and to the ODH. In cases where a crime was suspected, the administrator would report the incident to the local law enforcement. The policy revealed an alleged violation was a situation or occurrence that was observed or reported by staff, resident, relative or others but has not yet been investigated. The policy revealed all incidents of abuse would be reported immediately. The facility would also report the incident/allegation to the attending physician. The policy revealed once the administrator and ODH were notified, then an investigation of the allegation would be conducted. This deficiency represents non-compliance investigated under Complaint Number OH00159263.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to ensure call lights were within reach. This affected two residents (#33 and #36) out of six residents reviewed for call lights. This had the potential to affect 38 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #24, #25, #26, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, and #40) identified by the facility as capable of utilizing their call light to ring for assistance. The facility census was 40. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 04/09/21 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, and paranoid schizophrenia. Review of the care plan dated 03/13/24 revealed Resident #36 was at risk for falls due to impaired mobility, poor safety awareness, and unstable health condition. Interventions included maintaining her bed in the lowest position and ensuring the call light was within reach when in room. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had intact cognition. She required substantial to maximum staff assist with rolling left and right in bed, and was dependent on staff for transfers, toileting, hygiene, dressing, and personal hygiene. Observation on 11/07/24 at 11:13 A.M. revealed Resident #36 was lying in her bed which was against the window, and there was no call light within reach. Observation revealed Resident #36's call light was on the other bed in her room approximately ten feet away out of reach. Interview on 11/07/24 at 11:13 A.M. with Resident #36 revealed she did utilize her call light to call for staff assistance as she was dependent on staff for most of her care. She verified she was unable to reach her call light. Interview on 11/07/24 at 11:16 A.M. with the Director of Nursing (DON) verified Resident #36's call light was not within reach. 2. Review of the medical record for Resident #33 revealed an admission date of 10/22/24 with diagnoses including arthritis and hypertension. Review of the care plan dated 10/29/24 revealed Resident #33 was at risk for falls related to impaired mobility and pain. Interventions included providing assistance with transfers, maintaining her bed in the lowest position, and ensuring her call light accessible when she was in her room. Review of the admission MDS assessment dated [DATE] revealed Resident #33 had intact cognition. She had impairment on both her upper and lower extremities. She required staff assistance with her activities of daily living including dressing, toileting, hygiene, and rolling left and right in bed. Observation on 11/07/24 at 1:29 P.M. revealed Resident #33 was lying in her bed, and her call light was on her night stand out of reach. Interview on 11/07/24 at 1:29 P.M. with Resident #33 revealed she was unable to reach her call light and stated, the lady moved my call light and did not put it back. Interview on 11/07/24 at 1:31 P.M. with Certified Nursing Assistant (CNA) #618 verified Resident #33's call light was on her night stand out of reach. Interview on 11/23/24 at 1:00 P.M. with the DON revealed all residents residing in the facility were able to utilize their call light to ring for assistance except Residents #21 and #27 due to their cognitive ability. Review of the facility policy labeled, Call Light, Use Of, dated 11/30/23, revealed staff were to be sure call lights were always placed within reach of the resident. This deficiency represents non-compliance investigated under Master Complaint Number OH00159487.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure oxygen was being administered according to physician orders and failed to ensure there was appropriate signage indicating oxygen was in use. This affected one resident (#13) out of two residents reviewed for oxygen use. This had the potential to affect six additional residents (#15, #20, #21, #24, #28, and #38) identified by the facility with an order for oxygen. The facility census was 40. Findings include: Review of the medical record for Resident #13 revealed an admission date of 10/24/24 with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and dependence of oxygen. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had impaired cognition and received oxygen therapy. Review of the November 2024 physician orders revealed Resident #13 had a current order for three liters per minute of continuous oxygen due to shortness of breath. Review of the care plan dated 11/07/24 revealed Resident #13 had ineffective breathing patterns as evidenced by shortness of breath, labored respirations, and COPD. Interventions included administering oxygen per physician order, keeping the head of the bed elevated, monitoring respiration rate and depth, breathing sounds and reporting any abnormal findings. Observation on 11/07/24 at 9:07 A.M. revealed Resident #13 had an oxygen concentrator as well as one green oxygen e-cylinder tank (high pressure oxygen stored in a cylinder) secured in a portable oxygen holder in his room. Observation revealed Resident #13 was receiving oxygen per nasal cannula at 4.5 liters per minute that was connected to his oxygen concentrator. There was no signage outside of his room that indicated he had oxygen in use. Observation on 11/07/24 at 9:12 A.M. revealed Licensed Practical Nurse (LPN) #604 removed the green oxygen e-cylinder from Resident #13's room and placed it in a room labeled, Central Supply behind the entry door. In the room there were four empty oxygen e-cylinders and one other e-cylinder that was approximately one third full of oxygen. There was no signage outside the central supply that indicated the room contained oxygen. Interview on 11/07/24 at 10:10 A.M. with LPN #604 verified Resident #13's room did not have a sign on the outside of his room indicating he had oxygen in use. She also verified there was no sign on the central supply room that she had placed Resident #13's oxygen e-cylinder that was one third full of oxygen behind the entry door as well as contained five other oxygen e-cylinders. LPN #604 revealed the primary oxygen storage was outside in a shed, but they also stored oxygen in the central supply room. She verified Resident #13 was receiving 4.5 liters of oxygen per minute per nasal cannula. Interview on 11/07/24 at 12:57 P.M. with the Director of Nursing (DON) verified Resident #13 had an order for three liters of continuous oxygen per minute and not 4.5 liters. She also revealed the facility utilized an outside storage shed to store oxygen, and she did not know that staff were utilizing the central supply room to store oxygen. She verified any room that had oxygen should have an oxygen in use sign on the outside of the room, including Resident #13's room and the central supply room. Review of the facility policy labeled, Oxygen Administration, dated 11/30/23, revealed staff would check the physician order for liter flow and method of administration. The policy revealed an oxygen in use sign would be placed. This deficiency was an incidental finding identified during the complaint investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, facility policy review, and review of the memorandum from the Department of Health & Human Services, the facility failed to ensure proper infection control measures were implemented at all times. The facility failed to initiate and use enhanced barrier precautions (EBP) for Resident #13. This affected one resident (#13) of one resident observed for EBP and had the potential to affect 11 residents (#1, #7, #11, #12, #13, #18, #20, #21, #24, #26, and #38) identified by the facility that were to be on EBP. The facility failed to ensure staff did not carry medications against their chest/body potentially causing infection control cross contamination affecting one resident (#13) of three residents reviewed for medication administration. The facility failed to cleanse the blood pressure cuff/monitor between resident use which affected one resident (#13) out of two residents reviewed for monitoring of blood pressure. The facility failed to ensure Resident #35's bed pan was stored in a sanitary manner which affected one resident (#35) out of one resident reviewed for bed pan storage. The facility census was 40. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 10/24/24 with diagnoses including chronic obstructive pulmonary disease (COPD), acute kidney failure, congestive heart failure (CHF), and dependence on supplemental oxygen. Review of the Medicare five- day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had impaired cognition. He required substantial to maximum assistance with rolling left and right regarding bed mobility and transfers. Review of the November 2024 physician orders revealed Resident #13 had a treatment dated 10/30/24 to his coccyx pressure wound to cleanse, pat dry, apply Medi honey (wound and burn gel), pack with calcium alginate, and cover with a dry dressing daily and as needed. There was no physician order for EBP. Review of the care plan dated 11/07/24 revealed Resident #13 had an alteration in skin integrity as he had a coccyx wound. Interventions included EBP with high contact care and treatments as ordered. Observation on 11/07/24 at 9:07 A.M. revealed Resident #13 had a sign on the outside of his doorway that indicated Resident #13 was on EBP, indicating staff were to wear gloves and a gown during high contact resident care activities. Licensed Practical Nurse (LPN) #604 entered Resident #13's room and applied gloves and no gown. LPN #604 leaned over Resident #13's bed to auscultate his lung sounds with her stethoscope as the top of her uniform encountered his gown. She then proceeded to reposition Resident #13 in bed which required substantial assistance as she rolled him from his right side to his back lifting his right shoulder region to continue to listen to his lungs as well as to obtain his blood pressure. While repositioning resident #13, LPN #604 came in direct contact with Resident #13. She then left the room to prepare his medications including Advair diskus inhaler, Spiriva Respimat inhaler, budesonide aerosol treatment, a medication cup with nine oral medications and a cup of water in which she gathered all at once with her bilateral arms and held tightly against her chest region against her uniform as she walked to Resident #13's room. She proceeded then to reapply gloves but no gown and assisted Resident #13 from a lying position to sitting by placing both arms underneath his arms and her uniform and upper body in direct contact with his upper body as he was dependent on her transferring him from lying to sitting position to the edge of his bed. Interview on 11/07/24 at 10:10 A.M. with LPN #604 verified she had carried his medications including holding his Advair diskus inhaler (glucocorticoid), Spiriva Respimat inhaler (bronchodilator), and budesonide aerosol (corticosteroid) treatment against her chest region coming in contact with her uniform. She