**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interview, the facility failed to ensure transportation to and from scheduled eye surgery for Former Resident #120. This affected one (Former Resident #120) of three residents reviewed for transportation assistance. Findings include: Review of medical record for Former Resident #120 noted an admission date of 10/27/23 and discharge date of 01/31/25. Diagnoses included schizophrenia, glaucoma, and non-compliance with medication regimen. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Former Resident #120 had intact cognition and required supervision for activities of daily living. Review of Former Resident #120's scheduled outside appointments for September 2024 through January 2025 revealed Former Resident #120 was scheduled to leave the facility on 01/27/25 at 5:30 A.M. for laser eye surgery related to a diagnosis of glaucoma. Review of a nurse progress note dated 01/27/25 timed 5:56 A.M. revealed Former Resident #120 was unable to go to appointment because no staff was available. Interview on 03/03/25 at 12:50 P.M. with the Director of Nursing (DON) revealed she was not sure why Former Resident #120 was not taken to her scheduled eye surgery on 01/07/25. The DON stated she met with the Transportation Coordinator weekly to set up transportation to outside appointments. Staff did not contact her on 01/27/25 regarding the appointment. Interview on 03/03/25 at 1:06 P.M. with Transportation Coordinator (TC) #200 revealed she was told there was not enough staff to take Former Resident #120 to her scheduled eye surgery. TC #200 stated she was responsible for tracking the appointments but was unable to provide specific information related to why Former Resident #120 was not taken to her scheduled surgery on 01/27/25. Review of the undated facility policy Resident Transportation revealed the facility would assist residents in making transportation arrangements to and from any needed services, such as dental visits or physician visits in the event the resident required such assistance. This deficiency represents non-compliance investigated under Complaint Number OH00161972.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility policy and procedure, and interview, the facility failed to ensure Resident #32 and #113's aerosol treatments were administered per the physician order. This affected two residents (Resident #32 and Resident #113) of three residents reviewed for medication administration records. Findings include: 1. Record review for Resident #32 revealed an admission date of 07/21/21. Diagnosis included chronic obstructive pulmonary disease, acute and chronic respiratory failure, chronic diastolic congestive diastolic congestive heart failure, Parkinson's disease, muscle weakness and altered mental status. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #32 revealed Resident #32 was cognitively intact. Resident #32 had debility cardiorespiratory conditions with anxiety and depression disorders. Review of the care plan for Resident #32 dated 09/22/21 revealed Resident #32 had an activity of daily living (ADL) self-care performance deficit, requires assistance with ADL's related to Parkinson's, COPD/SOB on rest, exertion and lying flat, chronic respiratory failure/, CHF, and morbid obesity. Interventions included to administer medications per medical provider's orders. Review of the physician orders for Resident #32 dated 11/14/24 revealed Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram (mg) per three milliliters (ml) one vial inhale orally three times a day for COPD and every four hours as needed for wheezing and shortness of breath. Observation on 11/20/24 at 10:08 A.M. revealed Resident #32 was sleeping in his chair next to his bed. Observation revealed multiple items were lying on top the bed including dried food items, empty used Styrofoam cups, an aerosol tubing and mouthpiece (not in a bag), cans, lotion, socks toilet paper rolls and empty wrappers. Observation on 11/21/24 at 10:31 A.M. revealed Resident #32 was sitting up in his chair. Observation revealed the medicine cup connected to the aerosol tubing still had a clear liquid in the cup. The tubing, cup and mouthpiece were lying on the bed unbagged. Observation of medication administration on 11/21/24 at 11:48 A.M. with Licensed Practical Nurse (LPN) #255 revealed when the nurse entered the resident room, Resident #32 had his aerosol machine on, and he was self-administering the aerosol treatment. LPN #255 revealed he must have had some left from this morning. LPN #255 shut off the aerosol machine and added a new three ml vial of Ipratropium-Albuterol solution to the remaining solution in the aerosol cup, turned the aerosol machine back on and handed the mouthpiece to Resident #32 who continued the treatment. Observation revealed LPN #255 did not assess Resident #32's lung status prior to administration. LPN #255 confirmed she did not observe to see if Resident #32 completed the morning aerosol dose. Review of the Medication Administration Record (MAR) for Resident #32 revealed on 11/21/24 the aerosol treatments were scheduled for 6:00 A.M., 2:00 P.M. and 10:00 P.M.; As needed doses were also scheduled but not signed on 11/21/24 as used. The last dose provided prior to 11/21/24 at 11:48 A.M. was 11/21/24 at 6:00 A.M. 2. Record review for Resident #113 revealed an admission date of 09/19/24. Diagnosis included chronic obstructive pulmonary disease, emphysema, muscle weakness and need for assistants with personal care. Review of the Medicare five-day MDS revealed Resident #113 was cognitively intact. Resident #113 required partial moderate assistants with eating and oral hygiene. Resident #113 had medically complex conditions including COPD. Review of the care plan for Resident #113 dated 09/20/24 revealed Resident #113 had chronic obstructive pulmonary disease and emphysema with shortness of breath while lying flat. Interventions included to administer medications per the physician orders. Review of the physician orders for Resident #113 dated 10/29/24 revealed an order to administer Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram (mg) per three milliliters (ml) one vial inhale orally three times a day. Observation on 11/20/24 at 10:10 A.M. revealed Resident #113 was lying in bed. Observation revealed Resident #113 had an aerosol tubing and mouthpiece lying on the edge of the bed, unbagged. Resident 3113 revealed staff never placed his aerosol tubing in a bag. Observation on 11/21/24 at 10:36 A.M. revealed Resident #113 was lying in bed. Resident #113's medicine cup connected to the tubing still had a clear liquid in the cup. The tubing, cup and mouthpiece were lying on the bed. Resident #113 revealed he was taking a break from the aerosol treatment. Observation of medication administration with LPN #255 on 11/21/24 at 11:53 A.M. revealed Resident #113 still had a clear liquid in the cup of the aerosol tubing. The tubing, cup and mouthpiece was still unbagged. LPN #255 verified the liquid in the aerosol cup was the remainder of the morning dose. LPN #255 confirmed she did not observe to see if Resident #113 completed the morning aerosol dose. Resident #113 dropped the aerosol tubing and mask on the floor, LPN #255 obtained a new mask, placed the new Ipratropium-Albuterol Solution dose in the aerosol med cup and initiated the aerosol treatment. Observation revealed LPN #255 did not assess Resident #113's lung status prior to administration. LPN #255 confirmed she worked on different days throughout the facility and had worked with all residents residing in the facility. Review of the MAR for Resident #113 revealed on 11/21/24 the aerosol treatments were scheduled for A.M., afternoon and HS; The last dose provided prior to 11/21/24 at 11:53 A.M. was 11/21/24 A.M. Interview on 11/20/24 at 11:58 A.M. with Registered Nurse Unit Manager #274 revealed prior to administering an aerosol treatment, the nurse was required to check the residents pulse ox, check lung sounds pre and post treatment. The nurse was required to stay with the resident until the treatment was complete. Interview on 11/20/24 at 12:02 P.M. with Director of Nursing (DON) revealed nurses were to stay within the area while the resident completed the aerosol treatment and check on the resident frequently to assure the treatment was completed then nurses were to clean the aerosol medicine cup and mouthpiece between uses and keep stored in a plastic bag when not in use to prevent contamination. If the resident did not complete the aerosol treatment, the nurse would notify the physician and never add an additional dose. Review of the facility policy titled, Nebulizer Treatments undated revealed a nebulizer was a medication delivery system that creates a fine mist or aerosol that is directly inhaled for delivery of the medication to the bronchial tree. Collect data for respirations, pulse and breath sounds pretreatment. Place medication in the dispensing container per provider/physician order. Assist resident to administer the treatment including correct holding of the nebulizer dispenser and placing mouth on mouthpiece sealing with closed lips and breathing through mouth. Turn machine on, nurse to remain in close vicinity during treatment. Repeat collection of data for respirations, pulse and lung sounds post treatment. This deficiency represents non-compliance investigated under Complaint Number OH00159291.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure infection control was maintained during and after aerosol treatments for Resident #32 and #113. This affected two residents (Resident #32 and Resident #113) of three residents reviewed for infection control. Findings include: 1. Record review for Resident #32 revealed an admission date of 07/21/21. Diagnosis included chronic obstructive pulmonary disease, acute and chronic respiratory failure, chronic diastolic congestive diastolic congestive heart failure, Parkinson's disease, muscle weakness and altered mental status. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #32 revealed Resident #32 was cognitively intact. Resident #32 had debility cardiorespiratory conditions with anxiety and depression disorders. Review of the care plan for Resident #32 dated 09/22/21 revealed Resident #32 had an activity of daily living (ADL) self-care performance deficit, requires assistance with ADL's related to Parkinson's, COPD/SOB on rest, exertion and lying flat, chronic respiratory failure/, CHF, and morbid obesity. Interventions included to administer medications per medical provider's orders. Review of the physician orders for Resident #32 dated 11/14/24 revealed Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram (mg) per three milliliters (ml) one vial inhale orally three times a day for COPD and every four hours as needed for wheezing and shortness of breath. Observation on 11/20/24 at 10:08 A.M. revealed Resident #32 was sleeping in his chair next to his bed. Observation revealed multiple items were lying on top the bed including dried food items, empty used Styrofoam cups, an aerosol tubing and mouthpiece (not in a bag), cans, lotion, socks toilet paper rolls and empty wrappers. Observation on 11/21/24 at 10:31 A.M. revealed Resident #32 was sitting up in his chair. Observation revealed the medicine cup connected to the aerosol tubing still had a clear liquid in the cup. The tubing, cup and mouthpiece were lying on the bed unbagged. Observation of medication administration on 11/21/24 at 11:48 A.M. with Licensed Practical Nurse (LPN #255) revealed when the nurse entered the resident room, Resident #32 had his aerosol machine on, and he was self-administering the aerosol treatment. LPN #255 revealed he must have had some left from this morning. LPN #255 shut off the aerosol machine and added a new three ml vial of Ipratropium-Albuterol solution to the remaining solution in the aerosol cup, turned the aerosol machine back on and handed the mouthpiece to Resident #32 who continued the treatment. LPN #255 confirmed she also worked on 11/20/24 and confirmed Resident #32's aerosol tubing, cup, and mouthpiece were never kept in a bag during her shift on either day. LPN #255 also confirmed the mouthpiece or cup were not cleaned between uses. 2. Record review for Resident #113 revealed an admission date of 09/19/24. Diagnosis included chronic obstructive pulmonary disease, emphysema, muscle weakness and need for assistants with personal care. Review of the Medicare five-day MDS revealed Resident #113 was cognitively intact. Resident #113 required partial moderate assistants with eating and oral hygiene. Resident #113 had medically complex conditions including COPD. Review of the care plan for Resident #113 dated 09/20/24 revealed Resident #113 had chronic obstructive pulmonary disease and emphysema with shortness of breath while lying flat. Interventions included to administer medications per the physician orders. Review of the physician orders for Resident #113 dated 10/29/24 revealed an order to administer Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram (mg) per three milliliters (ml) one vial inhale orally three times a day. Observation on 11/20/24 at 10:10 A.M. revealed Resident #113 was lying in bed. Observation revealed Resident #113 had an aerosol tubing and mouthpiece lying on the edge of the bed, unbagged. Resident 3113 revealed staff never placed his aerosol tubing in a bag. Observation on 11/21/24 at 10:36 A.M. revealed Resident #113 was lying in bed. Resident #113's medicine cup connected to the tubing still had a clear liquid in the cup. The tubing, cup and mouthpiece were lying on the bed. Resident #113 revealed he was taking a break from the aerosol treatment. Observation of medication administration with LPN #255 on 11/21/24 at 11:53 A.M. revealed Resident #113 still had a clear liquid in the cup of the aerosol tubing. The tubing, cup and mouthpiece was still unbagged. LPN #255 verified the liquid in the aerosol cup was the remainder of the morning dose. LPN #255 verified the tubing, cup, and mouthpiece were not in a bag. LPN #255 confirmed she also worked on 11/20/24 during the day shift and Resident #113's aerosol tubing, cup and mask were not placed in a bag the entire shift on either day. LPN #255 also confirmed the mouthpiece or cup were not cleaned between uses. LPN #255 confirmed she did not observe to see if Resident #113 completed the morning aerosol dose. LPN #255 confirmed she worked on different days throughout the facility and had worked with all residents residing in the facility. Interview on 11/20/24 at 11:58 A.M. with Registered Nurse (RN) Unit Manager (UM) #274 revealed after completing an aerosol treatment the nurse was to rinse the aerosol cup out and restore the aerosol tubing, cup and mouthpiece in a plastic bag. Interview on 11/20/24 at 12:02 P.M. with DON revealed nurses were to stay within the area while the resident completed the aerosol treatment and check on the resident frequently to assure the treatment was completed then nurses were to clean the aerosol medicine cup and mouthpiece between uses and keep stored in a plastic bag when not in use to prevent contamination. If the resident did not complete the aerosol treatment, the nurse would notify the physician and never add an additional dose. Review of Device Cleaning and Infection Control in Aerosol Therapy/Respiratory Care dated 06/01/15 revealed cleaning an aerosol tubing or mouthpiece after each use is crucial to prevent the buildup medication residue, bacteria and potential contaminants that can lead to infection, clog the device, and affect the proper delivery of medication when used again. Storage included to store in a plastic bag or and airtight container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident wheelchairs were maintained in a clean and sanitary manner. This affected four residents (Resident #13, Resident #18, Resident #32, Resident #18, and Resident #105) of five residents observed for sanitary wheelchairs. Findings include: 1. Record review for Resident #32 revealed an admission date of 07/21/21. Diagnosis included Parkinson's disease and muscle weakness. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #32 revealed Resident #32 was cognitively intact. Resident #32 used a wheelchair for mobility. Resident #32 had debility cardiorespiratory conditions with anxiety and depression disorders. Review of the care plan for Resident #32 revealed Resident #32 had an activity of daily living (ADL) self-care performance deficit and required assistance with ADL's related to Parkinson's. Observation on 11/20/24 at 10:08 A.M. revealed Resident #32 was sleeping in a bedside chair. Observation revealed Resident #32's back rest on his wheelchair was fringed with multiple tears. Observation revealed the seat cushion had a large tear exposing the foam inside. Under the cushion revealed a large amount of dried food crumbs and particles. The frame of the wheelchair was covered in a thick film of dust and the foot pedals had a large amount of embedded dirt. Observation and interview on 11/20/24 at 10:15 A.M. with Certified Nursing Assistant (CNA) #321 confirmed the condition of Resident #32's wheelchair. CNA #321 revealed night shift was supposed to clean wheelchairs. Interview on 11/20/24 at 11:28 A.M. with Resident #32 revealed They never clean my wheelchair, it's always dirty, I am just use to it. 2. Record review for Resident #18 revealed an admission date of 11/13/24. Diagnosis included postprocedural seroma of the skin and subcutaneous tissue, need for assistants with personal care and muscle weakness. Review of the Brief Interview for Mental Status dated 11/14/24 revealed Resident #18 was cognitively intact. Review of the Fall Risk Observation tool revealed Resident #18 used a wheelchair for mobility. Review of the Nursing admission assessment dated [DATE] at 3:43 P.M. revealed Resident #18 required a wheelchair for longer distances, the wheelchair was provided by the facility. Observation on 11/20/24 at 10:32 A.M. revealed Resident #18 was sitting in the lounge. The right armrest of Resident #18's wheelchair had multiple tears. The wheel chair frame had a large amount of thick dust and behind the locks was a buildup of food crumbs. Interview with Resident #18 at this time revealed the facility had not cleaned his chair. Observation and interview on 11/20/24 at 10:36 A.M. with Director of Maintenance confirmed Resident #18's wheelchair right armrest had multiple tears. The wheel chair frame had a large amount of thick dust and behind the locks was a buildup of food crumbs. 3. Record review for Resident #105 revealed an admission date of 09/21/24. Diagnosis included paraplegia, muscle weaknesses, lack of coordination, and need for assistance with personal care. Review of the admission Medicare five-day MDS dated [DATE] revealed Resident #105 was cognitively intact. Resident #105 used a wheelchair for mobility. Resident #105 required substantial/maximum assistants with transfers. Observation on 11/20/24 at 10:34 A.M. revealed Resident #105 was sitting in the lounge. Resident #105 revealed staff never cleaned his wheelchair. Observation revealed the entire frame and behind the locks had thick filmy dust covering. Observation and interview on 11/20/24 at 10:35 A.M. with Director of Maintenance confirmed Resident #105's wheelchair frame and behind the locks had a thick filmy dust covering. 