**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure staff followed the policy to check placement of the resident's gastrostomy tube (G-tube) before medication was administered. This affected one (#62) of four residents observed for medication administration. The facility census was 60. Findings included: Review of an admission medical record for Resident #62 revealed an admission on [DATE]. Diagnoses for Resident #62 included: moderate protein-calorie malnutrition and dysphagia (difficulty swallowing foods or liquids) in the oral phase. Review of the admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/11/24, revealed Resident #62 had severe cognitive impairment. The MDS indicated Resident #62 was dependent on staff for completion of all activities of daily living (ADLs). The MDS also revealed Resident #62 received 51% or more of their total calories and fluid intake through their feeding tube. Review of Resident #62's care plan dated 12/10/24, included a focus area, for at nutritional and dehydration risk related to dependence on a G-tube and the need for a therapeutic formula. The care plan directed staff to provide tube feeding and check residuals per orders. Review of Resident #62's Physician Order Summary Report for active physician orders as of 12/11/24, revealed an order dated 12/04/24, to check the residual volume, hold the tube feeding, and notify the physician if the residual was over 60 milliliters. The Physician Order Summary Report also revealed an order dated 12/09/24, to check the resident's G-tube placement every shift. Observation on 12/11/24 at 8:40 A.M., during the medication administration, Registered Nurse (RN) #3 prepared medication to administer to Resident #62 by way of the G-tube. After preparation, at 9:10 A.M., RN #3 placed the G-tube feeding pump on hold, flushed the tube with water, and then pulled back on the syringe to check residual, which was clear with tan colored particles. The observation revealed RN #3 proceeded to administer Resident #62's medications. Interview on 12/11/24 at 9:20 A.M., with RN #3 stated she instilled water by way of a syringe to check the placement of Resident #62's G-tube. RN #3 stated she should not have used water to check placement because there was a danger that water could have gone into the wrong place (somewhere other than the resident's stomach). Interviewed on 12/12/24 at 2:16 P.M., with the Director of Nursing (DON) stated nurses should not use water to check G-tube placement because if the tube was not in the correct location, the installation of water could cause harm to the resident. Interview on 12/12/24 at 2:20 P.M., the Administrator stated she expected the nurses to use the facility policy when they checked G-tube placement. Review of the policy titled, Confirming Placement of Feeding Tubes, revised November 2018, indicated, the purpose of this procedure is to ensure proper placement of an existing feeding tube prior to administering enteral feedings or medication. According to the policy, To confirm placement of an existing feeding tube at the bedside: 1. Test whether the tube is properly positioned: a. Observe for symptoms of elevated gastric residual volume (GRV): (1) A sharp increase in residual volume may indicate that a small bowel tube has moved into the stomach. (2) Little to no residual volume may suggest that the tube has migrated from the stomach to the esophagus. b. Observe and check the pH [potential of hydrogen] of aspirate: (1) Fasting stomach contents will have a clear and colorless or grassy green and brown appearance. (2) Fluids from the pleural space [lungs] may have a pale yellow, serous appearance. (3) Post-pyloric/small bowel contents can be bile-stained, light to dark yellow or greenish-brown. (4) Fasting stomach acid will have a pH of 5 or less. (5) Fluid from the pleural space will have a pH of 7 or higher. (6) A pH of 5 or less suggests that the tube is placed in the stomach. However, a pH of 6 or greater is not definitive of placement outside the stomach. 2. If the above suggests improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician. When correct tube placement has been verified, flush tubing with at least 30 mL [milliliters] warm water (or prescribed amount).