stated, so much stuff to carry that she did not have a choice. She also verified Resident #13 had a sign on the outside of his door indicating he was to be on EBP including during high contact care, and she verified she had repositioned him in bed and transferred him from a lying to sitting position. She revealed she had not received anything in report that Resident #13 had a contagious disease and stated, I do not believe he has anything. She revealed EBP was to protect the staff from getting something from a resident including a contagious disease. Interview on 11/07/24 at 12:57 P.M. with the Director of Nursing (DON) revealed she the infection control preventionist. She verified Resident #13 had a pressure wound and required EBP during high contact care. She verified high contact care would include repositioning a resident with bed mobility and transferring from lying to sitting positions that required substantial to dependent staff assistance. She verified EBP was to reduce transmission of multidrug-resistant organisms (MDRO) from staff to resident. She also verified a nurse should not carry medication, including inhalers against her chest/body while carrying them into a resident room. Review of the facility policy labeled, Medication Administration- General Guidelines, dated November 2021, revealed staff administering medications were to adhere to good handwashing. There was nothing in the policy regarding ensuring medications were not held against a staff's body while carrying the medications into a resident's room. Review of facility policy labeled, Enhanced Barrier Precautions, dated 11/30/23, revealed EBP were an infection control intervention designed to reduce transmission of MDRO. EBP were to be used for residents with wounds, indwelling medical devices, and known infection. The policy revealed gowns and gloves were to be used for high contact resident care activities including dressing, transferring, providing hygiene, and changing linens. Review of the memorandum, QSO-24-08-NH, entitled Enhanced Barrier Precautions in Nursing Homes, dated 03/20/24, by the Centers for Medicare & Medicaid Services, Department of Health & Human Services revealed EBP were an infection control intervention designed to reduce MDRO. EBP are used in conjunction with standard precautions and expand the use of Personal Protective Equipment (PPE) by donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP were indicated for residents with any of the following including wounds. EBP were indicated for high-contact resident care activities including transferring. The effective date for implementation of EBP under the guidelines was 04/01/24. 2. Observation revealed on 11/07/24 at 8:50 A.M. LPN #604 obtained Resident #14's blood pressure utilizing an electric blood pressure monitor by applying the blood pressure cuff to Resident #14's right arm. LPN #604 then removed the blood pressure cuff and returned to the nursing medication cart lying the electric blood pressure monitor on top of the cart without cleaning the cuff and/or monitor. Observation revealed on 11/07/24 at 9:07 A.M. LPN #604 picked up the same electric blood pressure monitor without cleaning the device and entered Resident #13's room to obtain his blood pressure. LPN #604 applied the blood pressure cuff to Resident #13's left arm to obtain his blood pressure. LPN #604 then removed the blood pressure cuff and returned to the nursing medication cart lying the electric blood pressure monitor on top of the cart without cleaning the cuff and/ or monitor. Interview on 11/07/24 at 10:10 A.M. with LPN #604 verified she had not cleaned the blood pressure cuff and/or monitor between taking Resident #14's blood pressure and Resident #13's blood pressure. LPN #604 stated, I forgot. Interview on 11/07/24 at 12:57 P.M. with the DON also verified a blood pressure cuff and/or monitor was to be cleaned between each resident. Review of the facility policy labeled, Equipment and Supplies for administering Medications, dated November 2021, revealed the charge nurse on duty was to ensure equipment related to medication administration was clean and orderly. There was nothing identified specially in the policy regarding cleaning the blood pressure cuff and/or monitor between each resident. 3. Review of the medical record for Resident #35 revealed an admission date of 10/13/24 with diagnoses included emphysema, hemiplegia following cerebral infarction affecting left dominant side, and congestive heart failure. Review of the admission MDS assessment dated [DATE] revealed Resident #35 had intact cognition and was dependent on staff with toileting hygiene. She was frequently incontinent with urine and always incontinent of bowel. Review of the care plan dated 10/29/24 revealed Resident #35 had an activities of daily living performance deficit related to hemiplegia, weakness and difficulty walking. Interventions included offering and assisting with bedpan per resident request. Observation on 11/07/24 at 10:48 A.M. revealed Resident #35 was on the bed pan and had requested Certified Nursing Assistant (CNA) #618 provide toileting hygiene including removing her from the bed pan. Resident #35 requested the surveyor not observe, and her request was honored. Observation on 11/07/24 at 1:30 P.M. revealed there was a grey bed pan lying on the floor in Resident #35's bathroom under the sink without covering. Interview on 11/07/24 at 1:31 P.M. with CNA #618 verified that the bed pan was Resident #35's and that it was lying on the floor without covering. She was asked how the facility stored bedpans, and she stated usually like that in the bathroom on the floor. Interview on 11/13/24 at 1:00 P.M. with the DON revealed the facility did not have a policy regarding the storage bedpans. She verified bedpans should be maintained in the resident's bathroom but in a bag, not directly on the floor. This deficiency was an incidental finding identified during the complaint investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of the facility self-reported incident (SRI) tracking number (#)253244 and facility investigation, review of staffing schedules and punch detailed report and review of the facility abuse policy, the facility failed to enforce their abuse policy including reporting an allegation of abuse promptly, immediately investigating the allegation of staff-to-resident abuse and ensuring the alleged perpetrator did not continue providing direct care to all residents after the alleged allegation was made on 10/04/24. This affected one resident (#28) and placed a potential risk of abuse for all 40 residents residing in the facility. Findings included: Review of the medical record for Resident #28 revealed an admission date of 08/22/24 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, and spinal stenosis. There was no documentation in the nursing notes from 10/04/24 to 10/23/24 regarding any allegation of staff-to-resident abuse. Review of the care plan dated 08/30/24 revealed Resident #28 had a self-care performance deficit related to fatigue, COPD, and weakness. Interventions included extensive assistance with toileting needs, monitoring for fatigue, and providing rest periods as needed. Review of the Time Entry Report from 10/03/24 to 10/23/24 revealed Certified Nursing Assistant (CNA) #602 worked on 10/03/24 from 11:00 P.M. to 6:57 A.M., 10/05/24 from 6:59 P.M. to 6:58 A.M., 10/06/24 from 7:00 P.M. to 6:55 A.M., 10/08/24 from 11:00 P.M. to 6:56 A.M., 10/11/24 from 11:00 P.M. to 7:00 A.M., 10/14/24 from 11:02 P.M. to 7:05 A.M., 10/15/24 from 10:58 A.M. to 6:56 A.M., 10/17/24 from 10:53 A.M. to 7:00 A.M., 10/18/24 6:57 A.M. to 7:00 A.M., 10/19/24 from 11:00 A.M. to 6:55 A.M., 10/20/24 from 10:54 A.M. to 6:58 A.M., and 10/22/24 from 10:57 A.M. to 6:58 A.M. He was removed from the schedule from 10/23/24 to 10/28/24 (after which he returned to work). Review of the facility staffing schedule dated 10/03/24 revealed the following staff worked from 11:00 P.M. to 7:00 A.M.: Registered Nurse (RN) #608, RN #617, CNA #602, CNA #644, and Former CNA #662. Review of the additional staffing schedules from 10/04/24 to 10/23/24 revealed CNA #602 worked on the east unit (men's unit) on 10/05/24, 10/06/24, 10/09/24, 10/11/24, and 10/14/24. He worked on the west unit (women's unit) on 10/08/24, 10/15/24, and 10/22/24. The facility had two units east and west, and CNA #602 had worked both units from 10/04/24 to 10/23/24. Review of the witness statement dated 10/04/24 and signed by CNA #602 revealed he was providing incontinence care to Resident #28, and she had a bowel movement and in the process of cleaning her up, she asked CNA #602 to stop as he was not cleaning her correctly. CNA #602 revealed he stopped giving her care, repositioned her in bed and went and got CNA #662. The statement revealed after CNA #662 came into the room, CNA #602 left out of the room and went to provide care to another resident. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had intact cognition and was dependent on staff assistance with rolling left and right in bed, toileting, hygiene, and transfers. She was always incontinent with urine and bowel. She had no behaviors that were identified. Review of the nursing note dated 10/23/24 at 3:47 P.M. and authored by the Director of Nursing (DON) revealed Resident #28 was interviewed, her chart was reviewed, and Resident #28 denied any psychological and/or psychosocial effects related to the allegation of receiving improper incontinence care. She was joyful and in a pleasant mood and stated she felt safe in the facility. A skin assessment was completed without any findings. Nurse Practitioner (NP) #661 was notified. Review of SRI #253244 dated 10/23/24 revealed the facility filed an allegation of neglect as Former CNA #662 reported that Resident #28 informed her that CNA #602 did not adequately clean her peri area during incontinence care after having a bowel movement. The facility initiated an investigation, and CNA #602 was suspended pending the outcome of the investigation. The SRI revealed Resident #28 denied allegations and that she felt safe and appropriately cared for by the facility. The facility unsubstantiated the allegation. Review of the undated Cleveland Division of Police service number 2024-313919 revealed Officer #663 responded. Officer #663 did not file an official report. Review of the facility timeline of events dated 10/23/24 and labeled, Timeline of Events- Resident #28- Allegation of Sexual Assault completed by the Administrator revealed on 10/03/24 at approximately 5:00 P.M. (which after clarification with Administrator should have been 10/04/24) Former CNA #662 informed the DON that Resident #28 had stated CNA #602, had used his fingers to wipe her in the front and in the back during incontinence care. The DON notified the Administrator, and they interviewed Resident #28 who stated CNA #602 did not do anything wrong, he just did not clean her up how she liked to be cleaned. Resident #28 asked him to stop and get a female aide. Resident #28 denied sexual abuse, and the facility educated CNA #602 on female hygiene including incontinence care. On 10/23/24, the Administrator was contacted by Regional Director of Operations #667 that Former CNA #662 alleged that a resident was sexually assaulted (resident or perpetrator was not identified) as a male aide stuck his finger in her butt. The timeline revealed an SRI was filed and an investigation was initiated. CNA #602 was suspended pending the investigation. The police were