4. Record review for Resident #13 revealed an admission date of 08/15/24. Diagnosis included surgical aftercare following surgery on the circulatory system, chronic obstructive pulmonary disease, muscle weakness, difficulty in walking, and need for assist with personal care. Review of the quarterly MDS dated [DATE] revealed Resident #13 was severely cognitively impaired. Resident 13 used a wheelchair for mobility and required supervision or touch assistants with transfers to and from the bed. Observation on 11/20/24 at 10:37 A.M. revealed Resident #13 was sitting in the lounge. Observation of the wheelchair revealed a large amount of very thick filmy dust on the entire frame of the wheelchair with dried food particles behind the handbrakes. Observation and interview on 11/20/24 10:38 A.M. with Director of Nursing (DON) confirmed Resident #13's wheelchair had thick filmy dust on the entire frame of the wheelchair with dried food particles behind the handbrakes. DON revealed the resident wheelchairs had a weekly cleaning schedule and Resident #13's wheelchair should have been cleaned. This deficiency represents non-compliance investigated under Complaint Number OH00159291.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review the facility failed to ensure tube feeding was administered according to physician orders. This affected two residents (#35 and #86) of three residents reviewed for enteral nutrition. The facility census was 122. Findings include: 1. Observation of Resident #86 at 12:05 P.M. on 03/26/24 revealed she was not interviewable. Her tube feed was Nutren 2.0 running at 50 milliliters (ml) per hour with a programmed water flush of 240 ml every four hours. Record review of Resident #86 revealed she was admitted [DATE] and had diagnoses including anoxic brain damage, tracheostomy status, and chronic respiratory failure. She had an active order dated 02/26/24 for Nutren 2.0 to run at 55 ml per hour, and an active order dated 03/29/23 to flush with 200 ml of water every four hours. Interview with Licensed Practical Nurse (LPN) #203 on 03/26/24 at 12:14 P.M. confirmed Resident #86's tube feed was not running at the ordered rate. 2. Observation of Resident #35 at 12:07 P.M. on 03/26/24 revealed she was not interviewable. Her tube feed was Vital 1.5 running at 50 ml per hour with a programmed water flush of 150 ml every four hours. Record review of Resident #35 revealed she was admitted [DATE] and had diagnoses including unspecified dementia, malignant neoplasm of colon, and type II diabetes. She had an active order dated 03/08/24 for Vital 1.5 to run at 60 ml per hour, and an active order dated 02/26/24 to flush with 50 ml of water every hour. Interview with LPN #203 on 03/26/24 at 12:14 P.M. confirmed Resident #35's tube feed was not running at the ordered rate. Review of the facility's undated enteral nutrition policy revealed tube feeds administered via electronic pump were to be programmed according to the physician's ordered rate. This deficiency was an incidental finding identified during the complaint investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to honor Resident #54's preferences regarding when she wanted to get out of bed and how long she remained out of bed. This affected one of resident reviewed for preferences. Findings include: Review of Resident #54's medical records revealed an admission date of 11/03/23. Diagnoses included Multiple Sclerosis and need for personal care assistance. Review of Resident #54's care plan dated 11/03/23 revealed Resident #54 had self care deficits. Interventions included two or more staff for transfers. Review of Resident #54's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition and was dependent for transfers. Interview with Resident #54 on 01/09/24 at 7:46 A.M. revealed staff did not return her to bed as she requested. Resident #54 stated she had been left in her wheelchair for more than five hours on occasions. Interview with Resident #54 on 01/10/23 at 11:06 A.M. revealed she requested to be out of bed earlier in the morning and State Tested Nurse Aide (STNA) #585 told her she would assist her out of bed prior to lunch. Interview on 01/10/24 at 2:24 P.M. with STNA #585 revealed she was aware of staff who did not provide timely assistance for Resident #54's transfers. STNA #585 stated there were staff who refused to assist Resident #54 out of bed and also had left Resident #54 up her wheelchair for long periods of time. STNA #585 stated she was aware Resident #54 preferred to be out of bed prior to lunch; however, she had not assisted Resident #54 out of bed because she did not have time. STNA #585 indicated her shift was over at 2:30 P.M. Observation on 01/10/24 at 2:40 P.M. revealed Registered Nurse (RN) #595 and Licensed Practical Nurse (LPN) #603 assisting Resident #54 out of bed via a Hoyer (mechanical) lift. Interview with RN #595 and LPN #603, at time of observation, revealed they were aware Resident #54 preferred to out of bed prior to lunch and were unable to provide information regarding why Resident #54 had not been assisted out of bed prior to the observation.

**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 Resident #76 received the necessary services to maintain clean hair. This affected one (Resident #76) out of three residents reviewed for activities of daily living. The facility census was 111. Findings include: Review of Resident #76's medical record revealed and admission date of 01/13/23 and diagnoses included anoxic brain damage, chronic respiratory failure with hypoxia, and abnormal posture. Review of Resident #76's care plan dated 01/25/23 revealed Resident #76 had an activity of daily living (ADL) self-care performance deficit and required assistance with all ADLs. Resident #76 would maintain current level of function. Interventions included Resident #76 was dependent for shower, bathing and required two or more helpers to assist. Review of Resident #76's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status was not conducted due to Resident #76 was rarely or never understood. Resident #76's upper and lower extremities had impairment on both sides. Resident #76 was dependent on staff for ADLs and used a manual wheelchair. Observation of Resident #76 on 01/08/24 at 3:35 P.M. revealed she was lying in bed with her eyes closed and did not respond when spoken to. Resident #76's hair was very greasy. Observation of Resident #76 on 01/09/24 at 1:38 P.M. revealed she was sitting in a padded chair in her room and her hair remained very greasy. Interview of State Tested Nursing Assistant (STNA) #585 on 01/09/24 at 1:50 P.M. confirmed Resident #76's hair was very greasy. STNA #585 stated Resident #76 was not usually on her assignment and she was shocked at how greasy Resident #76's hair was. STNA #585 stated Resident #76's hair needed washed. Interview of Licensed Practical Nurse (LPN) #508 on 01/09/24 at 1:53 P.M. confirmed Resident #76 had very greasy hair. LPN #508 stated Resident #76 sweated a lot and that contributed to her greasy hair. Review of the facility's undated policy titled Routine Resident Care revealed it was the policy of the facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social and spiritual needs and honor resident lifestyle preferences while in the care of the facility. The facility would provide routine daily care by a certified nursing assistant under the supervision of a licensed nurse including but not limited to bathing, dressing, eating and hydration and toileting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure prompt physician notification and timely care related to Resident #65's reddened and painful external genitals. This affected one (#65) of two residents observed for skin impairment. The facility census was 110. Findings include: Review of Resident #65's medical records revealed an admission date of 03/06/23. Diagnoses included multiple sclerosis, muscle weakness and neuromuscular bladder. Review of the care plan dated 12/10/23 revealed Resident #65 was at risk for impaired skin integrity. Interventions included apply barrier cream after incontinence care. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had intact cognition and was dependent for toileting and personal hygiene. Review of skin assessments dated 12/28/23 and 01/05/24 revealed Resident #65 had no skin impairment. Observation of incontinence care on 01/10/24 at 10:48 A.M. for Resident #65 with State Tested Nursing Assistant (STNA) #585 revealed reddened areas to the head of Resident #65's penis, shaft of penis and scrotum. STNA #585 stated she had not cared for Resident #65 for at least two weeks and was not aware of the reddened areas prior to the current observation. STNA #585 completed Resident #65's incontinence care and applied barrier cream to the reddened areas. Interview with Resident #65 at the time of the observation revealed he had pain in his penis area. Interview on 01/11/24 at 10:23 A.M. with STNA #559 revealed she had cared for Resident #65 the previous week and had observed his reddened penis and scrotum. STNA #559 reported the reddened areas to Licensed Practical Nurse (LPN) #519. At the time of interview STNA #559 performed incontinence care for Resident #65 and indicated the reddened areas to his penis and scrotum appeared to be worse from when she had cared for him the previous week. During the provision of incontinence care STNA #559 exited Resident #65's room and returned with LPN #519. LPN #519 observed Resident #65's penis and scrotum and stated she had not been aware of the reddened areas previously. STNA #559 then stated to LPN #519 she had informed her of the reddened areas the previous week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review the facility failed to provide care and services to ensure Resident #59 was provided incontinence care timely and Resident #80's urine specimen was sent to the lab timely and urinary tract infection treated promptly. This affected one resident (Resident #59) of three residents reviewed for incontinence and one resident (Resident #80) of three residents reviewed for urinary tract infections. The facility census was 111. Findings include: 1. Review of Resident #59's medical record revealed an admission date of 02/24/21 and diagnoses included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, type two diabetes mellitus with hyperglycemia, and need for assistance with personal care. Review of Resident #59's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 was cognitively intact. Resident #59 was dependent on facility staff for toileting and personal hygiene. Review of Resident #59's care plan dated 03/05/21 revealed Resident #59 had incontinence of bowel and bladder at times. Resident #59 would remain free of skin breakdown due to incontinence. Interventions included check Resident #59 for incontinence, wash, rinse, and dry perineum and change clothing as needed after incontinence episodes; Resident #59 used disposable incontinence briefs and change as needed, and Resident #59 preferred double briefs. Interview of Resident #59 on 01/08/24 at 9:46 A.M. revealed Resident #59 had not had her incontinence brief changed since last night. Resident #59 stated it often happened that her incontinence brief was not changed timely and sometimes it was not changed until after lunch was served. Resident #59 stated it was uncomfortable lying in urine. Observation of State Tested Nursing Assistants (STNAs) #549 and #723 providing incontinence care for Resident #59 on 01/08/24 at 10:18 A.M. revealed Resident #59 was wearing two incontinence briefs which were saturated with urine. Resident #59's sheet, and reusable chux pad were wet with urine and an outline of dried yellow urine could be seen around the wet urine on both the sheet and reusable chux pad. Resident #59 stated she was not changed timely, her incontinence brief was not changed often enough and that was why she requested two incontinence briefs. STNAs #549 and #723 confirmed Resident #59's two incontinence briefs were saturated with urine and her sheet and chux pad were wet with urine and also had dried urine on them. STNAs #549 and #723 stated the night shift aides did not always change residents timely and it depended on what aides were working. STNA #549 stated some night shift aides changed residents timely and some did not. Resident #59's bottom and top of posterior thighs were a little reddened, and there was no skin breakdown. Review of Resident #59's aide charting revealed Resident #59's incontinence brief was changed on 01/07/24 at 11:27 P.M. and there was no further evidence Resident #59's incontinence brief was changed until 01/08/24 at 1:14 P.M. Interview of the Director of Nursing (DON) on 01/11/24 at 7:09 A.M. revealed typically it would not be alright for a resident to have two incontinence briefs on, but if it was their preference it would be allowed. The DON was not aware Resident #59 requested two incontinence briefs because she was not changed timely and would look into the matter. Review of the facility's undated policy titled Routine Resident Care revealed it was the policy of the facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social and spiritual needs and honor resident lifestyle preferences while in the care of the facility. The facility would provide routine daily care by a certified nursing assistant with specialized training in rehabilitation, restorative care under the supervision of a licensed nurse including but not limited to toileting, providing care for incontinence with dignity and maintaining skin integrity. 2. Review of Resident #80's medical record revealed an admission date of 03/13/23 and diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the left non-dominant side, chronic obstructive pulmonary disease, and epilepsy. Review of Resident #80's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 had moderate cognitive impairment. Resident #80 was dependent on staff for Activity of Daily Living (ADL). Review of Resident #80's care plan dated 03/24/23 revealed Resident #80 was incontinent of urine related to impaired cognition, impaired mobility, neurological conditions. Resident #80 would decrease frequency of incontinence episodes. Interventions included to observe for signs and symptoms of a urinary tract infection such as pain, burning, cloudiness, fever, altered mental status, foul smelling urine etcetera. Observe and report to medical provider if identified. Review of Resident #80's progress notes dated 12/22/23 at 10:26 A.M. revealed Resident #80 was having hematuria (blood in urine). The Nurse Practitioner was notified and new orders were given for a STAT (immediate) Complete Blood Count with differential, Basic Metabolic Panel, and urinalysis, culture and sensitivity. The Nurse Practitioner was made aware the urinalysis and urine culture and sensitivity could not be collected until 12/26/23 due to the holiday. Review of Resident #80's physician orders from 12/22/23 through 12/28/23 did not reveal orders for a urinalysis or a urine culture and sensitivity. Review of Resident #80's physician orders dated 12/28/23 revealed urine for urinalysis and urine culture and sensitivity to be collected for pickup on 12/29/23. Review of Resident #80's progress notes from 12/23/23 through 01/02/24 did not reveal further documentation related to the appearance of Resident #80's urine or symptoms of a urinary tract infection. The progress notes did not have documentation regarding Resident #80's orders for a urinalysis and urine culture and sensitivity. Review of Resident #80's progress notes dated 01/02/24 at 12:51 P.M. revealed an order was placed for a urinalysis and a urine culture and sensitivity to be completed on 01/03/24. Review of Resident #80's physician orders dated 01/02/24 revealed an order for a urinalysis and a urine culture and sensitivity to be collected for lab pickup on 01/03/24. Review of Resident #80's progress notes dated 01/02/24 at 3:10 P.M. revealed a urine specimen was collected via straight catheter for lab pick up on 01/03/24. Review of Resident #80's progress notes dated 01/04/24 at 12:25 P.M. revealed Resident #80's urinalysis results showed white blood cells greater than 50, culture and sensitivity pending. Review of Resident #80's Lab Results Report revealed Resident #80's urinalysis with culture and sensitivity was reported on 01/07/24 at 2:51 P.M. The Report included Resident #80's urine had greater than 100,000 colony forming units per milliliter of Escherichia Coli (E Coli). Review of Resident #80's progress notes dated 01/08/24 at 2:47 P.M. revealed Resident #80's urinalysis was reviewed by the Nurse Practitioner and new orders for Cipro (antibiotic) 250 milligrams (mg) by mouth two times a day for three days for urinary tract infection. Review of Resident #80's physician orders dated 01/08/24 at 2:56 P.M. revealed Ciprofloxacing HCl Oral tablet 250 mg, give 250 mg by mouth every morning and at bedtime for E Coli for three days. Interview of Clinical Manager/Registered Nurse (CM/RN) #595 on 01/09/24 at 4:27 P.M. revealed she was the Infection Preventionist for the facility. CM/RN #595 revealed when a resident (not hospice)had symptoms of a urinary tract infection the Nurse Practitioner was notified and orders were obtained for a urinalysis and culture and sensitivity. The specimen was usually collected within 48 hours. Pain with urination, change in color or smell, and blood in urine were all symptoms of a urinary tract infection. If the nurse was not able to obtain the urine specimen within 48 hours for reasons like she was not able to straight cath the resident, the resident was incontinent, or the resident refused then the Nurse Practitioner or physician would be notified. Interview of Licensed Practical Nurse (LPN) #584 on 01/10/24 at 8:53 A.M. revealed on 12/22/23 an aide told her Resident #80 had blood in his urine. LPN #584 contacted the Nurse Practitioner and received an order for a urinalysis and culture and sensitivity. LPN #584 could not obtain the urine specimen right away because the lab was closed for the Christmas holiday and Resident #80's urinalysis and culture and sensitivity would have to wait until 12/26/23 to be collected. The lab would not collect a STAT urine on the weekends or holidays. LPN #584 stated Resident #80 was for sure straight cathed on 12/26/23 because she was told on 12/27/24 that a urinalysis was pending. Interview of the Director of Nursing (DON) on 01/10/24 at 1:27 P.M. revealed an attempt to collect Resident #80's urine was made on 12/28/23's night shift for pick up on 12/29/23. The attempt to collect Resident #80's urine was unsuccessful because enough urine could not be collected from the straight cath. The DON stated Resident #80's urine was unable to be collected until 01/02/24 because the lab would not take urine specimens on any weekend. The DON did not see any documentation in Resident #80's progress notes regarding why the urine specimen was not collected before 01/02/24 including if the Nurse Practitioner or Physician was informed that the urine could not be collected. The DON was off work on those days and did not know why the urine was not collected sooner. The DON stated she would think the antibiotics should have been started before 01/08/24. The urinalysis results were reported on 01/03/24 and the urine culture and sensitivity results were reported on 01/07/24. Review of the facility lab STAT (immediately) Test List dated 10/2022 included urinalysis.