notified on 10/23/24 but due to high call volume, it was unsure when an officer could come. The timeline revealed on 10/25/24 the police arrived and interviewed Resident #28 and CNA #602 with no report filed. Review of the Shower/ Bath Sheet dated 10/23/24 and completed by the DON revealed Resident #28 had no skin concerns. Review of the witness statement dated 10/23/24 and authored by Registered Nurse (RN) #608 revealed she had worked 10/04/24 on the west hall (women side), and she was unaware of any accusations, including abuse. Review of the additional witness statements dated 10/25/24 and completed by Licensed Practical Nurse (LPN) #653 and CNA #635 revealed they were not aware of any allegations of abuse. There were no other witness statements including Former CNA #662 and Former Scheduler/CNA #664. Review of the witness statement dated 10/25/24 and authored by CNA #644 revealed she entered Resident #28's room, and Resident #28 revealed that she had just received a call from corporate and Resident #28 proceeded to tell CNA #644 that CNA #602 entered her room to clean her up, and he took a towel and wrapped the washcloth around his finger and went up one side of her vaginal area and then turned her over and went up her buttocks. The statement revealed Resident #28 stated CNA #602 did not wash her properly and as a woman, she felt it was degrading. Interview on 11/07/24 at 10:51 A.M. with Resident #28 revealed a guy (CNA #602) entered her room to clean her up and took his finger and swiped her as she demonstrated by taking her index finger in front of her in a slow manner. She revealed he took his finger across her buttock. She revealed she felt CNA #602's mind was on someone else during the incident as she was not sure what he was thinking. She revealed it was not right how he was doing it as she stated maybe he got into it with his girlfriend or something. She denied that the incident was abusive but stated again, it was not right the way he changed me. She revealed she had reported it because she did not want the same thing to happen to someone else. She had previous male caregivers, and that was not the issue, it was the way he did it. She remained focused during the interview regarding the way he took his finger and swiped her up and down her butt. Interview on 11/07/24 at 3:15 P.M. and 11/13/24 at 11:47 A.M. with Former CNA #662 revealed from 10/03/24 to 10/04/24 she worked 11:00 P.M. to 7:00 A.M. with CNA #602 and CNA #644. During that shift, she had not provided any care for Resident #28, and Resident #28 had not voiced any concerns. She denied that CNA #602 ever came and asked her to provide incontinence care for Resident #28 during that shift. Former CNA #662 revealed she then came back to work on second shift on 10/04/24 and at approximately 3:40 P.M., she had entered Resident #28's room, and Resident #28 asked who the guy was with the yellow hoodie last night. Former CNA #662 asked her what she meant, and Resident #28 stated he took his finger and inserted his finger in her butt and removed it and did it again. Former CNA #662 stated that Resident #28 stated the towel was dry and had no water and he did it twice and when Resident #28 was describing the concern, she held up her middle finger indicating he had used his middle finger. Former CNA #662 revealed Resident #28 stated she had a lot of pressure; it was hurting, and she did not want CNA #602 to take care of her again. Former CNA #662 revealed she immediately reported it to the Administrator and DON and verified she reported exactly what Resident #28 stated word for word. Former CNA #662 revealed she felt it was abuse. She stated that the Administrator and DON did go into Resident #28's room, but she did not feel the incident was thoroughly investigated as CNA #602 was never suspended, and when the Administrator left for the day, she had commented understand some people are miserable. She revealed she was terminated from the facility, and she felt it was a result of reporting the incident because CNA #602 was a relative of the Administrator. She revealed that Former Scheduler/ CNA #664 had also stated Resident #28 reported the incident to her, and she reported the incident. Interview on 11/07/24 at 12:36 P.M. with the Administrator revealed that Former CNA #662 came into the DON's office where she and the DON were present and stated that CNA #602 had not cleaned Resident #28 properly. She revealed that Former CNA #662, DON and herself went into Resident #28's room and believed it was more a concern that CNA #602 was a new aide, and Resident #28 was concerned he did not clean her properly by getting into every, nook and cranny as well as CNA #602 did not feel comfortable cleaning a woman's anatomy. She denied at any time that Resident #28 or Former CNA #662 had communicated any allegation of potential sexual abuse. She revealed Former CNA #662 had never said anything regarding sexual abuse until she was terminated and contacted the corporate office on 10/23/24 stating Resident #28 was sexually assaulted by CNA #602. She then filed an SRI regarding the allegation. Interview on 11/07/24 at 12:57 P.M. with the DON revealed on 10/04/24 Former CNA #662 came to her office and said that she was the only one in the office. She verified the Administrator was not in the office at the time Former CNA #662 came to her office. The DON revealed Former CNA #662 stated CNA #602 had used his finger to wipe her: swiping up her buttock and down but stated she could not remember exactly what Former CNA #662 said. The DON revealed she immediately went to speak with Resident #28 because the way it was described by Former CNA #662 it was vulgar but again stated she could not remember the exact wording, but that it sounded off. She revealed Former CNA #662 and herself were in Resident #28's room, and Resident #28 stated he took his finger and stuck it up her butt but when she clarified by asking if she felt sexually assaulted, or violated she denied and instead revealed CNA #602 had not cleaned her properly as he did not get in her butt cheeks. She revealed Resident #28's daughter came in as well, and she got the Administrator, especially because of the verbiage Resident #28 was using and they interviewed her again. She revealed it did not sound good how Resident #28 was describing it as he was swiping his finger up and down her butt but again, she denied abuse and instead it sounded as CNA #602 had not provided proper incontinence care. They provided education to CNA #602. Interview on 11/07/24 at 2:54 P.M. with CNA #602 revealed on 10/04/24 he removed Resident #28's brief, and he completed one wipe using a washcloth across the front of her waistline above her genital area as she was wet from urine. CNA #602 revealed he could not remember if she was incontinent of bowel movement as he had just seen the front of Resident #28. He revealed he never rolled her over or provided any incontinence care to her rectal/buttock area as again he stated he had just wiped one time in the front. He revealed Resident #28 stated she would feel better with a female aide, so he went and got Former CNA #662 who completed the rest of her care. He denied at any time that he was sexually inappropriate or abusive. He revealed he was suspended for two or three days (could not remember the exact dates) as he stated the Administrator stated another aide had made an allegation, but that Resident #28 denied it. He did verify he was related to the Administrator. Interview on 11/07/24 at 3:37 P.M. with Resident #28's daughter revealed she talked with her mother on the morning of 10/04/24, and she said that a gentleman had cleaned her up the previous night. She revealed Resident #28 stated he wiped her kind of weird and she thought it was concerning as she said he wiped her by using two fingers up across her buttocks as she said, he swiped his fingers. She revealed she felt her mother may have used the wrong terminology as when she asked her mother if she felt it was sexual, she stated no, but it felt uncomfortable. She verified she was in the room when the Administrator and DON were questioning her mother, and she shared the same thing that she had on the phone that she did not feel it was sexual, but she did state, I felt it was uncomfortable how he wiped me. Interview on 11/07/24 at 5:00 P.M. with the Administrator and DON verified they had not reported the incident, including filing an SRI, had not contacted the police and had not notified the physician on 10/04/24 regarding the incident, as they did not see it as sexual abuse after speaking with Resident #28. They verified the facility abuse policy revealed the facility was to report all allegations of abuse to the Ohio Department of Health (ODH) and then investigate the allegation. They verified that according to their abuse policy; the facility would immediately remove the alleged perpetrator from the facility and schedule pending the outcome of the investigation to protect the residents and/or residents. They also verified they had not obtained a witness statement from Former CNA #662 or from Resident #28 except what was placed in the timeline which was completed on 10/23/24. Interview on 11/13/24 at 8:40 A.M. with Former Human Resources (HR)/Payroll #665 revealed she was not directly involved but heard from Former Scheduler/ CNA #664 that Former CNA #662 was upset that she reported an allegation of sexual abuse involving CNA #602 and Resident #28, and it was not investigated because the Administrator was related to CNA #602. She revealed she asked the DON about the incident, and the DON stated, oh we did a soft file on it as they had talked with Resident #28, and CNA #602 had not cleaned her up properly. She revealed in her conversation with Former Scheduler/ CNA #664 it sounded more like an allegation of sexual abuse, and the facility did not report it until Former CNA #662 contacted corporate regarding the allegation. She revealed that was one of the main reasons she resigned, as she felt she should be privy to that information especially when staff feel the situation was being swept under the rug due to CNA #602 being a relative to the Administrator. Interview on 11/13/24 at 9:01 A.M. with Former Scheduler/CNA #664 revealed the morning of 10/04/24 she was working on the floor as there was a staffing shortage, and she was helping out. She revealed on 10/04/24 between 8:30 A.M. and 10:00 A.M. (she could not remember exact time), she was in Resident #28's room, and Resident #28 seemed upset and stated, she never wanted that man to take care of her again. Resident #28 stated CNA #602 rolled her over and took his finger and wiped up her butt crack and then rolled her back over and used his finger up and down the crack of her buttocks. Former Scheduler/CNA #664 revealed Resident #28 stated I am no damn fool; I know the difference between a finger and a towel as she repeated it was something skinny which was how she knew it was his finger. She immediately stopped the resident and went and got the DON. Resident #28 then communicated the same facts to the DON, and the DON questioned Resident #28 to see if she felt harmed or abused, and Resident #28 stated no. Resident #28 told the DON several times that she felt uncomfortable during the incident, and she stated. It ain't right, and I am not dumb. Former Scheduler/CNA #664 revealed she did not feel Resident #28 was conveying to the DON that it was a hygiene issue, but instead felt Resident #28 was reporting how uncomfortable she felt because he used his finger