Based on observation and interview the facility failed to provide a clean and sanitary environment. This affected Resident #18. The facility census was 110. Findings include: Observation on 01/10/24 at 11:15 A.M. revealed Resident #18 was in bed and non verbal. Further observation revealed a tube feeding pole next to the resident's bed that had dried tube feeding formula on it. Dried tube feeding formula was also observed on the wall behind the pole and underneath the pole. Further observation revealed a towel underneath the tube feeding pole that had dried tube feed and gnats on it. At time of observation Licensed Practical Nurse (LPN) #576 entered Resident #18's room and confirmed the observation.

Based on resident interviews and record review the facility failed to promptly address concerns regarding palatability of food. This affected 105 residents who received meals from the kitchen. Six residents received nothing by mouth (#3, #18, #20, #53, #76 and #90). The census was 111. Findings include: Review of the food council minutes for the past year revealed the following concerns from 01/10/23 through 12/23/23. On 01/10/23: The food is cold mostly at breakfast. Staff are telling residents they do not have something because they don't want to make it. Not using hot plates on the weekends. On 02/21/23: Burnt grilled cheese. Can we have a whole baked potatoe, not half? On 03/15/23: Roast pork and beef could be more tender. On 05/16/23: Condiments are missing on trays. Breakfast is usually cold-are pellet warmers on? and Not getting what is on ticket. On 06/20/23: Cold food. On 07/11/23: Rice is always overcooked. Broccoli is overcooked. Chicken was dry. On 08/24/23: Chicken tenders and patties are hard. Broccoli is overcooked. Diced potatoes are overcooked and mushy; more meat. On 09/12/23: Roast pork and beef are tough. On 10/02/23: Cook fish longer-feels slimy. On 12/13/23: Oven roasted potatoes are rock hard. Interviews on 01/08/24 and 01/09/24 revealed the following 11 complaints about the food. 1. Interview on 01/08/24 at 9:51 A.M. with Resident #59 revealed the food is terrible. It is cold at times. Dinner yesterday had meat that was so hard you could not cut it or put a fork in the fish. I only ate the potatoes, portions are small. 2. Interview on 01/08/24 at 10:06 A.M. with Resident #49 revealed the food was inedible. 3. Interview on 01/08/24 at 10:19 A.M. with Resident #28 revealed meat was tough. Food was cold at times and the portions are small. 4. Interview on 01/08/24 at 11:01 A.M. with Resident #6 revealed they have small portions. 5. Interview on 01/08/24 at 11:30 A.M. with Resident # 1 revealed The food is hard as a rock. 6. Interview on 01/08/24 at 1:56 P.M. with Resident #31 revealed The eggs are burnt and they try to hide it underneath. They are not following the preferences and the meat is hard. 7. Interview on 01/08/24 at 2:39 P.M. with Resident #7 revealed The food is horrible. 8. Interview on 01/09/24 at 7:51 A.M. with Resident #54 revealed The food is cold everyday. The portions are small and they need more meat. 9. Interview on 01/09/24 at 10:23 A.M. with Resident #260 revealed The food is horrible. They do not use pellets [plate warmers] on the weekends. 10. Interview on 01/09/24 at 10:51 A.M. with Resident #21 revealed Sometimes the food is horrid. Can't cut it with a knife. We eat PBJ's. Sick of it! 11. Interview on 01/09/24 at 4:00 P.M. with Resident #51 revealed they never use pellets on the weekends. Review of the facility policy titled Food: Quality and Palatability, revised 09/2017, revealed food would be palatable, attractive and served at a safe and appetizing temperature. Review of the facility policy titled Ohio Resident Grievance, dated 05/30/19, revealed the facility was to provide resident centered care meeting psychosocial , physical and emotional needs and concerns of the residents.

**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 restorative therapy services were initiated and completed for Residents #20, #54, #80, #100 and #360 per discharge recommendations from therapy. This affected five (Residents #20, #54, #80, #100 and #360) of 14 residents who had restorative services recommended by therapy. The facility census was 111. Findings include: 1. Review of Resident #80's medical record revealed an admission date of 03/13/23 and diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction affecting the left non-dominant side, chronic obstructive pulmonary disease, and epilepsy. Review of Resident #80's Physical Therapy Discharge summary dated [DATE] included Restorative Nursing Program/Functional Maintenance Program (RNP/FMP), to facilitate Resident #80 maintaining current level of performance and in order to prevent decline, development and instruction in the following RNPs have been completed with interdisciplinary team (IDT), Range of Motion (ROM) (active) and ROM (passive). Review of Resident #80's care plan did not reveal a care plan related to restorative services. Review of Resident #80's Therapy Referral to Restorative dated 09/04/23 revealed active range of motion (AROM), passive range of motion (PROM) of bilateral lower extremities (BLE) to prevent contractures, skin breakdown one to two times a day, five to seven times a week for 10 to 15 minutes. Review of Resident #80's medical record including aide charting from 12/01/23 through 01/09/24 did not reveal evidence restorative services recommendations were completed. Observation on 01/10/24 at 8:30 A.M. revealed Resident #80 was lying in bed on his left side with his legs bent and pulled up towards his chest. Resident #80 stated it was hard for him to move around because his legs did not want to stretch out. Interview of Director of Rehab (DOR) #722 on 01/09/24 at 3:39 P.M. revealed after a resident's therapy was completed a restorative program was recommended for each resident if it was indicated and the recommendations were given to the Director of Nursing (DON). The DON put the recommendations in the task charting in the resident's medical record for the aides to complete. Interview of the DON on 01/10/24 at 9:38 A.M. revealed the facility did not have a restorative program. The DON stated she started working in the facility in September 2023. DOR #722 gave her resident referrals for restorative therapy services when therapy was completed and the DON put the restorative tasks in the residents' medical records for the aides to complete. The DON confirmed Resident #80's medical record aide charting did not have documentation aides provided restorative services. The DON could not say if a referral was not received from DOR #722 or the referral was not put in Resident #80's aide charting. The DON confirmed Resident #80 did not receive restorative services after his discharge from therapy. Interview of State Tested Nursing Assistants (STNAs) #505 and #549 on 01/11/24 at 1:42 P.M. revealed if a resident needed restorative therapy services it was documented in the aide charting and if they were not sure if a resident needed services they would check the Point of Care (POC) aide charting. STNA #505 stated if a resident received restorative services it was for a certain amount of minutes each day. STNA #505 stated if an STNA was from an agency or new to the facility they could look in the aide charting to find out which residents needed restorative services. When asked which residents in their assignments received restorative services, STNAs #505 and #549 did not indicate Resident #80 received restorative therapy. Review of the facility's undated policy titled Restorative Program revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. Safety was a primary concern for the residents, staff and visitors. The purpose of the policy was to provide direction and guidance to the clinical team to assess and implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Resident evaluation for consideration of the restorative treatment plan would include but was not limited to cognitive abilities to participate independently or with assistance, medical conditions to participate independently or with assistance. Care plan addresses but not limited to types of treatments, measurable objectives, resident goals, provided for increasing and or promotion independence to the extent clinically possible for ROM and mobility. 2. Review of Resident #100's medical record revealed an admission date of 10/28/23 and diagnoses included unspecified abnormalities of gait and mobility, weakness, and metabolic encephalopathy. Review of Resident #100's Therapy Referral to Restorative dated 11/20/23 revealed walk to dine or walking daily one to two times a day, four to five times per week for 10 to 15 minutes. Resident #100 required contact guard times one and needed to stay close to walker. Resident #100 was recommended to walk 100 to 150 feet using a front wheeled walker. Review of Resident #100's medical record including aide charting from 12/01/23 through 01/09/24 did not reveal documentation restorative services were initiated or provided. Interview of Director of Rehab (DOR) #722 on 01/09/24 at 3:39 P.M. revealed after a resident's therapy was completed a restorative program was recommended for each resident if it was indicated and the recommendations were given to the Director of Nursing (DON). The DON put the recommendations in the task charting in the resident's medical record for the aides to complete. Interview of the DON on 01/10/24 at 9:38 A.M. revealed the facility did not have a restorative program. The DON stated she started working in the facility in September 2023. The DON indicated DOR #722 gave her resident referrals for restorative therapy services when therapy was completed and the DON put the restorative tasks in the resident's medical record for the aides to complete. Follow up interview of the DON on 01/11/24 at 10:56 A.M. revealed Resident #100 was independent and not appropriate for restorative services. Interview of State Tested Nursing Assistants (STNAs) #505 and #549 on 01/11/24 at 1:42 P.M. revealed if a resident needed restorative therapy services it was documented in the aide charting and if they were not sure if a resident needed services they would check the Point of Care (POC) aide charting. STNA #505 stated if a resident received restorative services it was for a certain amount of minutes each day. STNA #505 stated if an STNA was from an agency or new to the facility they could look in the aide charting to find out which residents needed restorative services. When asked which residents in their assignments received restorative services, STNAs #505 and #549 did not indicate Resident #100 received restorative therapy. Review of the facility's undated policy titled Restorative Program revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. Safety was a primary concern for the residents, staff and visitors. The purpose of the policy was to provide direction and guidance to the clinical team to assess and implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Resident evaluation for consideration of the restorative treatment plan would include but was not limited to cognitive abilities to participate independently or with assistance, medical conditions to participate independently or with assistance. Care plan addresses but not limited to types of treatments, measurable objectives, resident goals, provided for increasing and or promotion independence to the extent clinically possible for ROM and mobility. 3. Review of Resident #360's medical record revealed an admission date of 09/29/23 and diagnoses included chronic obstructive pulmonary disease, unspecified abnormalities of gait and mobility. Review of Resident #360's Therapy Referral to Restorative dated 12/08/23 revealed Resident #360 was recommended transfers to chair, toilet in room, sit-to-stand (STS) transfers to front wheeled walker (FWW) one to two times per day, three to five times a week for 10 to 15 minutes. Amount of assistance was contact guard times one and safety cues for hand placement. Review of Resident #360's medical record including aide charting from 12/01/23 through 01/09/24 did not reveal documentation restorative services were initiated or provided. Interview of Director of Rehab (DOR) #722 on 01/09/24 at 3:39 P.M. revealed after a resident's therapy was completed a restorative program was recommended for each resident if it was indicated and the recommendations were given to the Director of Nursing (DON). The DON put the recommendations in the task charting in the resident's medical record for the aides to complete. Interview of the DON on 01/10/24 at 9:38 A.M. revealed the facility did not have a restorative program. The DON stated she started working in the facility in September 2023. The DON indicated DOR #722 gave her resident referrals for restorative therapy services when therapy was completed and the DON put the restorative tasks in the resident's medical record for the aides to complete. Follow up interview of the DON on 01/11/24 at 10:56 A.M. revealed Resident #360 was continent, used a wheelchair to go to the bathroom and she did not feel he was appropriate for restorative services. Interview of State Tested Nursing Assistants (STNAs) #505 and #549 on 01/11/24 at 1:42 P.M. revealed if a resident needed restorative therapy services it was documented in the aide charting and if they were not sure if a resident needed services they would check the Point of Care (POC) aide charting. STNA #505 stated if a resident received restorative services it was for a certain amount of minutes each day. STNA #505 stated if an STNA was from an agency or new to the facility they could look in the aide charting to find out which residents needed restorative services. When asked which residents in their assignments received restorative services, STNAs #505 and #549 did not indicate Resident #360 received restorative therapy. Review of the facility's undated policy titled Restorative Program revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. Safety was a primary concern for the residents, staff and visitors. The purpose of the policy was to provide direction and guidance to the clinical team to assess and implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Resident evaluation for consideration of the restorative treatment plan would include but was not limited to cognitive abilities to participate independently or with assistance, medical conditions to participate independently or with assistance. Care plan addresses but not limited to types of treatments, measurable objectives, resident goals, provided for increasing and or promotion independence to the extent clinically possible for ROM and mobility. 4. Review of Resident #20's medical record revealed an admission date of 09/11/20 and diagnoses included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, contracture of muscle right and left hands, and need for assistance with personal care. Review of Resident #20's Physical Therapy Discharge summary dated [DATE] included Restorative Nursing Program/Functional Maintenance Program (RNP/FMP), to facilitate Resident #20 maintaining current level of performance and in order to prevent decline, development and instruction in the following RNPs have been completed with the interdisciplinary team (IDT): bed mobility and range of motion (ROM), active. Review of Resident #20's Wellness/Restorative Referral Form dated 05/15/23 included to increase, maintain bilateral lower extremity (BLE) knee, ankle ROM. Exercises to improve BLE mobility and strength. This was to be completed two to three times per day, six to seven times a week for 10 to 15 minutes. The exercises could be completed by one staff person, and the packet was in Resident #20's room. The exercises included knee, hip, ankle active and passive ROM. Review of Resident #20's care plan revised 05/30/23 did not reveal a care plan related to restorative services. Review of Resident #20's medical record including aide charting from 12/01/23 through 01/09/24 did not reveal evidence restorative services recommendations were completed. Interview of Director of Rehab (DOR) #722 on 01/09/24 at 3:39 P.M. revealed after a resident's therapy was completed a restorative program was recommended for each resident if it was indicated and the recommendations were given to the Director of Nursing (DON). The DON put the recommendations in the task charting in the resident's medical record for the aides to complete. Interview of the DON on 01/10/24 at 9:38 A.M. revealed the facility did not have a restorative program. The DON stated she started working in the facility in September 2023. The DON indicated DOR #722 gave her resident referrals for restorative therapy services when therapy was completed and the DON put the restorative tasks in the resident's medical record for the aides to complete. Interview of State Tested Nursing Assistants (STNAs) #505 and #549 on 01/11/24 at 1:42 P.M. revealed if a resident needed restorative therapy services it was documented in the aide charting and if they were not sure if a resident needed services they would check the Point of Care (POC) aide charting. STNA #505 stated if a resident received restorative services it was for a certain amount of minutes each day. STNA #505 stated if an STNA was from an agency or new to the facility they could look in the aide charting to find out which residents needed restorative services. When asked which residents in their assignments received restorative services, STNAs #505 and #549 did not indicate Resident #20 received restorative therapy. Review of the facility's undated policy titled Restorative Program revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. Safety was a primary concern for the residents, staff and visitors. The purpose of the policy was to provide direction and guidance to the clinical team to assess and implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Resident evaluation for consideration of the restorative treatment plan would include but was not limited to cognitive abilities to participate independently or with assistance, medical conditions to participate independently or with assistance. Care plan addresses but not limited to types of treatments, measurable objectives, resident goals, provided for increasing and or promotion independence to the extent clinically possible for ROM and mobility. 