during her care, and that it was not right. Former Scheduler/CNA #664 revealed believed it was possible sexual abuse by the way Resident #28 described it. She heard other staff state Resident #28 shared the same story with them, and she was worried as it felt like the facility did not investigate the incident. She revealed since she was the scheduler, she knew CNA #602 had not been removed from the schedule after she had reported the incident on 10/04/24. She also verified she had not filled out a witness statement regarding the incident that she reported on 10/04/24. Interview on 11/13/24 at 12:25 P.M. with Assistant Director of Nursing (ADON)/LPN #652 verified on review of the staffing schedules from 10/04/24 to 10/23/24 that CNA #602 worked both units (west and east). She revealed most the time he worked the east unit, but there were two residents on the men's unit (Resident #1 and Resident #18) that did not want a male caregiver, so in that situation she stated the aides would work it out themselves which rooms the male aide then would take for the female aide to have an even split. She revealed she had no documentation on which days CNA #602 worked with which residents. He most likely did pick up a few rooms on the female side the days he was assigned on the east unit. Interview on 11/13/24 at 1:10 P.M. with CNA #644 revealed she was providing care to Resident #28 (unsure of date), and Resident #28 stated that she had talked with corporate about an incident that had occurred. She revealed Resident #28 stated CNA #602 had used a finger to wrap the washcloth around and went up one side and turned her over and went up the other. She stated the way Resident #28 was describing the incident was odd and just did not sound right, especially how CNA #602 had used his finger. She revealed Resident #28 stated she felt degraded as a woman. She revealed she then reported it to the DON immediately. Review of the facility policy labeled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated 02/08/24, revealed the facility would immediately report all allegations to the administrator and to the ODH. In cases where a crime was suspected, the administrator would report the incident to the local law enforcement. The policy revealed an alleged violation was a situation or occurrence that was observed or reported by staff, resident, relative or others but has not yet been investigated. The policy revealed all incidents of abuse would be reported immediately. The facility would also report the incident/allegation to the attending physician. The policy revealed once the administrator and ODH were notified, then an investigation of the allegation would be conducted. The policy also revealed if a staff member was accused, the facility would immediately remove that staff member from the facility until the outcome of the investigation in order to protect the resident/residents. The policy revealed the person investigating the incident should interview the resident, the accused, and all witnesses and document evidence of the investigation. The investigation must be completed within five working days. This deficiency represents non-compliance investigated under Complaint Number OH00159263.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of the facility self-report incident (SRI) tracking number (#)253244 and investigation, staffing schedules and punch detailed report, and review of the facility abuse policy, the facility failed to immediately investigate and implement protective measures upon receiving an allegation of staff-to-resident abuse to prevent further abuse including not allowing the alleged perpetrator to continue to provide direct care from 10/04/24 to 10/23/24 while a thorough investigation was completed. This affected one resident (#28) and had the potential to affect all 40 residents residing in the facility. Findings include: Review of the medical record for Resident #28 revealed an admission date of 08/22/24 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, and spinal stenosis. There was no documentation in the nursing notes from 10/04/24 to 10/23/24 regarding any allegation of staff-to-resident abuse. Review of the care plan dated 08/30/24 revealed Resident #28 had a self-care performance deficit related to fatigue, COPD, and weakness. Interventions included extensive assistance with toileting needs, monitoring for fatigue, and providing rest periods as needed. Review of the Time Entry Report from 10/03/24 to 10/23/24 revealed Certified Nursing Assistant (CNA) #602 worked on 10/03/24 from 11:00 P.M. to 6:57 A.M., 10/05/24 from 6:59 P.M. to 6:58 A.M., 10/06/24 from 7:00 P.M. to 6:55 A.M., 10/08/24 from 11:00 P.M. to 6:56 A.M., 10/11/24 from 11:00 P.M. to 7:00 A.M., 10/14/24 from 11:02 P.M. to 7:05 A.M., 10/15/24 from 10:58 A.M. to 6:56 A.M., 10/17/24 from 10:53 A.M. to 7:00 A.M., 10/18/24 6:57 A.M. to 7:00 A.M., 10/19/24 from 11:00 A.M. to 6:55 A.M., 10/20/24 from 10:54 A.M. to 6:58 A.M., and 10/22/24 from 10:57 A.M. to 6:58 A.M. He was removed from the schedule from 10/23/24 to 10/28/24 (after which he returned to work). Review of the facility staffing schedule dated 10/03/24 revealed the following staff worked from 11:00 P.M. to 7:00 A.M.: Registered Nurse (RN) #608, RN #617, CNA #602, CNA #644, and Former CNA #662. Review of the additional staffing schedules from 10/04/24 to 10/23/24 revealed CNA #602 worked on the east unit (men's unit) on 10/05/24, 10/06/24, 10/09/24, 10/11/24, and 10/14/24. He worked on the west unit (women's unit) on 10/08/24, 10/15/24, and 10/22/24. The facility had two units east and west, and CNA #602 had worked both units from 10/04/24 to 10/23/24. Review of the witness statement dated 10/04/24 and signed by CNA #602 revealed he was providing incontinence care to Resident #28, and she had a bowel movement and in the process of cleaning her up, she asked CNA #602 to stop as he was not cleaning her correctly. CNA #602 revealed he stopped giving her care, repositioned her in bed and went and got CNA #662. The statement revealed after CNA #662 came into the room, CNA #602 left out of the room and went to provide care to another resident. CNA #602 stated that Resident #28 never stated that she had any issues. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had intact cognition and was dependent on staff assistance with rolling left and right in bed, toileting, hygiene, and transfers. She was always incontinent with urine and bowel. She had no behaviors that were identified. Review of the nursing note dated 10/23/24 at 3:47 P.M. and authored by the Director of Nursing (DON) revealed Resident #28 was interviewed, her chart was reviewed, and Resident #28 denied any psychological and/or psychosocial effects related to the allegation of receiving improper incontinence care. She was joyful and in a pleasant mood and stated she felt safe in the facility. A skin assessment was completed without any findings. Nurse Practitioner (NP) #661 was notified. Review of SRI #253244 dated 10/23/24 revealed the facility filed an allegation of neglect as Former CNA #662 reported that Resident #28 informed her that CNA #602 did not adequately clean her peri area during incontinence care after having a bowel movement. The facility initiated an investigation, and CNA #602 was suspended pending the outcome of the investigation. The SRI revealed Resident #28 denied allegations and that she felt safe and appropriately cared for by the facility. The facility unsubstantiated the allegation. Review of the facility timeline of events dated 10/23/24 and labeled, Timeline of Events- Resident #28- Allegation of Sexual Assault completed by the Administrator revealed on 10/03/24 at approximately 5:00 P.M. (which after clarification with Administrator should have been 10/04/24) Former CNA #662 informed the DON that Resident #28 had stated CNA #602, had used his fingers to wipe her in the front and in the back during incontinence care. The DON notified the Administrator, and they interviewed Resident #28 who stated CNA #602 did not do anything wrong, he just did not clean her up how she liked to be cleaned. Resident #28 asked him to stop and get a female aide. Resident #28 denied sexual abuse, and the facility educated CNA #602 on female hygiene including incontinence care. On 10/23/24, the Administrator was contacted by Regional Director of Operations #667 that Former CNA #662 alleged that a resident was sexually assaulted (resident or perpetrator was not identified) as a male aide stuck his finger in her butt. The timeline revealed an SRI was filed and an investigation was initiated. CNA #602 was suspended pending the investigation. The police were notified on 10/23/24 but due to high call volume, it was unsure when an officer could come. The timeline revealed on 10/25/24 the police arrived and interviewed Resident #28 and CNA #602 with no report filed. Review of the undated Cleveland Division of Police service number 2024-313919 revealed Officer #663 responded. Officer #663 did not file an official report. Review of the facility investigation dated 10/23/24 revealed six residents (three male residents #1, #6, #18 and three female residents #24, #30, and #43) were interviewed and asked the following questions: do you feel safe in the facility, are you comfortable with male caregivers, and has any care giver, male or female, provided care to you that made you feel uncomfortable. No concerns were identified. Review of the witness statement dated 10/23/24 and authored by Registered Nurse (RN) #608 revealed she had worked 10/04/24 on the west hall (women side), and she was unaware of any accusations, including abuse. Review of the additional witness statements dated 10/25/24 and completed by Licensed Practical Nurse (LPN) #653 and CNA #635 revealed they were not aware of any allegations of abuse. There were no other witness statements including Former CNA #662 and Former Scheduler/CNA #664. Review of the witness statement dated 10/25/24 and authored by CNA #644 revealed she entered Resident #28's room, and Resident #28 revealed that she had just received a call from corporate and Resident #28 proceeded to tell CNA #644 that CNA #602 entered her room to clean her up, and he took a towel and wrapped the washcloth around his finger and went up one side of her vaginal area and then turned her over and went up her buttocks. The statement revealed Resident #28 stated CNA #602 did not wash her properly and as a woman, she felt it was degrading. Interview on 11/07/24 at 10:51 A.M. with Resident #28 revealed a guy (CNA #602) entered her room to clean her up and took his finger and swiped her as she demonstrated by taking her index finger in front of her in a slow manner. She revealed he took his finger across her buttock. She revealed she felt CNA #602's mind was on someone else during the incident as she was not sure what he was thinking. She revealed it was not right how he was doing it as she stated maybe he got into it with his girlfriend or something. She denied that the incident was abusive but stated again, it was not right the way he changed me. She revealed she had reported it because she did not want the same thing to happen to someone else. She had previous male caregivers, and that was not the issue, it was the way he did it. She remained focused during the interview regarding the way he took his finger and swiped her up and down her butt. Interview on 11/07/24 at 3:15 P.M. and 11/13/24 at 11:47 A.M. with Former CNA #662 revealed from 10/03/24 to 10/04/24 she worked 11:00 P.M. to 7:00 A.M. with CNA #602 and CNA #644. During that shift, she had not provided any care for Resident #28, and Resident #28 had not voiced any concerns. She denied that CNA #602 ever came and asked her to provide incontinence care for Resident #28 during that shift. Former CNA #662 revealed she then came back to work on second shift on 10/04/24 and at approximately 3:40 P.M., she had entered Resident #28's room, and Resident #28 asked who the guy was with the yellow hoodie last night. Former CNA #662 asked her what she meant, and Resident #28 stated he took his finger and inserted his finger in her butt and removed it and did it again. Former CNA #662 stated that Resident #28 stated the towel was dry and had no water and he did it twice and when Resident #28 was describing the concern, she held up her middle finger indicating he had used his middle finger. Former CNA #662 revealed Resident #28 stated she had a lot of pressure; it was hurting, and she did not want CNA #602 to take care of her again. Former CNA #662 revealed she immediately reported it to the Administrator and DON and verified she reported exactly what Resident #28 stated word for word. Former CNA #662 revealed she felt it was abuse. She stated that the Administrator and DON did go into Resident #28's room, but she did not feel the incident was thoroughly investigated as CNA #602 was never suspended, and when the Administrator left for the day, she had commented understand some people are miserable. She revealed she was terminated from the facility, and she felt it was a result of reporting the incident because CNA #602 was a relative of the Administrator. She revealed that Former Scheduler/ CNA #664 had also stated Resident #28 reported the incident to her, and she reported the incident. Interview on 11/07/24 at 12:36 P.M. with the Administrator revealed that Former CNA #662 came into the DON's office where she and the DON were present and stated that CNA #602 had not cleaned Resident #28 properly. She revealed that Former CNA #662, DON and herself went into Resident #28's room and believed it was more a concern that CNA #602 was a new aide, and Resident #28 was concerned he did not clean her properly by getting into every, nook and cranny as well as CNA #602 did not feel comfortable cleaning a woman's anatomy. She denied at any time that Resident #28 or Former CNA #662 had communicated any allegation of potential sexual abuse. She revealed Former CNA #662 had never said anything regarding sexual abuse until she was terminated and contacted the corporate office on 10/23/24 stating Resident #28 was sexually assaulted by CNA #602. She then filed an SRI regarding the allegation. Interview on 11/07/24 at 12:57 P.M. with the DON revealed on 10/04/24 Former CNA #662 came to her office and said that she was the only one in the office. She verified the Administrator was not in the office at the time Former CNA #662 came to her office. The DON revealed Former CNA #662 stated CNA #602 had used his finger to wipe her: swiping up her buttock and down but stated she could not remember exactly what Former CNA #662 said. The DON revealed she immediately went to speak with Resident #28 because the way it was described by Former CNA #662 it was vulgar but again stated she could not remember the exact wording, but that it sounded off. She revealed Former CNA #662 and herself were in Resident #28's room, and Resident #28 stated he took his finger and stuck it up her butt but when she clarified by asking if she felt sexually assaulted, or violated she denied and instead revealed CNA #602 had not cleaned her properly as he did not get in her butt cheeks. She revealed Resident #28's daughter came in as well, and she got the Administrator, especially because of the verbiage Resident #28 was using and they interviewed her again. She revealed it did not sound good how Resident #28 was describing it as he was swiping his finger up and down her butt but again, she denied abuse and instead it sounded as CNA #602 had not provided proper incontinence care. They provided education to CNA #602. Interview on 11/07/24 at 2:54 P.M. with CNA #602 revealed on 10/04/24 he removed Resident #28's brief, and he completed one wipe using a washcloth across the front of her waistline above her genital area as she was wet from urine. CNA #602 revealed he could not remember if she was incontinent of bowel movement as he had just seen the front of Resident #28. He revealed he never rolled her over or provided any incontinence care to her rectal/buttock area as again he stated he had just wiped one time in the front. He revealed Resident #28 stated she would feel better with a female aide, so he went and got Former CNA #662 who completed the rest of her care. He denied at any time that he was sexually inappropriate or abusive. He revealed he was suspended for two or three days (could not remember the exact dates) as he stated the Administrator stated another aide had made an allegation, but that Resident #28 denied it. He did verify he was related to the Administrator. Interview on 11/07/24 at 3:37 P.M. with Resident #28's daughter revealed she talked with her mother on the morning of 10/04/24, and she said that a gentleman had cleaned her up the previous night. She revealed Resident #28 stated he wiped her kind of weird and she thought it was concerning as she said he wiped her by using two fingers up across her buttocks as she said, he swiped his fingers. She revealed she felt her mother may have used the wrong terminology as when she asked her mother if she felt it was sexual, she stated no, but it felt uncomfortable. She verified she was in the room when the Administrator and DON were questioning her mother, and she shared the same thing that she had on the phone that she did not feel it was sexual, but she did state, I felt it was uncomfortable how he wiped me. Interview on 11/07/24 at 5:00 P.M. with the Administrator and DON verified they had not completed an investigation until 10/23/24. They verified that the facility policy revealed if a staff member was accused of abuse, the facility would immediately remove that staff member from the facility until the outcome of the investigation in order to protect the resident/residents. They verified the policy revealed that the person investigating the incident should interview the residents, the accused, and all witnesses and document evidence of the investigation. They also verified the investigation must be completed within five working days. Interview on 11/13/24 at 8:40 A.M. with Former Human Resources (HR)/Payroll #665 revealed she was not directly involved but heard from Former Scheduler/ CNA #664 that Former CNA #662 was upset that she reported an allegation of sexual abuse involving CNA #602 and Resident #28, and it was not investigated because the Administrator was related to CNA #602. She revealed she asked the DON about the incident, and the DON stated, oh we did a soft file on it as they had talked with Resident #28, and CNA #602 had not cleaned her up properly. She revealed in her conversation with Former Scheduler/ CNA #664 it sounded more like an allegation of sexual abuse, and the facility did not report it until Former CNA #662 contacted corporate regarding the allegation. She revealed that was one of the main reasons she resigned, as she felt she should be privy to that information especially when staff feel the situation was being swept under the rug due to CNA #602 being a relative to the Administrator. Interview on 11/13/24 at 9:01 A.M. with Former Scheduler/CNA #664 revealed the morning of 10/04/24 she was working on the floor as there was a staffing shortage, and she was helping out. She revealed on 10/04/24 between 8:30 A.M. and 10:00 A.M. (she could not remember exact time), she was in Resident #28's room, and Resident #28 seemed upset and stated, she never wanted that man to take care of her again. Resident #28 stated CNA #602 rolled her over and took his finger and wiped up her butt crack and then rolled her back over and used his finger up and down the crack of her buttocks. Former Scheduler/CNA #664 revealed Resident #28 stated I am no damn fool; I know the difference between a finger and a towel as she repeated it was something skinny which was how she knew it was his finger. She immediately stopped the resident and went and got the DON. Resident #28 then communicated the same facts to the DON, and the DON questioned Resident #28 to see if she felt harmed or abused, and Resident #28 stated no. Resident #28 told the DON several times that she felt uncomfortable during the incident, and she stated. It ain't right, and I am not dumb. Former Scheduler/CNA #664 revealed she did not feel Resident #28 was conveying to the DON that it was a hygiene issue, but instead felt Resident #28 was reporting how uncomfortable she felt because he used his finger during her care, and that it was not right. Former Scheduler/CNA #664 revealed believed it was possible sexual abuse by the way Resident #28 described it. She heard other staff state Resident #28 shared the same story with them, and she was worried as it felt like the facility did not investigate the incident. She revealed since she was the scheduler, she knew CNA #602 had not been removed from the schedule after she had reported the incident on 10/04/24. She also verified she had not filled out a witness statement regarding the incident that she reported on 10/04/24. Interview on 11/13/24 at 12:25 P.M. with Assistant Director of Nursing (ADON)/LPN #652 verified on review of the staffing schedules from 10/04/24 to 10/23/24 that CNA #602 worked both units (west and east). She revealed most the time he worked the east unit, but there were two residents on the men's unit (Resident #1 and Resident #18) that did not want a male caregiver, so in that situation she stated the aides would work it out themselves which rooms the male aide then would take for the female aide to have an even split. She revealed she had no documentation on which days CNA #602 worked with which residents. He most likely did pick up a few rooms on the female side the days he was assigned on the east unit. Interview on 11/13/24 at 1:10 P.M. with CNA #644 revealed she was providing care to Resident #28 (unsure of date), and Resident #28 stated that she had talked with corporate about an incident that had occurred. She revealed Resident #28 stated CNA #602 had used a finger to wrap the washcloth around and went up one side and turned her over and went up the other. She stated the way Resident #28 was describing the incident was odd and just did not sound right, especially how CNA #602 had used his finger. She revealed Resident #28 stated she felt degraded as a woman. She revealed she then reported it to the DON immediately. Review of the facility policy labeled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated 02/08/24, revealed once the administrator and ODH were notified, then an investigation of the allegation would be conducted. The policy also revealed if a staff member was accused of abuse, the facility would immediately remove that staff member from the facility until the outcome of the investigation in order to protect the resident/residents. The policy revealed the person investigating the incident should interview the resident, the accused, and all witnesses and document evidence of the investigation. The investigation must be completed within five working days. This deficiency represents non-compliance investigated under Complaint Number OH00159263.