5. Review of Resident #54's medical record revealed an admission date of 11/03/23 and diagnoses included multiple sclerosis, unspecified abnormalities of gait and mobility, and weakness. Review of Resident #54's Therapy Referral to Restorative included right knee brace four to five hours daily, hip abduction brace daily one time a day, six to seven times a week for four hours. Amount of assistance was one person to don brace. Review of Resident #54's medical record including aide charting from 12/01/23 through 01/09/24 did not reveal documentation restorative services were initiated or provided Interview of Director of Rehab (DOR) #722 on 01/09/24 at 3:39 P.M. revealed after a resident's therapy was completed a restorative program was recommended for each resident if it was indicated and the recommendations were given to the Director of Nursing (DON). The DON put the recommendations in the task charting in the resident's medical record for the aides to complete. Interview of the DON on 01/10/24 at 9:38 A.M. revealed the facility did not have a restorative program. The DON stated she started working in the facility in September 2023. The DON indicated DOR #722 gave her resident referrals for restorative therapy services when therapy was completed and the DON put the restorative tasks in the resident's medical record for the aides to complete. Interview of State Tested Nursing Assistants (STNAs) #505 and #549 on 01/11/24 at 1:42 P.M. revealed if a resident needed restorative therapy services it was documented in the aide charting and if they were not sure if a resident needed services they would check the Point of Care (POC) aide charting. STNA #505 stated if a resident received restorative services it was for a certain amount of minutes each day. STNA #505 stated if an STNA was from an agency or new to the facility they could look in the aide charting to find out which residents needed restorative services. When asked which residents in their assignments received restorative services, STNAs #505 and #549 did not indicate Resident #54 received restorative therapy. Review of the facility's undated policy titled Restorative Program revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical and emotional needs and concerns of the residents. Safety was a primary concern for the residents, staff and visitors. The purpose of the policy was to provide direction and guidance to the clinical team to assess and implement a plan of action for resident-specific care to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Resident evaluation for consideration of the restorative treatment plan would include but was not limited to cognitive abilities to participate independently or with assistance, medical conditions to participate independently or with assistance. Care plan addresses but not limited to types of treatments, measurable objectives, resident goals, provided for increasing and or promotion independence to the extent clinically possible for ROM and mobility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure monitoring of residents on oxygen for complications such as skin integrity issues, failed to ensure protective foam was applied to oxygen tubing to protect skin integrity, and failed to ensure current physician orders for the use of oxygen. This affected four (#6, #22, #40 and #45) of five residents observed for oxygen therapy. The facility census was 110. Findings include: 1. Review of Resident #6's medical records revealed an admission date of 08/29/23. Diagnoses included respiratory failure and chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had intact cognition. Review of the care plan dated 12/03/23 revealed Resident #6 had COPD. Interventions included provide oxygen therapy as ordered and change oxygen tubing per policy. Review of current physician orders for January 2024 revealed no orders related to oxygen therapy. Interview on 01/08/24 at 11:07 A.M. with Resident #6 revealed she wore her oxygen continuously and she had a sore area to the back of her right ear. Resident #6 stated she had requested foam ear pieces to be placed on her oxygen tubing over a month ago, however she had not been given them. Observation at time of interview revealed a reddened area to the back of Resident #6's right ear with a small amount of blood around the reddened area. Interview on 01/09/24 at 3:03 P.M. with Resident #6 revealed she still did not have any foam placed on her oxygen tubing. At time of interview Registered Nurse (RN) #595 entered Resident #6's room and confirmed no foam on the oxygen tubing and Resident #6 had a reddened area to her right ear. RN #595 stated foam should be placed on the oxygen tubing for residents who wore continuous oxygen. 2. Review of Resident #40's medical records revealed an admission date of 01/28/23. Diagnoses included chronic obstructive pulmonary disease (COPD). Review of care plan dated 09/22/23 revealed Resident #40 had COPD. Interventions included administer oxygen as ordered and change oxygen tubing per policy. Review of current physician orders for January 2024 revealed Resident #40 was ordered oxygen at four liters per minute. Observation on 01/09/24 at 3:20 P.M. revealed Resident #40 was in a wheelchair in his room. Resident #40 had toilet tissue wrapped around his oxygen tubing near his ear. Interview with Resident #40 at time of observation revealed the oxygen tubing had irritated his ears and he had asked the staff to place foam to the tubing over a month ago. Resident #40 further stated he had cut a piece of the oxygen tubing a long time ago (unable to state specific timeframe) that was placed in his nose because it had irritated the inside of his nose and caused a blister. Observation revealed the prong intended to sit inside the left nostril had been cut. LPN #576 confirmed the observations and stated Resident #40 should have had foam dressing to his oxygen tubing to protect the skin behind his ears and his oxygen tubing should have been changed once Resident #40 had cut the nasal prong off. 3. Review of Resident #45's medical records revealed an admission date of 04/24/23. Diagnoses included asthma. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had intact cognition. Review of Resident #45's care plan dated 10/12/23 revealed Resident #45 had asthma. Interventions included administer oxygen as ordered and change oxygen tubing per policy. Review of current physician orders for January 2024 revealed no orders regarding oxygen therapy. Observation on 01/09/24 at 3:14 P.M. revealed Resident #45 was resting in bed. Further observation revealed no foam to Resident #45's oxygen tubing. At the time of the observation, Licensed Practical Nurse (LPN) #576 confirmed there was no protective foam on the oxygen tubing to protect the skin behind Resident #45's ears. LPN #576 stated Resident #45 should have had foam placed on the oxygen tubing. 4. Review of Resident #22's medical records revealed an admission date of 07/29/22. Resident #22 had a diagnosis of chronic obstructive pulmonary disease (COPD). Review of the care plan dated 12/18/23 revealed Resident #22 had COPD. Interventions included administer oxygen as ordered and change oxygen tubing per policy. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition. Review of current physician orders for January 2024 revealed no orders related to oxygen therapy. Observation on 01/09/24 at 3:17 P.M. revealed Resident #22 was up in a wheelchair in her room. Further observation revealed no foam to Resident #22's oxygen tubing. At the time of the observation, Licensed Practical Nurse (LPN) #576 confirmed there was no protective foam on the oxygen tubing to protect the skin behind Resident #22's ears. LPN #576 stated Resident #22 should have had foam placed on the oxygen tubing.

Based on observation and interview the facility failed to ensure expired medications were discarded. This had the potential to affect 51 residents residing on the A and C halls. Facility census was 111. Findings include: Observation of medication administration on 01/09/23 at 10:02 A.M. with Licensed Practical Nurse (LPN) #576 for Resident #51 revealed LPN #576 obtained a bottle of aspirin 81 milligrams (mg). Further observation revealed the aspirin had an expiration date of December 2023. LPN #576 confirmed the expiration date and stated she did not check the expiration date prior to preparing the medications. Further observation of the medication cart with LPN #576 revealed a bottle of oyster shell supplement with an expiration date of November 2023 and multiple loose unidentifiable pills in various areas of the drawers. LPN #576 confirmed the loose pills and expired medications and stated she did not check the medication cart and was not aware of who was responsible for checking the carts. Observation of another medication cart on 01/09/23 with Registered Nurse (RN) #529 revealed a bottle of vitamin C with an expiration date of October 2023, a bottle of Optium (vitamin supplement) with an expiration date of December 2023 and aspirin 325 mg with an expiration date of August 2023. RN #529 verified the expired medications and stated she did not check the expiration dates prior to administering medications. Review of facility's undated policy titled Stock Medications revealed medications were to be discarded when out of date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of Covid-19, the facility failed to maintain proper infection control procedures to prevent the spread of infection. This affected four residents (#7, #42, #65 and #88) and had the potential to affect eight residents (#17, #26, #42, #47, #52, #56, #71 and #102) residing on the D hall. The facility census was 110. Findings include: 1. Review of Resident #42's medical records revealed an admission date of 04/22/23. Diagnoses included respiratory failure and chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition. Resident #15 required set up assistance with eating and was dependent with toileting. Review of physician orders dated 01/05/24 revealed Resident #42 was on droplet precautions related to Covid positive results. Observation on 01/08/24 at 8:40 A.M. revealed signs posted outside of Resident #42's room that indicated Resident #42 was on isolation precautions and gown, gloves, mask and face shield were required prior to entering the room. Further observation revealed State Tested Nursing Assistant (STNA) #527, who was wearing a surgical mask, don a gown and gloves prior to entering Resident #42's room. Observation of the isolation bin located outside of Resident #42's room revealed the bin only contained gowns. Interview with STNA #42 upon exiting Resident #42's room revealed Resident #42 was Covid positive. STNA #42 confirmed she did not wear an N95 mask or eye protection while in Resident #42's room. STNA #527 was unaware a N95 was required when entering Resident #42's room. STNA #527 confirmed the isolation bin located outside of the room did not contain masks or face shields and stated surgical masks were located at the nurses station and she was unaware of where to locate a N95 mask or face shield. Interview on 01/10/24 at 12:45 P.M. with Registered Nurse (RN) #595 revealed she was the infection preventionist. RN #595 confirmed Resident #42 was Covid positive and stated staff were required to wear gown, gloves, N95 mask and eye protection prior to entering a Covid positive room. Review of facility policy titled Precaution and Transmission Based Precautions, revised 06/25/21 revealed staff were required to wear N95 mask, face shield, gown and gloves during care of Covid positive residents. Review of the CDC guidance updated 11/30/23 revealed recommended infection prevention and control practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection includes health care providers who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH approved particulate respirator with N95 filters or higher, gown, gloves, or a face shield that covers the front and sides of the face. 2. Observation of wound care for Resident #88 with Licensed Practical Nurse (LPN) #569 and the Wound Nurse Practitioner (WNP) on 01/09/24 at 2:20 P.M. revealed Resident #88 had a wound to his sacrum (tailbone) area and wounds to his left foot. LPN #569 and WNP did not disinfect the bedside table before placing the wound care supplies onto the bedside table. LPN #569 and WNP cleansed Resident #88's sacral wound and did not change their gloves prior to placing a clean dressing to the wound. LPN #569 and WNP proceeded to cleanse Resident #88's wounds on his left foot, wearing the same gloves that were worn during care of the sacral wound. LPN #569 and WNP cleansed Resident #88's foot wound and did not change their gloves prior to placing a new dressing to the foot wounds. Interview with LPN #569 and the WNP, after completion of wound care, confirmed they did not disinfect the beside table prior to placing wound supplies on it and they did not change their gloves or complete hand hygiene during wound care. 3. Observation of incontinence care for Resident #65 with State Tested Nurse Aide (STNA) #585 on 01/10/24 at 10:48 A.M. revealed Resident #65 was incontinent of stool. STNA #585 provided Resident #65 with incontinence care and did not remove her soiled gloves or wash her hands prior to assisting Resident #65 with dressing. Interview with STNA #585 on 01/10/24 at 11:57 A.M. confirmed STNA #585 did not change her soiled gloves after providing incontinence for Resident #65 stating I guess I never thought of doing that. 4. Observation of incontinence care for Resident #7 with State Tested Nurse Aide (STNA) #585 on 01/10/24 at 11:57 A.M. revealed Resident #7 was incontinent of urine. STNA #585 provided Resident #7 with incontinence care and did not remove her soiled gloves or wash her hands prior to applying lotion to Resident #7's arms and legs. Interview with STNA #585 confirmed she did not change her soiled gloves after providing incontinence care for Residents #7 and stated I guess I never thought of doing that. After the incontinence care was completed for Resident #7, Licensed Practical Nurse (LPN) #576 entered Resident #7's room to administer insulin. LPN #576 administered the insulin into the subcutaneous tissue of Resident #7's abdomen without wearing gloves. Interview with LPN #576 at time of observation revealed she should have worn gloves during insulin administration but she had forgotten.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews with staff and residents the facility failed to have sufficient staffing. This affected Residents #6, #10, #50, #36, #54, #59 and #105 and had the potential to affect all residents. The census was 111. Findings include: 1. Interview on 01/08/24 at 11:01 A.M. with Resident #6 revealed she waited over two hours for her call light to be answered on occasions. Interview on 01/08/24 at 10:34 A.M. with Resident #10 revealed she did not get her medications in a timely manner most days, it was inconsistent. She stated she did not get regular showers or bed baths. Interview on 01/08/24 at 2:20 P.M. with Resident #50 regarding staffing revealed They need more. When are they going to close this place? Interview on 01/08/24 at 2:41 P.M. with Resident #36 revealed he was told on more than one occasion not to put his call light on during meal tray pass. He also stated he made his own bed because staff did not get to it timely. Interview on 01/09/24 at 7:46 A.M. with Resident #54 revealed staff had not provided timely assistance into bed. Resident #54 stated she had been left in her wheelchair for more than five hours on occasions. 2. Observations throughout the survey from 01/08/24 through 01/11/24 revealed excessive call lights use and State Tested Nurse Aides (STNAs) appeared to be rushed and overwhelmed. Residents were observed in the halls looking for staff assistance. Interview on 01/10/24 at 2:15 P.M. with STNA #624 revealed concerns related to staffing. STNA #624 stated he was aware of residents on the C and D hall that had not received timely care that included incontinence care and showers. STNA #624 stated call lights had not been answered timely on occasions due to not enough staff. Interviews on 01/10/24 from 4:00 P.M. through 500 P.M. with STNA #505, STNA #539 and STNA #549 revealed they had up to 12 to 17 residents on their assignment at times. They stated there were many residents who required mechanical lifts and the acuity levels of the residents on Units C and D was high. STNA #505 stated charting did not get completed because they did not have time. Interview on 01/11/24 at 11:40 A.M. with STNA #559 revealed concerns related to staffing. STNA #559 stated there was not enough staff to provide timely incontinence care on occasions. STNA #559 stated residents had to wait long periods of time for their call lights to be answered and sometimes it took 45 minutes or longer to answer call lights. Review of the assignment sheets for Units C and D revealed there were 23 residents who needed assistance with transfers via a mechanical lift requiring two staff members. Interview with Licensed Practical Nurse #603 on 01/10/24 at 5:10 P.M. verified the number of residents on the C and D units needing mechanical lifts. 