Based on interview, record review and review of facility policy, the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) committee that met at least quarterly consisted of the required members, including the medical director or his/her designee. This had the potential to affect all 40 residents residing in the facility. Finding include: Review of the QAPI sign-in sheets from 10/20/23 to 08/21/24 revealed a QAPI meeting was held on 03/01/24, and Medical Director #660 attended the meeting. A QAPI sign-in sheet revealed a meeting was held on 06/27/24, and Medical Director #660 or designee had not attended. A QAPI meeting sign-in sheet revealed a meeting was held on 08/21/24, and Nurse Practitioner #661 attended the meeting as the medical director's designee. There was no evidence from 03/02/24 to 08/21/24 (over five months) that the facility had a QAPI meeting that the medical director and/or his designee attended. Interview on 11/13/24 at 9:00 A.M. with the Administrator verified she had no documented evidence from 03/02/24 to 08/21/24 (over five months) that the facility had a QAPI meeting that the medical director and/or his designee attended. Review of the facility policy labeled, Quality Assurance Performance Improvement, dated 07/01/24, revealed the facility would systematically monitor and evaluate the quality and appropriateness of resident care, pursue opportunities to improve resident care, resolve identified problems, and identify opportunities for improvement. The policy did not include the required members that would attend these meetings, including the medical director and/or designee. This deficiency was an incidental finding identified during the complaint investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy, the facility failed to provide timely incontinence care, turning and repositioning, and positioning to prevent increased edema for one resident, Resident #30 of three residents reviewed for assistance provident with activities of daily living. The facility census was 32. Findings include: Record review for Resident # 30 revealed an admission date of 07/14/23. Diagnosis included urinary tract infection, hypertension, asthma and shortness of breath. Record review of the admission assessment dated [DATE] at 8:46 P.M. completed by Licensed Practical Nurse (LPN) #108 revealed Resident #30 was alert with occasional confusion and required one person assistants with positioning, transfers, ambulation, and total dependence for dressing and grooming. Resident #30 was incontinent of bowel and bladder. Resident #30's skin was within normal limits, there were no abnormal findings. Interventions to maintain skin integrity included a pressure reducing cushion to the chair and turn and reposition every two hours and as needed. Record review of the physician orders revealed Resident #30 received Aix 20 milligrams (mg) one time a day for edema. Review of the admission assessment revealed Resident #30 had no edema present. Record review of the Care assessment dated [DATE] revealed Resident #30 required partial moderate assistants with eating, toileting, perineal hygiene, toileting, and substantial/maximum assist with bathing, upper and lower body dressing. Record review of the progress note dated 02/17/23 at 2:56 P.M. completed by LPN #102 revealed Resident #30 had two plus pitting edema noted. Observation on 07/17/23 at 10:41 A.M. revealed Resident #30 was sitting up in a chair near his bed. Saturated blankets and sheets were lying near Resident #30 on the floor. The odor in Resident #30's room was a strong urine odor. State Tested Nurse Aide (STNA) #107 confirmed the strong urine odor and verified Resident #30's blankets and sheets lying next to him on the floor were saturated in urine. Resident #30 revealed he slept in the chair overnight because he does not sleep in a bed and had not for several years. Resident #30 had edema to his bilateral lower extremities. STNA #107 verified when she came at 7:00 A.M., Resident #30 was in the chair. The chair was similar to a kitchen chair, it did not recline. Resident #30 revealed he slept in a recliner chair at home and while in the hospital. Resident #30's pants were covered with food crumbs and saturated with urine covering the front of the pants. STNA #107 verified the pants Resident #30 was wearing was saturated with urine. STNA #107 stood Resident #30 up with the assistants of his walker. Resident #30's back of his pants were saturated with urine, the seat of the chair was saturated, and a puddle of urine was on the floor next to his chair. STNA #107 confirmed the areas was urine and revealed she did not check Resident #30 for incontinence because she thought Resident #30 was continent and used a urinal. STNA #107 confirmed Resident #30 did not have a pressure reduced cushion in his chair and she did not turn or reposition him this shift. Observation revealed an unused urinal was sitting across the room on a shelf out of Resident #30's reach. Observation during peri care revealed Resident #30 had dried pieces of stool hanging from several hairs near his scrotum. Resident #30 did not have a bowel movement prior to or during observation of incontinence care. Resident #30's buttocks and upper thighs were discolored (darker skin tone) with lines of the chair where he had been sitting. STNA #107 verified the dried stool particles and discolored skin and revealed she did not know Resident #30 required assistants with incontinence care, transfers, and ambulation. STNA #107 confirmed she was Resident #30's assigned caregiver and revealed she did not know him because he was new, he arrived three days ago. STNA #107 revealed there was no documentation available to her revealing the individual needs of the residents, she just knew how to care for them because she had done it for so long. Interview on 07/17/23 at 11:14 A.M. with Certified Nurse Practitioner (CNP) #105 revealed if a resident did not want to lay in bed and the resident had edema, she would expect the facility to provide a recliner chair to keep the residents legs elevated. Interview on 07/17/23 at 11:20 A.M. with LPN #102 revealed she received in report Resident #30 preferred to sleep in a chair. Resident #30 was incontinent and required assistants with care. Licensed Practical Nurse (LPN) #102 revealed the State Tested Nursing Assistant (STNA) received report from nurses regarding resident care but not usually until after 11:00 A.M. LPN #102 confirmed Resident #30 did not have a pressure reducing cushion to his chair and Resident #30 had pitting edema to the bilateral lower extremities. LPN #102 confirmed Resident #30's legs were not elevated and Resident #30 was not offered additional options to elevate his legs. Interview on 07/17/23 at 1:49 P.M. with the Director of Nursing (DON) revealed residents who required assistant with incontinence care should be checked every two hours and assisted with care as needed. DON revealed STNA's had electronic access to residents medical records and used a [NAME] (located in the electronical medical records) to determine the residents individual needs. DON confirmed Resident #30's information regarding his personal needs have not been placed in the [NAME] (electronic section of the medical records) for the STNA's use. DON revealed if a resident did not sleep in the bed, the facility would either provide a recliner or a wheelchair with elevated leg rests especially if they had edema. DON revealed the nurses did not notify him Resident #30 never slept in his bed. Review of the facility policy titled, Incontinence Care dated 10/20/22, revealed the purpose was to keep skin clean, dry, free of irritation and odor and to identify skin problems as soon as possible so treatment can be started and to prevent skin breakdown. This deficiency represents non-compliance investigated under Complaint Number OH00144168.

Based on record review, interview, and policy review the facility failed to ensure medications were administered as ordered. This affected three (Resident's #1, #20 and #22) of 11 residents reviewed for medications being administered as ordered. The facility census was 40. Findings include: 1. Review of the medial record for Resident #1 revealed an admission date of 04/04/19 with diagnoses including diabetes mellitus, dementia, human immunodeficiency virus (HIV), and chronic kidney disease. Review of the physician's orders dated 06/03/22 for Resident #1 revealed he had an order for Insulin Aspart Solution 100 units/milliliters (mL.), inject seven units subcutaneously with meals related for hyperglycemia and Insulin Aspart Solution 100 units/mL., sliding scale with meals (insulin amount given depending on blood sugar readings). Review of the Medication Administration Record (MAR) for June 2022 for Resident #1 revealed nursing staff did not administer Insulin Aspart Solution seven units with meals on 06/14/22, 06/15/22 and 06/24/22 at 5:00 P.M. The MAR also revealed nursing staff did not check Resident #1's blood sugar or administer sliding scale coverage with Insulin Aspart Solution on 06/12/22, 06/14/22, 06/15/22 and 06/24/22 at 5:00 P.M. Review of the MAR for July 2022 for Resident #1 revealed nursing staff did not administer Insulin Aspart Solution seven units with meals on 07/0/3/22 at 5:00 P.M. The MAR also revealed nursing staff did not check Resident #1's blood sugar or administer sliding scale coverage with Insulin Aspart Solution on 07/03/22 at 5:00 P.M. Review of Resident #1's care plan dated 05/09/22 revealed he was at risk for hyperglycemia (high blood sugar) and hypoglycemic (low blood sugar) reactions. Interventions included for the staff to administer medications as the physician ordered. Interview on 07/13/22 at 10:34 A.M. with the Director of Nursing (DON) verified the nursing staff had not signed off the MAR for the Insulin Aspart orders on the dates listed above. Review of the facility policy titled, Administration Procedures for All Medications, dated September 2018, revealed nursing staff were to document administration of medications in the MAR. 2. Review of the medical record for Resident #20 revealed an admission date of 02/08/22 with diagnoses including diabetes mellitus, dementia, congestive heart failure, and anxiety. Review of the physician's orders for Resident #20 revealed she was to have Ambien 5 milligrams (mg) (medication for insomnia) one time a day in the evening dated 04/28/22; Atorvastatin Calcium (medication for high cholesterol) 40 mg at bedtime dated 04/28/22; Protonix 40 mg (medication for acid reflux) to be given daily in the morning dated 04/29/22; Buspirone HCL 15 mg (medication for anxiety) to be administered one time a day at 4:00 P.M. dated 05/25/22; and Novolog Flex Pen Solution Pen-Injection 100 units/mL sliding scale based on blood sugar at meals for diabetes mellitus dated 06/13/22. Review of the MAR for June 2022 for Resident #20 revealed nursing staff did not administer Ambien 5 mg the evening of 06/14/22, 06/15/22 and 06/24/22; Atorvastatin Calcium 40 mg at bedtime on 06/14/22; Protonix 40 mg in the morning on 06/25/22 and 06/30/22; and Novolog Solution sliding scale or blood sugar on 06/14/22 at 11:30 A.M. and 4:30 P.M., and 06/15/22 at 4:30 P.M. Review of the MAR for July 2022 for Resident #20 revealed nursing staff did not administer Ambien 5 mg the evening of 07/03/22; Buspirone HCL 15 mg on 07/03/22 at 4:00 P.M.; and Protonix 40 mg in the morning of 07/02/22 and 07/10/22. Interview on 07/13/22 at 2:59 P.M. with the DON verified the medications were not signed off indicating they were not administered on the days listed above. Review of the facility policy titled, Administration Procedures for All Medications, dated September 2018, revealed nursing staff were to document administration of medications in the MAR. 3. Review of the medical record for Resident #22 revealed an admission date of 10/21/21 with diagnoses including diabetes mellitus, heart failure and depression. Review of the physician's orders for Resident #22 revealed orders for Insulin Glargine Solution 100 unit/mL, inject 6 units subcutaneously at bedtime for diabetes mellitus dated 01/27/22; Melatonin 5 mg at bedtime for insomnia dated 01/27/22; Polyethylene Glycol Powder 17 grams in the evening for constipation dated 02/04/22; Insulin Lispro Solution 100 units/mL, per sliding scale based on blood sugar results before meals dated 03/17/22; Lipitor 20 mg (medication for high cholesterol) in the evening dated 03/21/22; and Carvedilol 6.25 mg (medication for high blood pressure and heart failure) in the evening dated 05/21/22. Review of the MAR for June 2022 for Resident #22 revealed nursing staff did not administer Insulin Glargine Solution six units on 06/02/22, 06/10/22, 06/14/22, 06/15/22 and 06/24/22 at 8:00 P.M.; Melatonin 5 mg on 06/10/22, 06/14/22, 06/15/22 and 06/24/22 at 9:00 P.M.; Polyethylene Glycol Powder 17 grams on 06/10/22, 06/14/22, 06/15/22 and 06/24/22 on the evening shift; Insulin Lispro sliding scale and blood sugar checks on 06/02/22, 06/10/22, 06/14/22, 06/15/22 and 06/24/22 at 4:00 P.M.; Lipitor 20 mg on 06/10/22, 06/14/22, 06/15/22 and 06/24/22 in the evening; and Carvedilol 6.25 mg on 06/10/22, 06/14/22, 06/15/22 and 06/24/22 in the evening. Interview on 07/13/22 at 10:34 A.M. with the DON verified the medications were not signed off indicating they were not administered on the days listed above. Review of the facility policy titled, Administration Procedures for All Medications, dated September 2018, revealed nursing staff were to document administration of medications in the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review the facility failed to ensure pressure relieving interventions were implemented and pressure ulcer treatments were performed for Resident #35. This affected one (Resident #35) of one resident reviewed for pressure ulcers. The facility census was 40. Findings include: Review of the medical record revealed Resident #35 was admitted on [DATE] with diagnoses including dementia, lack of coordination, and hypertension. Review of the care plan dated 03/12/20 for Resident #35 revealed she had the potential for alteration in skin integrity related to incontinence, depression, need for personal assistance, and obesity. Interventions included to administer treatments as ordered, therapeutic specialty mattress to bed and monitor for functioning, and to turn and reposition as needed. Review of the physician's orders for Resident #35 revealed orders for skin prevention included a low air loss pressure mattress to the bed, check function every shift dated 05/12/20 and protective moisture barrier topically to bilateral buttocks every shift for protection, wash with soap and water and pat dry area before applying dated 05/12/20. Resident #35 had an order for turning and repositioning every two hours dated 07/05/22. She also had an order for a treatment to her left buttock and to clean with normal sterile saline, pat dry and apply Triad Cream (zinc-based cream) per incontinence episodes every shift dated 07/05/22. Review of Wound Physician #573's progress note dated 07/04/22 revealed Resident #35 had an abrasion to her left buttock observed initially on 07/04/22. The nursing staff was to cleanse the area with wound cleanser, apply Triad Cream twice daily and as needed, turn and reposition her every two hours, keep the peri area clean and dry, and use an air mattress. Review of the Wound Physician #573's progress note dated 07/11/22 revealed Resident #35 still had the left buttock abrasion but also had developed a right buttock stage two pressure area (partial-thickness loss of dermis) which was first observed on 07/11/22. The nursing staff was to cleanse the areas, apply Triad Cream twice daily and as needed, reposition the resident every two hours, keep her peri area clean and dry, and utilize an air mattress. Review of the Treatment Administration Record (TAR) for June 2022 revealed nursing staff did not apply moisture barrier on dayshift on 06/15/22, in the evening of 06/05/22, 06/14/22, 06/15/22 and 06/24/22, and on 06/03/22, 06/06/22, 06/11/22, 06/14/22, 06/21/22, 06/22/22, 06/23/22 and 06/26/22 at night; and did not check the function of the low air loss pressure redistribution mattress to the bed in the evening of 06/05/22, 06/14/22, 06/15/22 and 06/24/22, and on 06/03/22, 06/06/22, 06/11/22, 06/14/22, 06/21/22, 06/22/22, 06/23/22 and 06/26/22 at night. Review of the TAR for July 2022 revealed nursing staff did not apply moisture barrier on the evening shift on 07/04/22 and 07/10/22 and on night shift on 07/01/22, 07/04/22, 07/06/22, 07/09/22 and 07/10/22; check function of the low air loss pressure redistribution mattress to the bed on the evening shift on 07/04/22 and 07/10/22 and on night shift on 07/01/22, 07/04/22, 07/06/22, 07/09/22 and 07/10/22; turn and reposition the resident every two hours on 07/06/22, 07/09/22 and 07/10/22 in the evening and on 07/06/22 at night; and perform the treatment to the left buttock on 07/10/22 in the evening and at night on 07/06/22, 07/09/22 and 07/10/22. Interview on 07/13/22 at 10:34 A.M. with the Direct of Nursing (DON) verified the TARs for June 2022 and July 2022 to have treatments and skin prevention orders not documented as completed for the dates listed above. Review of the facility policy titled, Pressure Ulcer Prevention Protocols/Risk Assessment, dated 11/13/19, revealed the facility was to place a pressure redistribution mattress to the bed and to protect skin from moisture by utilizing techniques including applying moisture barrier and turning and repositioning the resident as appropriate to meet the resident's needs.

Based on interview, record review, and review of the facility policy on falls, the facility failed to ensure new fall prevention interventions were implemented after Resident #18 experienced falls. This affected one (Resident #18) of one resident reviewed for falls. The census was 40. Findings include: Review of the medical record for Resident #18 revealed an admission date of 08/18/20 with diagnoses including dementia with behavioral disturbance, schizoaffective disorder, delusional disorder, depression, muscle weakness, and difficulty in walking. Review of the fall investigations revealed Resident #18 experienced falls on 04/16/22, 05/21/22, and 07/01/22. Further review of the fall investigations revealed no new fall prevention interventions were implemented after Resident #18 experienced falls. Review of the falls care plan revised 07/12/22 revealed no new fall prevention interventions were implemented on or around 04/16/22, 05/21/22, and 07/01/22. Interview on 07/14/22 at 12:46 P.M. with the Director of Nursing (DON) verified no new interventions were implemented after Resident #18 experienced falls. Review of the facility policy titled Falls - Clinical Protocol, dated 11/13/2019, revealed facility staff and the resident's physician would identify pertinent interventions to try to prevent subsequent falls.

Based on record review, interview and policy review, the facility failed to ensure scheduled pain medications were administered to Resident #22 as ordered by the physician. The facility also failed to ensure pain assessments were performed as ordered by the physician for Resident #22. This affected one (Resident #22) of one resident assessed for pain management. The facility census was 40. Findings include: Review of the medial record for Resident #22 revealed an admission date of 10/21/21 with diagnoses including diabetes mellitus, chronic kidney disease, and osteoarthritis. Review of the care plan dated 11/03/21 for Resident #22 revealed she was at risk for pain discomfort related to osteoarthritis, cancer to her head/scalp area, depression, and diabetic neuropathy (weakness, numbness, and pain from nerve damage). Interventions included to assess for pain and to administer pain medications per the physician's order. Review of the physician's order dated 01/27/22 revealed nursing staff were to monitor for pain every shift. Resident #22 also had a physician's order dated 06/07/22 for Gabapentin 300 milligrams (mg) (nerve pain medication) two times a day for pain. Review of the Medication Administration Record (MAR) for June 2022 revealed nursing staff had not assessed Resident #22 for pain on the evening shifts of 06/10/22, 06/14/22, 06/15/22 and 06/24/22. The MAR also revealed Resident #22 had not received her Gabapentin 300 mg doses on the evening shift of 06/10/22, 06/14/22, 06/15/22 and 06/24/22 Review of the MAR for July 2022 revealed staff had not assessed Resident #22 for pain on the evening shift of 07/03/22. The MAR also revealed Resident #22 had not received her Gabapentin 300 mg. dose on 07/03/22 on the evening shift. Interview on 07/11/22 at 9:41 A.M. with Resident #22 revealed she did not get medications on time or at all including her pain medications. She stated she was in pain at times because the nursing staff did not administer her pain medications as ordered. Interview on 07/18/22 at 2:35 P.M. with the Director of Nursing (DON) verified Gabapentin was not signed off on the MAR as administered on the dates listed above. The DON also verified the pain assessments were not signed off as completed on the MAR on the dates listed above. Review of the facility policy titled, Pain Assessment and Management, dated 11/13/19, revealed the staff were to assess the resident's pain and consequences of pain at each shift and document.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure Resident #20 was free of significant medication errors. This affected one (Resident #20) of one resident reviewed for significant medication errors. The facility census was 40. Findings include: Review of the medical record revealed Resident #20 was admitted on [DATE] with diagnoses including dementia, schizophrenia, and anxiety. Review of the handwritten physician medication order dated 06/23/22 revealed Resident #20 was ordered Lexapro 10 milligrams (mg) daily for seven days and then increase Lexapro to 20 mg daily. Review of the Medication Administration Record (MAR) for June 2022 revealed Resident #20 had an order for Lexapro 10 mg one time a day for antidepressant for seven days then increase to 20 mg daily dated 06/24/22. Review of the MAR for July 2022 revealed Resident #20 was administered Lexapro 10 mg on 07/01/22, 07/02/22, 07/04/22 and 07/05/22 at 4:00 P.M. Lexapro 10 mg was discontinued on 07/06/22. Resident #20 had another order for Lexapro dated 07/01/22 for 20 mg and was administered this medication on 07/01/22, 07/03/22, 07/04/22 and 07/05/22 at 6:00 A.M. Resident #20 received Lexapro 30 mg on 07/01/22, 07/04/22, and 07/05/22. Interview on 07/13/22 at 4:05 P.M. with Pharmacist #567 revealed Lexapro is given at 10 mg for the first seven days to assess for toxicity to the resident. Pharmacist #567 stated the medication is then increased to Lexapro 20 mg daily. Interview on 07/13/22 at 4:11 P.M. with the Direct of Nursing (DON) verified the medication error of Resident #20's Lexapro 10 mg not being discontinued on 06/30/22 after seven days per the physician's order. The DON verified Resident #20 received a total of 30 mg of Lexapro on 07/01/22, 07/04/22, and 07/05/22 per the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the facility's administration procedures for all medications, the facility failed to ensure medications were dated when opened and disposed of when expired or discontinued. This affected two (Resident's #1 and #20) of two residents whose insulins were stored in the medication cart. The facility census was 40. Findings include: 1. Review of the medical record revealed Resident #1 was admitted on [DATE] with diagnoses including diabetes mellitus and dementia. Review of the physician's orders revealed Resident #1 had an order dated [DATE] for Insulin Aspart Solution (medication for diabetes), inject seven units subcutaneously with meals. He also had an order dated [DATE] for Insulin Aspart Solution for sliding scale, which would provide a dose depending on the resident's blood sugar. Resident #1's blood sugars were noted to range from 123 to 435 in [DATE]. Resident #1's blood sugars were noted to be between 68 to 538 in [DATE]. Observation on [DATE] at 12:43 P.M. with Licensed Practical Nurse (LPN) #557 of the [NAME] Medication Cart revealed Resident #1 had two Insulin Aspart vials. One vial was dated [DATE] (the date the medication was opened) and the other vial was undated but had a pharmacy dispense date of [DATE]. LPN #557 stated she did not have time to go through the medication cart to date medications that the other nurses had opened. Review of the facility policy titled, Administration Procedures for All Medications, updated [DATE], stated staff were to check the expiration date on the package/container before administering any medications. The staff were to place a date on the container when opening multi-dose containers. 