3. Review of Resident #54's medical records revealed an admission date of 11/03/23. Diagnoses included Multiple Sclerosis and need for personal care assistance. Review of Resident #54's care plan dated 11/03/23 revealed resident had self care deficits. Interventions included two or more staff for toileting, transfers and bathing. Review of Resident #54's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition. Resident #54 was dependent for toileting and transfers. Interview on 01/10/23 at 11:06 A.M. with Resident #54 revealed she had requested to be out of bed earlier in the morning and stated State Tested Nurse Aide (STNA) #585 had told her she would assist her out of bed prior to lunch. Interview on 01/10/24 at 2:24 P.M. with STNA #585 revealed she was aware of staff who not provided timely assistance for Resident #54's transfers. STNA #585 stated there had been staff that refused to assist Resident #54 out of bed and also had left Resident #54 up her wheelchair for long periods of time. STNA #585 stated she was aware Resident #54 preferred to be out of bed prior to lunch, however she had not had time before the end of her shift at 2:30 P.M. to assist Resident #54 out of bed. STNA #585 stated there was not enough staff to provide timely care on occasions and stated at times she was lucky to be able to perform two rounds of incontinence care during her shifts. STNA #585 said the residents on the C and D hall had a hight acuity level and there was not enough staff to provide timely care to those residents. Observation on 01/10/24 at 2:40 P.M. revealed Registered Nurse (RN) #595 and Licensed Practical Nurse (LPN) #603 assisting Resident #54 out of bed via a Hoyer (mechanical) lift. Interview with RN #595 and LPN #603 at time of observation revealed they were aware Resident #54 preferred to out of bed prior to lunch time and were unable to provide information regarding why Resident #54 had not been assisted out of bed prior to the observation. 4. Review of the medical record for Resident #10 revealed an admission date of 04/13/23. Diagnoses included chronic kidney disease, type two diabetes mellitus and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #10 revealed she was dependent for showers. Review of Resident #10's shower sheets revealed she received bed baths on 12/11/23, 12/18/23, 01/04/24 and 01/08/24. Interview on 01/10/24 at 5:10 P.M. with Licensed Practical Nurse #603 revealed there was no other documentation regarding showers/bed baths for Resident #10. 5. Review of Resident #59's medical record revealed an admission date of 02/24/21 and diagnoses included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, type two diabetes mellitus with hyperglycemia, and need for assistance with personal care. Review of Resident #59's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 was cognitively intact. Resident #59 was dependent on facility staff for toileting and personal hygiene. Review of Resident #59's care plan dated 03/05/21 revealed Resident #59 had incontinence of bowel and bladder at times. Resident #59 would remain free of skin breakdown due to incontinence. Interventions included check Resident #59 for incontinence, wash, rinse, and dry perineum and change clothing as needed after incontinence episodes; Resident #59 used disposable incontinence briefs and change as needed, and Resident #59 preferred double briefs. Interview on 01/08/24 at 9:49 A.M. revealed Resident #59 did not always get out of bed, even though she would like to get out of bed. Resident #59 often chose not to get out of bed because when she did agree to get out of bed the State Tested Nurse Aides (STNAs) did not put her back to bed when she was ready. Resident #59 stated the STNAs told her she had to wait and the STNAs on the next shift would put her to bed. Resident #59 indicated she waited long periods of time before she was assisted into her bed. Observation of STNAs #549 and #723 providing incontinence care for Resident #59 on 01/08/24 at 10:18 A.M. revealed Resident #59 was wearing two incontinence briefs which were saturated with urine. Resident #59's sheet, and reusable chux pad were wet with urine and an outline of dried yellow urine could be seen around the wet urine on both the sheet and reusable chux pad. Resident #59 stated she was not changed timely, her incontinence brief was not changed often enough and that was why she requested two incontinence briefs. STNAs #549 and #723 confirmed Resident #59's two incontinence briefs were saturated with urine and her sheet and chux pad were wet with urine and also had dried urine on them. STNAs #549 and #723 stated the night shift aides did not always change residents timely and it depended on what aides were working. STNA #549 stated some night shift aides changed residents timely and some did not. Resident #59's bottom and top of posterior thighs were a little reddened, and there was no skin breakdown. Interview on 01/11/24 at 1:42 P.M. of STNA #549 revealed staffing could be better. STNA #549 stated the residents on the long term care hall, which is where she was usually assigned, required a lot of care and often two people were needed for transfers and to provide care for the residents. STNA #549 stated residents often had to wait for their care because she had to search for another STNA or nurse to help her and it took time to find someone. STNA #549 stated charting often did not get completed because she was too busy caring for residents. 6. Observation on 01/08/24 at 2:14 P.M. of Resident #105 revealed he was sitting in a wheelchair in the entrance to his room and asked the surveyor to put him back to bed. Resident #105 resided in a room towards the end of the hall and there were no staff in the hall or at the nursing station. Resident #105 stated a little louder than the first time he asked, please put me back to bed, I am tired. There were still no staff in sight and the surveyor told Resident #105 she would find a staff person to assist him into bed. Resident #105 stated even louder please, please put me back to bed. Resident #105 said please help me. Observation of Resident #105's bed revealed the mattress was bare and did not have sheets or bed linens on it. The surveyor searched for a few minutes and found State Tested Nursing Assistant (STNA) #585 to help Resident #105. STNA #585 stated Resident #105 was not in her assignment, but she would put him back to bed. STNA #585 had to find sheets and a blanket and make the bed before she could help Resident #105 to lay down.

Based on observation, diet guide review, scoop size review and interview, the facility failed to ensure proper portion sizes of the pureed and regular/soft diets were served. This had the potential to affect 90 of 94 residents residing at the facility. Four residents (#34, #63, #66, and #69) were identified to receive nothing by mouth (NPO). The facility census was 94. Findings include: Observation of the meal tray line on 09/16/23 at 4:58 P.M. revealed [NAME] #225 was plating resident food items. The menu consisted of a meatball sub, green beans and french fries. [NAME] #225 indicated residents were to receive three meatballs per sub, a three-ounce scoop of green beans and 13 or greater number of fries. Observation of [NAME] #225 revealed he used his gloved hand to grab french fries from the steam table and placed the fries on the residents' plates with the gloved hand. No measurement was observed. [NAME] #225 confirmed he would not measure or count the fries, it was an estimate. The cook confirmed residents receiving regular/soft diet were to get three ounces of green beans using the three ounce scoop. Continued observation on the tray line revealed each food item also came in a pureed consistency. The pureed green beans had a blue scoop handle, the pureed meat balls had a blue scoop handle, and the pureed potatoes had a green scoop handle. [NAME] #225 revealed he did not know what size scoop was in each pureed item and confirmed he did not know what size scoop should be used to serve each pureed item. Dietary Aids #202 and #150 were also present and confirmed they did not know the proper scoop size to use for each meal item. Interview on 09/16/23 at 6:32 P.M. with Culinary Director #166 revealed the blue handled scoop was a two-ounce scoop, and the green handled scoop was a 2.66-ounce scoop. Residents receiving a pureed diet were to receive three ounces per serving (a tan/beige handled scoop) for meat and vegetables. Culinary Director #166 also revealed potatoes should be four ounces per serving which was a grey handled scoop. Culinary Director #166 verified with the regular/soft textured foods, the french fries should have been a four ounce scoop per serving and the green beans should also have been a four ounce scoop per serving. Record review of the Dishes and Scoop Size Chart confirmed the blue handled scoop was two ounces and the green handled scoop was 2.66 ounces. Record review of the facility Diet Guide Sheet revealed mashed potato serving size was ½ cup = four ounces (grey scoop), green beans ½ cup = four ounces (grey scoop), beef should be three ounces = 3/8 cup (beige scoop), and French fries ½ cup = four ounces (grey scoop). This deficiency represents non-compliance investigated under Complaint Number OH00146003.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #80 had received adequate intravenous (IV) care as well as wound care. This affected one (Resident #80) of one resident observed for IV care and one of two residents observed for wound care. The facility identified two residents with IV's and 12 residents with wounds. The facility census was 83. Findings include: Review of Resident #80's medical records revealed an admission date of 05/16/22. Diagnoses included quadriplegia, tracheostomy, gastrostomy (feeding tube placement), dysphasia (difficulty swallowing) and pneumonia diagnosed on [DATE]. Review of care plan dated 10/18/22 revealed no plan related to infection. Review of the Minimum Data Set (MDS) dated [DATE] revealed no recorded cognition status related to resident was rarely understood. Resident required total dependence for toileting, personal hygiene and eating. Review of physician orders for November 2022 revealed resident was ordered tracheostomy care every shift, change trach ties two times a week and as needed, cleanse wound to back of neck with normal saline, apply medicated honey, calcium alginate (wound dressing) and cover with foam dressing every day shift, monitor intravenous (IV) site for signs and symptoms of infection or dressing compromise every shift, change IV dressing every seven days and also as needed (starting on 11/17/22), and Cefepime (IV antibiotic) 2 grams every 8 hours from 11/17/22-11/22/22. Review of progress note dated 10/13/22 at 6:21 A.M. revealed resident had large amounts of brownish green odorous secretions coming from the resident's trach. Review of progress note dated 10/13/22 at 10:22 A.M. revealed resident continued to have secretions. Physician was notified and advised to send the resident to the hospital for evaluation and treatment. Review of progress note dated 10/13/22 at 5:22 P.M. revealed facility had contacted the hospital and was advised resident was being admitted for shortness of breath. Review of progress note dated 11/16/22 revealed resident was readmitted to the facility and was treated for pneumonia. Observation on 11/21/22 at 3:00 P.M. with Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed Resident #80 had an IV to her left upper arm. An IV dressing was not intact on top or bottom and was rolling up on the side with black colored debris on the bottom of the dressing and was dated 11/10/22. Observation on 11/22/22 at 10:40 A.M. with ADON and Licensed Practical Nurse (LPN) #250 revealed Resident #80 had a wound to the back of her neck. ADON had removed a foam dressing that appeared to have black colored debris on it and was dated 11/20/22 that was not covering the resident's wound. LPN #250 had then proceeded to remove the resident's trach ties and a strong foul odor was detected as she removed the ties. Further observation revealed the resident's trach ties had a large amount of reddish brown discharge that had dried on the ties. Further observation revealed the resident had an open wound to the back of her neck that was bleeding with thick purulent drainage coming from it. LPN #250 had not cleansed the resident's wound and had then applied a new foam dressing. Further observation revealed Resident #80 had a large thick piece of crusted debris that was close to her trach that LPN #250 had removed, as LPN #250 had removed the crusted debris the resident trach was observed to have had green colored debris on the outside. During observation, Resident #80 had coughed up a thick white substance. LPN #250 had then removed the resident's inner cannula (tube inside the trach that can be removed and cleaned when obstructions are observed), as LPN #250 removed the cannula the device was observed to have been covered inside and out with the thick white substance. ADON stated it had appeared as if the resident had not received trach care recently due to the observations made, and stated trach care should be performed daily and also as needed. The DON was made aware of the observations with ADON and LPN #250 regarding Resident #80's care on 11/22/22 at 11:57 A.M. The DON stated the resident had recently been hospitalized for pneumonia and was at the hospital from [DATE]-[DATE]. Review of facility policy titled Tracheostomy Care revised 12/21/18 revealed the trach ties are to be changed twice weekly and as needed and the inner cannula was to be cleaned daily and as needed. This deficiency represents non-compliance investigated under Complaint Number OH00136900.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure tracheostomy care had been provided. This affected one resident (#80) of one observed for tracheostomy care. The facility identified three residents with tracheostomies. The facility census was 83. Findings include: Review of Resident #80's medical records revealed an admission date of 05/16/22. Diagnoses included quadriplegia, tracheostomy, gastrostomy (feeding tube placement), dysphasia (difficulty swallowing) and pneumonia diagnosed on [DATE]. Review of Resident #80's care plan dated 10/18/22 revealed no plan related to infection. Review of Resident #80's Minimum Data Set (MDS) dated [DATE] revealed no recorded cognition status related to resident was rarely understood. Resident required total dependence for toileting, personal hygiene and eating. Review of physician orders for November 2022 revealed Resident #80 was ordered tube feeding continuously, tracheostomy care every shift, and change trach ties two times a week and as needed. Review of progress note dated 10/13/22 at 6:21 A.M. revealed Resident #80 had large amounts of brownish green odorous secretions coming from the resident's trach. Review of progress note dated 10/13/22 at 10:22 A.M. revealed Resident #80 continued to have secretions. Physician was notified and advised to send the resident to the hospital for evaluation and treatment. Review of progress note dated 10/13/22 at 5:22 P.M. revealed facility had contacted the hospital and was advised Resident #80 was being admitted for shortness of breath. Review of progress note dated 11/16/22 revealed Resident #80 was readmitted to the facility and was treated for pneumonia. Observation on 11/22/22 at 10:40 A.M. with Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) #250 revealed Resident #80 had a wound to the back of her neck. ADON had removed a foam dressing that appeared to have black colored debris on it and was dated 11/20/22 that was not covering the resident's wound. LPN #250 then proceeded to removed the resident's trach ties and a strong foul odor was detected as she removed the ties. Further observation revealed Resident #80's trach ties had a large amount of reddish brown discharge that had dried on the ties. Further observation revealed the resident had an open wound to back of her neck that was bleeding and thick purulent drainage coming from it. LPN #250 had not cleansed the resident wound and had then applied a new foam dressing. Further observation revealed Resident #80 had a large thick piece of crusted debris that was close to her trach that LPN #250 had removed, as LPN #250 had removed the crusted debris the resident trach was observed to have had green colored debris on the outside. During observation Resident #80 had coughed up a thick white substance. LPN #250 had then removed the resident's inner cannula (tube inside the trach that can be removed and cleaned when obstructions are observed), as LPN #250 removed the cannula the device was observed to have been covered inside and out with the thick white substance. ADON stated it had appeared as if Resident #80 had not received trach care recently due to the observations made, and stated trach care should be performed daily and also as needed. The DON was made aware of the observations with ADON and LPN #250 regarding Resident #80's care on 11/22/22 at 11:57 A.M. The DON stated Resident #80 had recently been hospitalized for pneumonia and was at the hospital from [DATE]-[DATE]. Review of facility policy titled Tracheostomy Care revised 12/21/18 revealed the trach ties are to be changed twice weekly and as needed and the inner cannula was to be cleaned daily and as needed. This deficiency represents non-compliance investigated under Complaint Number OH00136900.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were free from significant medication errors. This affected two residents (Resident #36 and Resident #80) of five reviewed for medications. The facility census was 83. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 10/23/20. Diagnoses included urinary incontinence and kidney stones. Review of the plan of care dated 10/05/22 revealed Resident #36 had a potential for infection related to recurrent urinary tract infections (UTI). Interventions included monitor for signs and symptoms of infection and report findings to the physician. Review of the Minimum Data Set (MDS) assessment, dated 10/06/22, revealed Resident #36 had intact cognition. Resident #36 required extensive assistance with toileting and personal hygiene. Resident #36 was incontinent of bowel and bladder. Review of physician orders for November 2022 revealed Resident #36 was ordered Macrobid (antibiotic) 100 milligrams (mg) in the morning prophetically for UTI's, Premarin (vaginal cream) 0.5 grams vaginally every Monday, Wednesday and Friday for recurrent UTI's, and Cefuroxine (antibiotic) 500 mg twice a day from 11/19/22-11/23/22. Review of urinalysis report dated 11/18/22 revealed Resident #36 was positive for a UTI. Review of Resident #36's medication administration records (MAR) from October-November 2022 revealed Resident #36 did not receive Premarin on 10/03/22, 10/05/22, 10/10/22, 10/12/22, 10/14/22, 10/24/22, 10/26/22, 10/31/22, 11/02/22, 11/04/22, 11/07/22, 11/09/22, 11/14/22, and 11/21/22. Interview on 11/21/22 at 8:54 A.M. with Resident #36 revealed she had not been receiving her ordered Premarin regularly. Resident #36 stated the medication was supposed to be given three times a week and she stated on some occasions she had received it once per week and at times not at all during the week. Resident #36 stated the medication was to be used for recurrent UTI's, and Resident #36 stated she was currently being treated for a UTI. Interview on 11/21/22 at 12:18 P.M. with the Director of Nursing (DON) confirmed Resident #36's physician ordered medication Premarin used to help prevent recurrent UTI's was not administered as ordered by the physician and Resident #36 was currently being treated for a UTI. 2. Review of Resident #80's medical record revealed an admission date of 05/16/22. Diagnoses included quadriplegia, tracheostomy, gastrostomy (feeding tube placement), dysphasia (difficulty swallowing) and pneumonia diagnosed on [DATE]. Review of Resident #80's care plan dated 10/18/22 revealed no plan related to infection. Review of Resident #80's MDS dated [DATE] revealed no recorded cognition status related to resident was rarely understood. Resident required total dependence for toileting, personal hygiene and eating. Review of physician orders for November 2022 revealed Resident #80 was ordered Cefepime (intravenous antibiotic) every eight (8) hours from 11/16/22-11/22/22. Review of progress note dated 10/13/22 at 6:21 A.M. revealed Resident #80 had large amounts of brownish green odorous secretions coming from the resident's trach. Review of progress note dated 10/13/22 at 10:22 A.M. revealed Resident #80 continued to have secretions. Physician was notified and advised to send the resident to the hospital for evaluation and treatment. Review of progress note dated 10/13/22 at 5:22 P.M. revealed facility had contacted the hospital and was advised Resident #80 was being admitted for shortness of breath. Review of progress note dated 11/16/22 revealed Resident #80 was readmitted to the facility and was treated for pneumonia. Observation on 11/21/22 at 3:00 P.M. revealed Resident #80's intravenous (IV) antibiotic bag was hanging on an IV pole and the medication bag was full. Observation was confirmed with the DON and she was unable to state why the IV medication had not been administered. Interview on 11/21/22 at 3:37 P.M. with Licensed Practical Nurse (LPN) #305 revealed she had connected Resident #80's IV antibiotics up to the resident at approximately 10:00 A.M. LPN #305 stated LPN #286 had informed she had disconnected the resident after the infusion had been completed. LPN #305 stated she had not been aware the antibiotic had not been infused. Interview on 11/21/22 at 4:05 P.M. with LPN #286 revealed she had heard Resident #80's IV pump beeping and she had entered the resident's room and the pump had indicated the infusion was complete. LPN #286 stated she had disconnected the resident's IV tubing and she had not noticed the medication had not infused. Review of facility policy titled Medication Administration revised 04/20/17 revealed medications were to be administered as prescribed. This deficiency represents non-compliance investigated under Complaint Number OH00137236 and Complaint Number OH00136900.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure medications were stored in locked compartments, labeled, and only authorized personnel had access. This affected one resident (Resident #60) of three residents observed for medications being left unattended. The facility census was 83. Findings include: Review of Resident #60's medical records revealed an admission date of 07/22/16. Diagnoses included hypothyroidism and depression. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #60 had intact cognition. Resident #60 required extensive assist with toileting and personal hygiene. Review of current physician orders for November 2022 Levothyroxine (thyroid medication) 125 micrograms (mcg) at bedtime, [NAME] (thyroid medication) 30 milligrams (mg) at bedtime, and Buspar (antidepressant) 300 mg in the morning. Observation on 11/21/22 at 7:13 A.M. revealed Resident #60 was sleeping in her bed. Resident #60 was observed to have had two medication cups on her bedside table, one medication cup contained two small beige colored pills and the other cup had two small white pills and one large white pill. Observation on 11/21/22 at 7:24 A.M. with Licensed Practical Nurse (LPN) #212 confirmed Resident #60 had the two medication cups on her bedside table with the medications in them. LPN #212 stated medications should not be left unattended and medications should be monitored during consumption. LPN #212 stated the medication cup that contained the 2 beige colored pills could have possibly been the ordered Levothyroxine. LPN #212 stated she was unsure what the other three medications were. Interview on 11/21/22 at 7:30 A.M. with the Director of Nursing (DON) revealed medications should not be left unattended in the resident's room. The DON was made aware Resident #60 had two medication cups left on her bedside table. Review of facility policy titled Medication Administration revised 04/20/17 revealed medications should not be left unattended. This deficiency represents non-compliance investigated under Complaint Number OH00136629.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide timely incontinence care. This affected three residents (#22, #68 and #80) of three observed for incontinence care. The facility identified 47 incontinent residents. The facility census was 83. Finding include: Review of Resident #22's medical records revealed an admission date of 09/11/20. Diagnoses included dementia and dysphasia (difficulty swallowing). Review of care plan dated 10/18/22 revealed resident was incontinent of bowel and bladder. No interventions were specified in the care plan. Review of Minimum Data Set (MDS) dated [DATE] revealed resident had impaired cognition. Resident #22 required extensive assistance with toileting and personal hygiene. Resident was incontinent of bowel and bladder. Review of Resident #68's medical records revealed an admission date of 12/01/17. Diagnoses included overactive bladder and multiple sclerosis. Review of Resident #68's care plan dated 10/02/22 revealed resident had self care deficits. Interventions included provide incontinence care as needed. Review of Resident #68's MDS dated [DATE] revealed resident had intact cognition. Resident required extensive assistance with toileting and personal hygiene. Resident was incontinent of bowel and bladder. Review of Resident #80's medical records revealed an admission date of 05/16/22. Diagnoses included quadriplegia, and aphasia (difficulty speaking). Review of Resident #80's MDS dated [DATE] revealed resident required total dependence for toileting and personal hygiene. Resident was incontinent of bowel and bladder. Review of care plan dated 11/16/22 revealed Resident #80 was incontinent of bowel and bladder. Interventions included provide incontinence care as needed. Observation of incontinence care on 11/21/22 at 7:37 A.M. for Resident #68 with State Tested Nursing Assistant (STNA) #220 and Licensed Practical Nurse (LPN) #305 revealed resident was incontinent of a large amount of urine that had saturated through the resident's incontinence brief, to the sheet and on to the mattress. Resident #68's sheets were observed to have had urine that was up to the resident's middle back as well as to the resident's knees. Resident #68 stated she had not received incontinence care since dinner the previous evening. STNA #220 stated she had not provided incontinence care for Resident #80 and was unable to state when Resident #68 had last been provided incontinence care. Observation on 11/21/22 at 8:14 A.M. revealed Residents #22 and #80 had a strong odor of urine observed from the doorway. Observation of incontinence care on 11/21/22 at 8:28 A.M. for Resident #22 with STNA #220 and LPN #263 revealed resident was incontinent of a large amount of urine that had a stale odor. Further observation revealed Resident #22 was wearing two incontinence briefs. STNA #220 stated she had not provided the resident with incontinence care and stated she was unaware Resident #22 was wearing two incontinence briefs. LPN #263 stated residents should not be wearing two incontinence briefs. Resident #22 was not interviewable. Observation of incontinence care on 11/21/22 at 8:43 A.M. for Resident #80 with STNA #220 and LPN #263 revealed Resident #80 was incontinent of a large amount of urine. Resident #80 was observed to have been wearing two incontinence briefs and had a strong odor of stale urine. Resident #80 was non-verbal. STNA #220 stated she had not provided incontinence care for the resident and was unable to state when Resident #80 had last received incontinence care. STNA #220 stated residents should not be wearing two incontinence briefs. This deficiency represents non-compliance investigated under Complaint Number OH00137236, Complaint Number OH00137281 and Complaint Number OH00136900.

Based on observation, interview and record review, the facility failed to ensure a clean and sanitary kitchen. This affected 81 residents receiving food from the kitchen (Resident #55 and Resident #80 were ordered nothing by mouth) and specifically affected Resident #36. The facility census was 83 residents. Findings include: 1. Observation of the kitchen on 11/16/22 starting at 9:45 A.M. with Dietary Manager (DM) #247 revealed there was debris on the floor in the store room including jelly on the floor. A large bag of sugar was crumpled open with a Styrofoam cup inside. In the freezer, there was melted chocolate ice cream on the ground. On the wall edge there was a line of frozen green beans and corn on the ground. In the cooler, a bag of shredded cheese was not securely wrapped, labeled or dated. The floors in the kitchen were grimy and not clean especially around the steam table. Interview on 11/16/22 at 9:45 A.M. with DM #247 verified the lack of clean floors across the kitchen and the areas of improper food storage identified. DM #247 verified the facility had a cockroach issue at the beginning of November 2022 and housekeeping services helped to do a deep clean of the kitchen on 11/04/22 and 11/05/22. DM #247 stated the dry storage room was to be swept weekly and the floors were to be mopped daily. DM #247 indicated the freezer floors were not clean as there had not been any freezer cleaner since March 2022. DM #247 verified no cleaning documentation was available prior to 10/30/22 and provided the undated kitchen cleaning sheets that were for the week including 11/16/22. DM #247 verified the lack of cleaning in the kitchen was counterintuitive to the facility's efforts in managing their cockroach issue. Review of an undated kitchen daily assignment sheet provided to the surveyor on 11/16/22 revealed the morning cook assignments were signed off for the entire week even though it was only Wednesday [11/16/22]. Mopping the trayline cooler floor, sweeping and mopping the dry storeroom, sweeping and mopping the walk-in cooler were all not signed off as completed. 2. Interview on 11/21/22 at 8:54 A.M. with Resident #36 revealed the kitchen had a second nest of cockroaches and she was concerned about the cleanliness in the kitchen. Observation of the kitchen on 11/21/22 at 10:16 A.M. with Director of Maintenance (DOM) #218 and one other surveyor present revealed the center steam table in the kitchen did not have wheels so could not be moved for further cleaning. Using a flashlight, one cockroach was observed under the steam table and it was alive. Interview on 11/21/22 at 10:21 A.M. with DOM #218 verified the cockroach was still alive and was located in the kitchen. DOM #218 verified the facility recently had a cockroach problem and was going to call pest control services again for further treatment. Interview on 11/21/22 at 12:16 P.M. with Pest Control Technician (PCT) #302 and DOM #218 indicated the facility's last visit for cockroaches was on 11/10/22. This deficiency represents non-compliance investigated under Complaint Number OH00137236.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, resident interview, and staff interview, the facility failed to maintain privacy during care for Resident #4 and #86, and failed to treat Resident #6 with dignity and respect during a dressing change. This affected three residents (Resident #4, #6 #86) of 24 reviewed for dignity and respect. The facility census was 96 residents. Findings include. 1. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with the diagnoses of morbid obesity, venous insufficiency, obstructive sleep apnea, lymphedema, hyronephrosis, assistance with personal care, and COVID-19. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #4 had intact cognition and required extensive assistance of one staff member for Activities of Daily Living (ADL). Observation on 05/04/21 at 12:04 P.M. revealed agency Stated Tested Nursing Assistant (STNA) #77 was pushing Resident #4 down the C 200 hallway in the shower chair with just a hospital gown on. The resident was completely naked from the back exposing her buttocks to the other residents in the hallway. There were four male and two female resident sitting in the hallway who were able to witness Resident #4 being exposed. Interview on 05/04/21 at 12:05 P.M. with agency STNA #77 verified the buttocks of Resident #4 were exposed. Interview 05/05/21 12:21 P.M. with Resident #4 revealed the staff never cover her up and provide privacy when they push her down the hallway to the the shower room. She indicated her bottom was always exposed. Review of the facility policy, Resident Rights, dated 08/11/17 revealed it was the facility policy to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. The purpose of the policy was to guide employees in the general principles of dignity and respect of caring for residents, including the right to refuse treatment and care and the rights and safety of other residents, staff, and visitors. Care for resident would be provided in a safe respectful manner that includes care in a private setting. Review of the facility policy, Personal Bathing and Shower, dated 04/25/18 revealed prior to bringing resident to shower room or undressing in room, gather equipment, provide for covering for comfort and dignity such as towel and/or bath blankets. 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with the diagnoses of chronic respiratory failure, traumatic brain injury, altered mental status, COVID-19, contractures of the right elbow, left elbow, right hand, left hand, neuromuscular dysfunction of the bladder, hypertension, gastrostomy, and tracheotomy. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #6 had severely impaired cognition and required total assistance for all ADLs. Observation on 05/05/21 at 11:20 P.M. revealed Registered Nurse (RN) #31 preformed a dressing change on Resident #6. RN #31 never spoke to the resident or explained anything she was doing to the resident, she took his blanket completely off of him, she rolled him over, took off his Profo boots and socks without explaining anything she was doing to him. She took his incontinence undergarment off and cleaned up his bowel movement without explaining anything she was doing to him. Interview on 05/05/21 at 11:45 A.M. with RN #31 verified she had not explained anything to Resident #6. She indicated she had said hello to him when she went into the room but had not explained step by step what she was doing during his treatment change or during incontinent care. Review of the facility policy, Resident Rights, dated 08/11/17 revealed it was the facility policy to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. The purpose of the policy was to guide employees in the general principles of dignity and respect of caring for residents, including the right to refuse treatment and care and the rights and safety of other residents, staff and visitors. Care for resident would be provided in a safe respectful manner that includes care in a private setting. 3. Resident #86 was admitted to the facility on [DATE] with the diagnosis of cerebral infarction, chronic respiratory failure, and dehydration. The significant change comprehensive assessment dated [DATE] indicated the resident had mild cognitive impairment, and required extensive assistance with dressing, and had limited use of his right upper extremities. On 05/10/2021 at 10:02 A.M. the surveyor observed STNA #87 come out of Resident #86's room stating she would be back, and walk down the hallway. When surveyor looked in the room the resident was observed seated in his wheelchair facing the door without pants and his incontinence undergarment exposed. The surveyor verified this with LPN #26, who was the nurse on the unit at the time of the observation. She closed the door and counseled STNA #87 regarding privacy. STNA #87 was gone approximately five minutes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, resident interview and staff interview the facility failed to provide scheduled showers for Resident #43. This affected one resident (Resident #43) of one reviewed for choices. The facility census was 96 residents. Findings include: Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease, chronic pain, diabetes, major depressive disorder, insomnia, muscle weakness, schizoaffective disorder, anxiety disorder, hypertension, cerebral infraction, and age related physical debility. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #43 had intact cognition and required physical help with bathing. Review of the Activities of Daily Living computer tracking forms from 04/10/21 to present revealed Resident #43 received a shower on 04/22/21. Review of the Point Click Care shower task tracking from 04/11/21 to 05/11/21 revealed Resident #43 had received a shower on 04/22/21 with no other documentation of any other showers being given or refused. Interview on 05/04/21 at 9:45 A.M. Resident #43 indicated she has not had a shower in awhile. Interview on 05/11/21 at 12:28 P.M. Resident #43 stated she had received her shower on Monday 05/10/21 however, she did not receive one last Thursday, she indicated it was the first shower she has had in two months. She indicated she had refused her shower one time because there was poop on the bath chair and she told the nursing assistant she would have to clean it up first before she would sit in it. She indicated she use to get her showers all the time when another nursing assistant worked in the facility but she had quit. She indicated she has not been getting them on schedule since then. Interview on 05/11/21 at 12:46 P.M. the Director of Nursing indicated the nursing assistants were supposed to document in point of care when they give a resident a shower but with all the agency staff working it was hard to track them down if they forget to chart on someone. She verified there was no documentation Resident #43 had received her scheduled showers. Review of the facility policy, Personal Bathing and Shower dated 04/25/18 revealed the facility would provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety was a primary concerns for the resident staff and visitors. Residents have the right to choose their schedules, consistent with their interest, assessments, and care plans including choice for personal hygiene. This includes, but not limited to, choice about the schedule and type of activities for bathing that may include a shower, a bed-bath or tub bath, or combination and on different days. The facility would not develop a schedule for care, such as waking or bathing, for staff convenience and without the input of the resident/representative. This deficiency substantiates Complaint Numbers OH00122064 and OH00111582.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, review of the medical record and staff interview the facility failed to complete a dressing change as ordered for Resident #38. This affected one resident (Resident #38) of seven residents reviewed for pressure ulcers. Findings include: Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with the diagnoses of dementia with behavioral disturbance, psychotic disorder with delusion, polyosteoarthrutis, mood affective disorder, major depressive disorder, anxiety disorder, Alzheimer's disease, infectious and parasitic disease, schizoaffective disorder, hypertension and anemia. Review of the May 2021 physician's orders revealed Resident #38 had an order for bilateral first metatarsal head, left second toe, left great toe, left heel to cleanse with normal saline, apply Venelex ointment to discoloration and dorsal foot and toe Bilateral open areas apply medihoney gel with calcium alginate with calcium alginate rope between the toes, pad and protect bilateral feet and heels with abdominal dressings, secure with Kerlix every Monday, Wednesday and Friday and as needed. Observations on 05/03/21 at 10:10 A.M., 3:35 P.M., and 4:00 P.M. (after the Director of Nursing verified) revealed Resident #38 had both her feet wrapped in Kerlix and both were dated 4/28/21. Interview on 05/03/21 at 11:00 A.M. the Director of Nursing verified the bilateral dressings to Resident #38's feet were dated 04/28/21 and had not been done on Friday 04/30/21 as ordered. They had not been changed for five days. Review of the facility policy, Wound Care, dated 05/30/19 revealed residents admitted with or developed skin integrity issues would receive treatment as indicated based on location, stage and drainage. This deficiency substantiates Complaint Number OH00110980.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure consistent catheter care was provided for one resident. This affected one (Resident #34) of nine residents who received catheter care at the facility. The facility cenus was 96 residents. Findings include: Medical record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses that included cauda equnia syndrome, muscle weakness, and hydronephrosis with ureteropelvic junction obstruction. Review of Resident #34's quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed she required total dependence with one-person physical assist for toileting and extensive assistance with two plus physical assistance for personal hygiene. Review of Resident #34 care plan dated 03/26/21 revealed that the resident has an indwelling urinary catheter with a goal that the resident will show no signs or symptoms of a urinary tract infection through review the date. Review of Resident #34's May 2021 physician orders revealed that she does not have any orders regarding her catheter care. Interview on 05/03/21 at 3:33 P.M. Resident #34 revealed that she always seems to have a urinary tract infection, and she does not receive frequent catheter care. Observation on 05/05/21 at 11:25 A.M. of Resident #34's catheter care with State Tested Nursing Assistant (STNA) #54 revealed the STNA gathered supplies, washed hands, applied gloves, and then checked the residents tubbing for kinks. She then dipped a clean washcloth into the basin of water and cleaned the tubbing to the catheter from top to bottom. After cleaning the catheter tubbing, she changed her gloves but did not wash her hands. STNA #34 then dipped a new washcloth into the basin of water applied perineal wash to the washcloth and cleaned the resident's perineal area. After cleaning the resident's perineal area with her same gloves, she repositioned the resident, touched the resident's sheets, and replaced the perineal wash. STNA #34 then removed her gloves and pulled the bedside table into the hall before washing her hands. Interview on 05/05/21 at 11:34 A.M. with STNA #20 verified that catheter care was not done correctly according to infection control practices. Review of facility's catheter care documentation from 04/05/21-05/04/21 revealed catheter care was not provided on 04/09/21, 04/11/21, 04/12/21, 04/13/21, 04/14/21, 04/17/21, 04/19/21, 04/20/21, 04/21/21, 04/27/21, 04/28/21, 04/29/21, and 05/01/21. Review of the facility infection control logs revealed that the Resident #34 was treated five times for a urinary tract infection from November 2020 through March 2021. The dates included 11/26/20, 12/18/21, 01/05/21, 02/10/21, and 03/13/21. Interview on 05/11/21 at 10:34 A.M. with the Director of Nursing confirmed that according to documentation Resident #34 was not receiving catheter care twice as day as indicated in the facility's policy. She further revealed that Resident #34 does not have any physician orders regarding her catheter care, when to change her catheter, or how often to provide catheter care. Review of the facility policy Catheter Care, dated 05/01/17, revealed that the facility staff should perform catheter care at least twice daily on residents that have indwelling catheters, for as long as the catheter is in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, and staff interviews, the facility failed to ensure the dression on the peripherally inserted central catheter (PICC), which was used for intravenous medications was changed as ordered. This affected one (Resident #79) of three residents reviewed for PICC dressing changes. Findings include: Review of the medical record revealed Resident #79 was admitted to the facility on [DATE] with the diagnoses of cord compression, spinal stenosis, spondylosis, hypertension, neuromuscular dysfunction of the bladder, anemia, osteomyelitis, asthma, and atherosclerotic heart disease. Review of the admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #79 had moderately impaired cognition and required extensive assistance for all activities of daily living. The resident had not received intravenous medications. Review of a physician's order dated 04/27/21 revealed the PICC line dressing for Resident #79 was to be changed every week on Sunday. Observation on 05/10/21 at 1:40 P.M. revealed the PICC dressing for Resident #79 was dated 05/02. An interview at this time with Registered Nurse #30 verified the date on the PICC dressing for Resident #79 and indicated the dressing was ordered to be changed every seven days. This deficiency substantiates Complaint Number OH00110980.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Medical record review revealed that Resident #71 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, and dysphagia. Review of Resident #71's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance with one-person physical assistance for personal hygiene. Interview on 05/04/21 at 9:53 A.M. with Resident #71 revealed that facility staff do not provide him any mouth care, and that he does not have a toothbrush or toothpaste. Observation on 05/05/21 at 8:56 A.M. with State Tested Nursing Assistant (STNA) #71 revealed that the resident did not have a toothbrush, mouth wash, or any supplies to complete mouth care. Interview on 05/05/21 at 8:56 A.M. with State Tested Nursing Assistant (STNA) #81 revealed that she is responsible for Resident #71's morning care including mouth care, and that he has not been receiving mouth care. Review of the facility policy Oral Hygiene revised 04/25/18 revealed Mouth care and oral hygiene is part of the daily care of the resident. Oral hygiene may include brushing and rinsing of natural teeth, but may also involve cleaning oral devices including but not limited to dentures, partial plates, bridges or other dental appliances. Based on observations, resident interviews, and staff interviews, the facility failed to ensure nail care and mouth care was provided to the residents. This affected nine (Residents #6, #26, #38, #41, #55, #71, #84, #88 and #93) of 11 reviewed for activities of daily living. The facility census was 96 residents. Findings include: 1. Review of the medical record revealed Resident #88 was admitted to the facility on [DATE] with the diagnoses of chronic kidneys disease, dementia, hypertension, anxiety, major depression, and insomnia. Review of the quarterly MDS dated [DATE] revealed Resident #88 had severely impaired cognition and extensive assistance of one for personal hygiene. Review of the plan of care dated revealed Resident #88 had an ADL self care performance deficit related to weakness. Interventions included the resident required extensive assistance of one staff member for toilet use, transfer, repositioning, bathing personal hygiene, and oral care. Observations on 05/03/21 at 11:22 A.M., 05/04/21 at 9:35 A.M., and 05/05/21 at 9:26 A.M. revealed Resident #88 had long, dirty fingernails. On 05/05/21 at 11:07 A.M. interview and observation with the DON verified Resident #88 had long dirty fingernails. Interview on 05/05/21 at 2:00 P.M. with the DON revealed nails were to be trimmed and cleaned on shower days. Review of the facility policy Routine Resident Care, dated 05/29/19 revealed it was the policy of the facility to promote resident centered care by attending to the physical, emotional, social and spiritual needs and honor resident lifestyle preferences while in care of this facility. Licensed staff would include the following services based upon their scope of practice; assisting and teaching activities of daily living. Review of the facility policy Nail and Hair Hygiene Services, dated 05/30/19 revealed the facility would provide routine care for the residents for hygienic purposes and for the psychosocial well-being of the resident including but not limited to routine nail hygiene, care for ingrown or damaged nails would be provided on an individual care bases. These services were provided by the facility as part of regular grooming care. 2. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with the diagnoses of dementia with behavioral disturbance, psychotic disorder with delusion, polyosteoarthrutis, mood affective disorder, major depressive disorder, anxiety disorder, Alzheimer's disease, and schizoaffective disorder. Review of the quarterly MDS date 03/09/21 revealed Resident #38 had severely impaired cognition and required total assistance with all ADLs. Review of the plan of care dated 04/09/14 revealed Resident #38 had an ADL self-care performance deficit related to decreased mobility and decreased cognition. Interventions included the resident required extensive assistance of one staff member for personal hygiene. Observation on 05/03/21 at 10:10 A.M. and on 05/05/21 at 9:29 A.M. revealed Resident #38 had long, dirty fingernails. On 05/05/21 at 11:08 A.M. observation and interview with the DON verified Resident #38 had long, dirty fingernails which were curled into her contracted hands. Interview on 05/05/21 at 2:00 P.M. with the DON revealed nails were to be trimmed and cleaned on shower days. Review of the facility policy Routine Resident Care, dated 05/29/19 revealed it was the policy of the facility to promote resident centered care by attending to the physical, emotional, social and spiritual needs and honor resident lifestyle preferences while in care of this facility. Licensed staff would include the following services based upon their scope of practice; assisting and teaching activities of daily living. Review of the facility policy Nail and Hair Hygiene Services, dated 05/30/19 revealed the facility would provide routine care for the residents for hygienic purposes and for the psychosocial well-being of the resident including but not limited to routine nail hygiene, care for ingrown or damaged nails would be provided on an individual care bases. These services were provided by the facility as part of regular grooming care. 3. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with the diagnoses of sarcopenia, macular degeneration, dementia, hearing loss, legally blind, COVID-19, major depression, repeated falls, and need for assistance with personal care. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #26 had moderately impaired cognition and required extensive assistance with personal hygiene. Review of the plan of care dated 02/24/21 revealed Resident #26 had an ADL self-care performance deficit and required assistance with ADL cognitive deficit and sarcopenia. Interventions included to observe and anticipate resident's needs, place the call light within reach, therapy evaluations and treatment as per medical orders, required extensive one staff assistance with bed mobility, hygiene, bathing, transfers, dressing, and toileting. Observation on 05/03/21 at 10:00 A.M. and on 05/04/21 at 9:33 A.M. revealed Resident #26 had long, jagged, dirty fingernails. On 05/05/21 at 11:10 A.M. observation and interview with the DON verified Resident #26 had long, dirty and jagged fingernails. Interview on 05/05/21 at 2:00 P.M. the DON revealed nails were to be trimmed and cleaned on shower days. Review of the facility policy Routine Resident Care, dated 05/29/19 revealed it was the policy of the facility to promote resident centered care by attending to the physical, emotional, social and spiritual needs and honor resident lifestyle preferences while in care of this facility. Licensed staff would include the following services based upon their scope of practice; assisting and teaching activities of daily living. Review of the facility policy Nail and Hair Hygiene Services, dated 05/30/19 revealed the facility would provide routine care for the residents for hygienic purposes and for the psychosocial well-being of the resident including but not limited to routine nail hygiene, care for ingrown or damaged nails would be provided on an individual care bases. These services were provided by the facility as part of regular grooming care. 4. Review of the medical record revealed Resident #41 was admitted to the facility with the diagnoses of intracranial injury, amebic brain injury, hypertension, major depressive disorder, anemia, constipation, intracranial abscess, and granuloma. Review of the annual MDS assessment dated [DATE] revealed the resident had severely impaired cognition and required total assistance with ADLs. Review of the plan of care dated 03/16/21 revealed Resident #41 had an ADL self-care performance deficit and required assistance with ADL cognitive deficit. Interventions include the resident required extensive assistance with hygiene Observation on 05/03/21 at 9:58 A.M., 05/04/21 at 9:39 A.M., and on 05/05/21 at 9:26 A.M. revealed Resident #41 had long dirty fingernails. On 05/05/21 at 11:11 A.M. observation and interview with the DON verified Resident #41 had long dirty fingernails. Interview on 05/05/21 at 2:00 P.M. the DON revealed nails were to be trimmed and cleaned on shower days. Review of the facility policy Routine Resident Care, dated 05/29/19 revealed it was the policy of the facility to promote resident centered care by attending to the physical, emotional, social and spiritual needs and honor resident lifestyle preferences while in care of this facility. Licensed staff would include the following services based upon their scope of practice; assisting and teaching activities of daily living. Review of the facility policy Nail and Hair Hygiene Services, dated 05/30/19 revealed the facility would provide routine care for the residents for hygienic purposes and for the psychosocial well-being of the resident including but not limited to routine nail hygiene, care for ingrown or damaged nails would be provided on an individual care bases. These services were provided by the facility as part of regular grooming care. 5. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with the diagnoses of traumatic brain injury, anoxic brain damage, altered mental status, chronic obstructive pulmonary disease, epilepsy, COVID-19, major depression, anxiety disorder, chronic pain, migraine, asthma, and pulmonary embolism. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #55 had severely impaired cognition and required extensive assistance of one for personal hygiene. Review of the plan of care dated 05/03/21 revealed Resident #55 had an ADL self care performance deficit related to impaired balance, limited mobility, contractures and combative with care at times. Interventions included the resident required extensive assistance of one staff member for personal hygiene. Observations on 05/03/21 at 9:54 A.M. and on 05/05/21 at 9:26 A.M. revealed Resident #55 had long dirty fingernails. On 05/05/21 at 11:12 A.M. observation of the resident and interview with the DON verified Resident #55 had long dirty fingernails and a beard. Interview on 05/05/21 at 2:00 P.M. the DON revealed nails were to be trimmed and cleaned on shower days. Review of the facility policy Routine Resident Care, dated 05/29/19 revealed it was the policy of the facility to promote resident centered care by attending to the physical, emotional, social and spiritual needs and honor resident lifestyle preferences while in care of this facility. Licensed staff would include the following services based upon their scope of practice; assisting and teaching activities of daily living. Review of the facility policy Nail and Hair Hygiene Services, dated 05/30/19 revealed the facility would provide routine care for the residents for hygienic purposes and for the psychosocial well-being of the resident including but not limited to routine nail hygiene, care for ingrown or damaged nails would be provided on an individual care bases. These services were provided by the facility as part of regular grooming care. 6. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with the diagnoses of chronic respiratory failure, traumatic brain injury, altered mental status, COVID-19, contractures of the right elbow, left elbow, right hand, left hand, neuromuscular dysfunction of the bladder, hypertension, gastrostomy, and tracheotomy. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #6 had severely impaired cognition and required total assistance for all ADLs. Review of the plan of care dated 08/20/19 revealed Resident #6 had an Activity of Daily Living (ADL) self-care and performance deficit related to traumatic brain injury. Interventions included the resident required total assistance of staff member for personal hygiene. Observation on 05/03/21 at 9:32 A.M., 11:45 A.M., and 3:30 P.M. revealed Resident #6 had long dirty fingernails. On 05/05/21 at 11:13 A.M. observation of the resident and interview with the Director of Nursing (DON) verified Resident #6 had long dirty fingernails. Interview on 05/05/21 at 2:00 P.M. with the DON revealed nails were to be trimmed and cleaned on shower days. Review of the facility policy Routine Resident Care, dated 05/29/19 revealed it was the policy of the facility to promote resident centered care by attending to the physical, emotional, social and spiritual needs and honor resident lifestyle preferences while in care of this facility. Licensed staff would include the following services based upon their scope of practice; assisting and teaching activities of daily living. Review of the facility policy Nail and Hair Hygiene Services, dated 05/30/19 revealed the facility would provide routine care for the residents for hygienic purposes and for the psychosocial well-being of the resident including but not limited to routine nail hygiene, care for ingrown or damaged nails would be provided on an individual care bases. These services were provided by the facility as part of regular grooming care. 7. Review of the medical record revealed Resident #93 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease, sacral pressure ulcer, left heel pressure ulcer, iron deficiency anemia, nutritional deficiency, dementia, disorder of the kidneys and ureters, left hand contracture, neuromusculaer dysfunction of the bladder, adult failure to thrive, COVID-19, hypertension, osteoarthritis, colostomy, and insomnia. Review of the quarterly MDS dated [DATE] revealed Resident #93 had severely impaired cognition, and required total assistance with bed mobility, transfers, toilet use and personal hygiene. She had an ostomy and an indwelling catheter. Review of the plan of care dated 05/03/21 revealed Resident #93 had an ADL self-care performance deficit related to activity intolerance, wounds, and contracture. Interventions included the resident required extensive assistance of two staff members for personal hygiene. Observations on 05/03/21 at 9:25 A.M. and 11:15 A.M., and on 05/04/21 at 8:44 A.M., revealed Resident #93 had a left hand contracture with long dirty fingernails. Her nails were leaving an imprint on the palm of her hand but had not broken the skin. Observation on 05/05/21 at 11:20 A.M. with the DON revealed Resident #93 had long dirty fingernails. Interview at this time with DON verified Resident #93 had long, dirty fingernails. Interview on 05/05/21 at 2:00 P.M. the DON revealed nails were to be trimmed and cleaned on shower days. Review of the facility policy Routine Resident Care, dated 05/29/19 revealed it was the policy of the facility to promote resident centered care by attending to the physical, emotional, social and spiritual needs and honor resident lifestyle preferences while in care of this facility. Licensed staff would include the following services based upon their scope of practice; assisting and teaching activities of daily living. Review of the facility policy Nail and Hair Hygiene Services, dated 05/30/19 revealed the facility would provide routine care for the residents for hygienic purposes and for the psychosocial well-being of the resident including but not limited to routine nail hygiene, care for ingrown or damaged nails would be provided on an individual care bases. These services were provided by the facility as part of regular grooming care. 9. Resident #84 was admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease, muscle weakness, heart failure, type II diabetes, major depression and needs assistance with personal care. The annual comprehensive assessment dated [DATE] indicated the resident had mild cognitive impairment and required extensive assistance with personal hygiene. Observation of the resident's nails on 05/03/21 at 11:08 AM revealed the resident had a black substance beneath his nails. The surveyor asked if staff provided nail care when he was being bathed, and he stated no. Resident #84 was unable to clean his own nails. On 05/05/21 at 11:08 A.M. the DON and another surveyor observed Resident #84's finger nails. Interview with the DON at this time verified the resident had long dirty fingernails. This deficiency substantiates Complaint Number OH00122064.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure proper infection control practices were implemented during catheter care for Resident #34; failed to properly transport soiled linens in the hallway; and failed to follow proper infection control practice for a dressing change for Resident #93. This affected two (Residents #34 and #93) residents and had the potential to affect all 96 facility residents. Findings include: 1. Medical record review for Resident #34 revealed she was admitted to the facility on [DATE] with diagnoses that included, cauda equnia syndrome, muscle weakness, and hydronephrosis with ureteropelvic junction obstruction. Review of Resident #34's quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed she required total dependence with one-person physical assist for toileting and extensive assistance with two plus physical assistance for personal hygiene. Observation on 05/05/21 at 11:25 A.M. of Resident #34's catheter care with State Tested Nursing Assistant (STNA) #54 revealed the STNA gathered supplies, washed hands, applied gloves, and then checked the residents tubbing for kinks. She then dipped a clean washcloth into the basin of water and cleaned the tubbing to the catheter from top to bottom. After cleaning the catheter tubbing, she changed her gloves but did not wash her hands. STNA #34 then dipped a new washcloth into the basin of water applied perineal wash to the washcloth and cleaned the resident's perineal area. After cleaning the resident's perineal area with her same gloves, she repositioned the resident, touched the resident's sheets, and replaced the perineal wash. STNA #34 then removed her gloves and pulled the bedside table into the hall before washing her hands. Interview on 05/05/21 at 11:34 A.M. with STNA #20 verified that catheter care was not done correctly according to infection control practices. Review of the facility policy Catheter Care, dated 05/01/17, revealed that the facility staff should perform perineal care prior to catheter care. Review of the facility policy Standard Precautions, dated 04/01/17, revealed that hand hygiene should be performed when hands move from a contaminated body site to a clean body site during patient care. 2. Observation on 05/10/21 at 10:05 A.M. revealed STNA #73 transporting a bag of soiled linens down the hall. The bag was touching the facility floor as she walked down the hall and past the nurse's station. A wet streak was noted on the floor as she transported the bag down the hall. She then opened the soiled linen closet and disposed of of the bag. Interview on 05/10/21 at 10:10 A.M. STNA #73 confirmed the bag she was transporting down the hall was full of solid linens. 3. Review of the medical record revealed Resident #93 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's disease, sacral pressure ulcer, left heel pressure ulcer, iron deficiency anemia, nutritional deficiency, dementia, disorder of the kidneys and ureters, left hand contracture, neuromuscular dysfunction of the bladder, adult failure to thrive, COVID-19, hypertension, osteoarthritis, colostomy, and insomnia. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #93 had severely impaired cognition, required total assistance with bed mobility, transfers, toilet use, and personal hygiene. The resident had two stage four pressure ulcers with one present upon admission, an ostomy, and an indwelling catheter. Review of the physician's order dated 04/09/21 revealed Resident #93 had and order for a wound vacuum to her sacrum at 125 millimeters of mercury (mmHg) continuous, cleanse the sacral wound with wound cleanser, rinse with normal saline, apply Adaptic over the exposed bone with black wound vacuum foam every Monday, Wednesday, Friday and as needed. Observation on 05/05/21 at 10:30 A.M. revealed Registered Nurse (RN) #31 and Physician #86 changed the wound vacuum dressing for Resident #93. RN #31 removed the old dressing from the resident's bilateral heels; she washed her hands and put on gloves. She rolled the resident over to remove wound vacuum dressing, washed her hands and put on new gloves. She placed a clean bath towel directly on the resident's bed and placed her dressing supplies onto the towel. She cleaned the sacral wound, washed her hands and put on gloves. RN #31 had then took scissors directly out of her pants pocket, did not clean them and proceeded to cut the transparent wound film and black sponge for the wound vacuum with the scissors. She placed the black sponge inside the resident's sacral wound. RN #31 proceeded to discard all opened packages of wound vacuum supplies which were laying on the bath towel; she washed her hands and the replaced gloves. RN #31 placed all dressing supplies for the resident's heels on the bath towel on the bed where all the discarded dressing supplies were laying and proceeded to change Resident #93 heel dressings. Interview on 05/05/21 at 11:45 A.M. with RN #31 revealed the bath towel was her clean field but she verified the bed was not able to be cleaned and was not an appropriate clean field to set up on. She indicated she had cleansed her scissors prior to placing them in her pocket but verified she did not clean them after she took them out of her pocket prior to cutting the wound vacuum dressing and sponge. Review of the facility policy Wound Care, dated 05/30/19, revealed residents admitted with or developed skin integrity issues would receive treatment as indicated based on location, stage and drainage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 01/28/19 at 3:38 P.M. of the D-100 hall medication storage cart revealed Resident #55's Novolog Kwikpen was opened on 12/18/18 as identified in writing on the label and expired twenty-eight days after opening on 01/15/19. Review of Resident #55's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including type 2 diabetes with hyperglycemia and diabetic neuropathy. Review of Resident #55's MDS dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #55's physician orders revealed an order dated 05/07/18 to inject Novolog 20 units (fast acting insulin) subcutaneously before meals. Review of Resident #55's medication administration record (MAR) from 01/01/19 to 01/28/19 confirmed the fast acting insulin was administered daily. Interview on 01/28/19 at 3:40 P.M. with the DON confirmed Resident #55's insulin expired on 01/15/19 and the resident potentially received expired insulin. Review of the Insulin Storage Recommendation form revised 03/31/17 confirmed Novolog pens expire twenty-eight days after opening. 3. Observation on 01/28/19 at 3:44 P.M. of the D-200 hall medication storage cart revealed Resident #45's Novolog flexpen was opened on 12/18/18 as identified in writing on the label and expired twenty-eight days after opening on 01/13/19. Review of Resident #45's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease and type 2 diabetes mellitus without complications. Review of Resident #45's MDS dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #45's physician orders revealed an order dated 10/07/15 for Novolog flexpen inject 5 units subcutaneously two times a day every Tuesday, Thursday, and Saturday for diabetes and an order dated 10/07/15 to inject 5 units subcutaneously with meals every Sunday, Monday, Wednesday and Friday for diabetes. Review of Resident #45's MAR from 01/01/19 to 01/28/19 confirmed the resident was administered the fast acting insulin daily. Interview on 01/28/19 at 3:48 P.M. with the DON confirmed Resident #45's fast acting insulin expired on 01/13/19 and the resident potentially received expired insulin. Review of the Insulin Storage Recommendation form revised 03/31/17 confirmed Novolog pens expire twenty-eight days after opening. Based on observation, interview, record review, and review of Medication Administration policy and Insulin Storage recommendations the facility failed to ensure medications for Resident #96 were securely stored and Resident #55's and Resident #45's insulin were used before expiration dates This affected one (Resident #96) of 31 sampled residents and two (Residents #55 and #45) of two residents identified with expired medications during observation of four medication carts. Findings include: 1. Review of the medical record for Resident #96 revealed a date of birth as 03/13/65 and admission into the nursing facility on 07/22/16. The primary diagnosis for admission was cellulitis. Additional diagnoses included asthma, type II diabetes mellitus, depression, hypothyroidism, lymphedema, hypertension, obesity and fibromyalgia. Review of the comprehensive assessment (MDS 3.0) dated 01/15/19 revealed a brief interview for mental status (BIMS) was completed. Resident #96's score was 15 of a possible 15 and this indicated intact cognition. An interview was completed with Resident #96 on 01/28/19 at 3:20 P.M. at the bedside. During the interview a plastic basin was observed on the night stand located to the left of the resident. The contents of the basin included various lotions and hygienic products. Mixed amongst the items in the basin, were several prescription and over the counter medications. Observed in the plastic basin were the following medications: 1. Mupirocin cream (a prescription antibiotic) 2% with approximately one quarter of the cream left in the tube. 2. Coly-mycin S (prescription antibiotic ear drops) optic drops with most of the bottle used. 3. Proair HFA (a prescription inhaler used to treat shortness of breath) 90 micrograms per actuation. 4. Gingko Biloba, 120 milligram tablets with approximately 30 tabs left in the bottle. 5. Tolnaftate antifungal cream and this tube was approximately half used. 6. Cranberry tablets, 400 milligrams with approximately 10 tablets left in the bottle. 7. Hydrocortisone cream 2.5%, with approximately three quarters of the tube used. 8. Betamethasone valerate cream (a prescription used for itching) 0.1% with approximately half the tube used. 9. Alive gummies, women's 50 plus multivitamin with approximately 25 gummies in the bottle. At the time of the observation, Resident #96 stated she kept the medications at her bedside and was aware this was not a compliant practice. Resident #96 further stated, she hoped she did not get the nurses in trouble. Further discussion with Resident #96 revealed her husband would visit the facility frequently and often brought medications from home and gave them to her. The above medications were removed from the basin and placed on the table and the concern was brought to the attention of Licensed Practical Nurse (LPN) #500 who entered the room at 3:40 P.M. LPN #500 stated the medications should not have been left at the bedside unless a physician order was present. LPN #500 went to the bedside and immediately removed the medications which did not have orders from the physician to remain at the bedside. Review of the medical record including physician and nursing notes, medication review, interview with Resident #96 and staff interviews did not evidence any negative outcome from the deficiency. These findings were communicated to the Director of Nursing (DON) on 01/28/19 at 4:35 P.M. Review of the Policy and Standard Procedures document, Medication Administration, last revised 07/07/00, stated all medications will be administered only as prescribed and only by a licensed or authorized personnel and never leave medications unattended.