2. Review of the medical record revealed Resident #20 was admitted on [DATE] with diagnoses including diabetes mellitus and dementia. Review of the physician's orders revealed Resident #20 had an order dated [DATE] for Humalog KwikPen Solution (medication for diabetes), inject per sliding scale three times a day with meals. This order was discontinued on [DATE]. Resident #20's insulin order changed to Novolog Flex Pen on [DATE]. Observation on [DATE] at 12:43 P.M. with LPN #557 of the [NAME] Medication Cart revealed Resident #20 had two Humalog Kwik Pens. One Humalog Kwik Pen was dated [DATE] (the date the medication was opened) and the other Humalog Kwik Pen was undated but had a pharmacy dispense date of [DATE]. LPN #557 verified the Humalog Kwik Pens were expired and had been discontinued. Review of the facility policy titled, Administration Procedures for All Medications, updated [DATE], stated staff were to check the expiration date on the package/container before administering any medications. The staff were to place a date on the container when opening multi-dose containers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record for Resident #18 revealed an admission date of 08/18/2020 with diagnoses including dementia with behavioral disturbance, schizoaffective disorder, delusional disorder, and depression. Review of the physician's order dated 10/01/21 revealed Resident #18 had an advance directive including palliative care program for chronic kidney disease. There were no physician's orders for hospice services. Review of the quarterly MDS 3.0 assessments dated 01/18/22 and 04/18/22 and the significant change MDS 3.0 assessment dated [DATE] revealed hospice services had been documented for Resident #18. Interview on 07/11/22 at 12:44 P.M. with Resident #18's daughter revealed Resident #18 had never received hospice services while in the facility. She verified Resident #18 received palliative care. Interview on 07/11/22 at 1:29 P.M. with LPN #512, who was also the MDS nurse, revealed she had documented hospice services for Resident #18. LPN #512 verified Resident #18 was not receiving hospice services and she had documented this in error. Based on record review and interview, the facility failed to ensure assessments were accurately completed. This affected four (Resident's #1, #8, #18 and #35) of six residents reviewed for Minimum Data Set (MDS) 3.0 assessments recorded for hospice services. The facility census was 40. Findings include: 1. Review of the medical record revealed Resident #1 was admitted on [DATE] with diagnoses including dementia, chronic kidney disease, and diabetes mellitus. Review of the physician's order dated 12/27/21 revealed Resident #1 had an advance directive including palliative care program for chronic kidney disease. There were no physician's orders for hospice services. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed hospice services had been documented for Resident #1. Interview on 07/11/22 at 1:29 P.M. with Licensed Practical Nurse (LPN) #512, who was also the MDS nurse, revealed she had documented hospice services for Resident #1. LPN #512 verified Resident #1 was not receiving hospice services and she had documented this in error. 2. Review of the medical record revealed Resident #8 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus, and dementia. Review of the physician's order dated 08/26/21 revealed Resident #8 had an advance directive including palliative care program for COPD. There were no physician's orders for hospice services. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed hospice services had been documented for Resident #8. Interview on 07/11/22 at 1:29 P.M. with LPN #512, who was also the MDS nurse, revealed she had documented hospice services for Resident #8. LPN #512 verified Resident #8 was not receiving hospice services and she had documented this in error. 3. Review of the medical record revealed Resident #35 was admitted on [DATE] with diagnoses including dementia with behavioral disturbances. Review of the physician's order dated 02/10/21 revealed Resident #35 had an advance directive including palliative care program for dementia. There were no physician's orders for hospice services. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed hospice services had been documented for Resident #35. Interview on 07/11/22 at 1:29 P.M. with LPN #512, who was also the MDS nurse, revealed she had documented hospice services for Resident #35. LPN #512 verified Resident #35 was not receiving hospice services and she had documented this in error.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure dialysis residents were monitored before and after dialysis treatments. The facility also failed to ensure resident dialysis catheters were assessed as ordered by the physician. This affected three (Resident's #12, #22, and #140) of three residents receiving dialysis. The facility census was 40. Findings include: 1. Review of the medical record revealed Resident #12 was admitted on [DATE] with diagnoses including end stage renal disease and dependence on renal dialysis. There were no dialysis assessments performed for Resident #12 before going to dialysis or after returning. Review of the physician's order dated 02/01/22 revealed Resident #12 had dialysis on Tuesdays, Thursdays, and Saturdays. Resident #12 also had a physician's order dated 01/05/22 for staff to monitor the left inter-jugular dialysis site every shift for signs of infection and to ensure that ports are clamped; document abnormal findings; report to dialysis center and nephrologist; dressing changes per dialysis center-reinforce if needed; if the catheter was dislodged or bleeding was found, apply pressure for 15 minutes; and if bleeding does not stop call 911 and notify the physician and dialysis center. Review of the Treatment Administration Record (TAR) for June 2022, revealed assessments of the left inter-jugular dialysis site were not performed as ordered by the physician on dayshift on 06/15/22; on the evening shift on 06/04/22, 06/05/22, 06/14/22, 06/24/22; and on the night shift on 06/03/22, 06/06/22, 06/11/22, 06/14/22, 06/22/22, 06/23/22 and 06/26/22. Review of the TAR for July 2022, revealed assessments of the left-inter jugular dialysis site were not performed as the physician had ordered on the evening shift on 07/04/22, 07/06/22 and on 07/10/22; and on the night shift on 07/01/22, 07/04/22, 07/06/22, 07/09/22 and 07/10/22. Interview on 07/14/22 at 9:46 A.M. with the Director of Nursing (DON), verified there were no assessments before or after dialysis for Resident #12. The DON verified nursing staff had not signed off on the TAR for the dialysis site assessments ordered by the physician on the dates listed above. 2. Review of the medical record revealed Resident #22 was admitted on [DATE] with diagnoses including chronic kidney disease and dependence on renal dialysis. There were no dialysis assessments performed for Resident #22 before going to dialysis or after returning. Review of the physician's order dated 04/05/22 revealed Resident #22 had dialysis on Tuesdays, Thursdays, and Saturdays. Resident #22 also had a physician's order dated 04/05/22 for staff to assess her dialysis shunt every shift; assess for bruit, thrill, and signs of infection; document abnormal findings and report to the dialysis center and nephrologist; if bleeding was noted to apply pressure for 15 minutes, and if bleeding continued to call 911 and notify the doctor. Review of the TAR for June 2022, revealed assessments of the dialysis shunt were not performed as ordered by the physician on dayshift on 06/15/22; on the evening shift on 06/04/22, 06/05/22, 06/14/22, 06/24/22; and on the night shift on 06/03/22, 06/06/22, 06/11/22, 06/14/22, 06/21/22, 06/22/22, 06/23/22 and 06/26/22. Review of the TAR for July 2022, revealed assessments of the dialysis shunt were not performed as ordered by the physician on the evening shift on 07/06/22 and on 07/10/22; and on the night shift on 07/01/22, 07/04/22, 07/06/22, 07/09/22 and 07/10/22. Interview on 07/14/22 at 9:46 A.M. with the DON, verified there were no assessments before or after dialysis for Resident #22. The DON verified nursing staff had not signed off on the TAR for the dialysis shunt assessments ordered by the physician on the dates listed above. 3. Review of the medical record revealed Resident #140 was admitted on [DATE] with end stage renal disease and dependence on renal dialysis. There were no dialysis assessments performed for Resident #140 before going to dialysis or after returning. There were no physician's orders to assess Resident #140's dialysis shunt. Review of the physician's order dated 06/23/22 revealed Resident #140 had dialysis on Mondays, Wednesdays, and Fridays. Review of the TAR for June 2022, revealed Resident #140 had dialysis on 06/29/22. The nursing staff had not signed off on the TAR if Resident #140 had gone to dialysis on 06/24/22 or 06/27/22. Review of the TAR for July 2022, revealed Resident #140 had dialysis on 07/01/22 and 07/06/22. The nursing staff had not signed off on the TAR if Resident #140 went to dialysis on 07/04/22, 07/08/22 or 07/11/22. Review of the care plan dated 07/08/22 for Resident #140 revealed nursing staff were to notify the physician if dialysis shunt problems; if no bruit or thrill or bleeding; if signs and symptoms of infection at port site; abnormal lab values; signs and symptoms of fluid retention; peripheral edema; weight gain; neck vein distension, orthopnea (shortness of breath with lying flat), elevated blood pressure, tachycardia (fast heart rate); and tachypnea (fast breathing). Interview on 07/14/22 at 9:46 A.M. with the DON, verified there were no assessments before or after dialysis for Resident #140.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure medications in the [NAME] wing cart were secured under lock when the nurse was not in attendance. This had the potential to affect 17 residents (Resident #1, #4, #5, #6, #9, #13, #14, #15, #16, #18, #22, #24, #26, #35, #36, #187 and #189) on the [NAME] hall who received medications administered by the nursing staff. The facility census was 40. Findings Include: Observation on 05/15/19 at 4:30 P.M. in the [NAME] hallway revealed an unlocked medication cart stationed to the east of room [ROOM NUMBER]. No nurse was observed in the hallway or looking into the hallway. On 05/15/19 at 4:33 P.M. Licensed Practical Nurse #100 emerged from room [ROOM NUMBER] which was west of room [ROOM NUMBER], and past a large metal box fixed on the wall which extended approximately eight inches from the wall and approximately thirty three inches wide across the wall, partially blocking the view between the two rooms when standing at the doorway or in the hallway. Upon returning, LPN #100 placed medication on the top of the cart and confirmed she had left the cart unlocked while unattended and up the hallway out of view. The facility identified 17 residents, Resident #1, #4, #5, #6, #9, #13, #14, #15, #16, #18, #22, #24, #26, #35, #36, #187 and #189 on the [NAME] hall who received medications administered by the nursing staff. Review of the facility's policy, titled Medications, Biologicals, Syringes and Needles revised 10/31/16 revealed the facility was to ensure all medications and biologicals were securely stored in a locked cabinet /cart or locked medication room that was inaccessible by residents and visitors.