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to maintain a medication error rate of less than five percent (%). There were 3 medication errors of 38 medication opportunities, which resulted in a medication error rate of 7.89%. This affected two (#62 and #111) of four residents observed for medication administration. The facility census was 60. Findings included: 1. Review of an admission medical record for Resident #111 revealed an admission date of 12/04/24. Diagnoses for Resident #111 included: hypertensive urgency, hypertensive chronic kidney disease, atherosclerotic heard disease, and essential hypertension. Observation on 12/10/24 beginning at 8:14 A.M., during medication administration, Licensed Practical Nurse (LPN) #1 prepared one vitamin B12, 500 micrograms (mcg) and one enteric coated aspirin, 81 milligrams (mg). The medications were administered to Resident #111. Review of Resident #111's physician Order Summary Report for active orders as of 12/11/24, revealed orders dated 12/05/24, for one chewable aspirin (not enteric coated), 81 mg in the morning for stroke prevention and for cyanocobalamin (vitamin B12) 2000 mcg, one tablet every morning related to a vitamin B12 deficiency. Interview on 12/12/24 at 10:50 A.M., with LPN #1 stated she had only seen 81 mg on the aspirin bottle and did not read that the order was for a chewable aspirin. LPN #1 stated she was unable to remember giving vitamin B-12 to Resident #111, but remembered the surveyor looked at the medications and counted the number of pills placed in the resident's medication cup. Interview on 12/12/24 at 1:56 P.M., with the DON stated before medications are administered, she expected the nurse to check the resident's medication administration record (MAR), pull the medication, and check the medication against the MAR to make sure it was the right medication, right time, right route of administration, right dose, and the right resident. The DON stated if LPN #1 gave Resident #111 enteric coated aspirin and did not give the correct vitamin B-12 dosage, those were medication errors because the medications given did not match the physician's order. Interview on 12/12/24 at 2:05 P.M., with the Administrator stated before medications were administered, she expected the nurse to check the dose and to make sure it was the correct medication and the right time for the medication. 2. Review of an admission medical record for Resident #62 revealed an admission on [DATE]. Diagnoses for Resident #62 included: moderate protein-calorie malnutrition and dysphagia (difficulty swallowing foods or liquids) in the oral phase and epilepsy. Observation on 12/11/24 at 8:40 A.M., during medication administration, Registered Nurse (RN) #3 prepared levetiracetam (an anti-seizure medication) 100 milligrams/milliliter (mg/ml) oral solution for Resident #62. RN #3 poured 10 ml of levetiracetam solution into a medication cup and administered the medication to the resident by way of the resident's gastrostomy tube (G-tube). Review of Resident #62's Physician Order Summary Report, with active orders as of 12/11/24, revealed an order dated 12/04/24, for levetiracetam 500 mg/5 ml oral solution, give 5 ml per G-tube twice a day. Interview on 12/11/24 at 12:33 P.M., with RN #3 stated she could have sworn the order for the levetiracetam was for 10 ml. RN #3 reviewed Resident #62's medication administration record (MAR) and stated the order for the resident's levetiracetam was to give 5 ml. RN #3 stated she made an error and looked at the wrong entry on the MAR. RN #3 stated if a resident received too much levetiracetam, it could cause levetiracetam toxicity, and she would notify the physician about the medication error. Interview on 12/12/24 at 2:16 P.M., with the Director of Nursing (DON) stated she expected the nurse to administer the right dose of medication to the right resident. The DON stated the danger of getting too much levetiracetam could be an elevated level of the medication. Review of the policy titled, Administering Medications, revised August 2024, indicated, Medications are administered in accordance with prescriber orders, including any required time frame. The policy specified, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, resident interview, staff interview, medical record review, and policy review, the facility failed to ensure medications were not left unattended at the bedside. This affected one (#45) of three sampled residents reviewed for potential accidents. The facility census was 60. Findings included: Review of the admission medical record for Resident #45 revealed an admission date of 08/18/22. Diagnoses for Resident #45 included: neurocognitive disorder with Lewy bodies (a neurological brain disorder with symptoms of Alzheimer's disease) and aphasia (the inability to verbally express ideas and thoughts). Review of the quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 09/20/24, revealed Resident #45 had severe cognitive impairment. Review of Resident #45's care plan, revised 03/20/23, included a focus area indicating the resident had impaired decision-making ability and impaired memory. The care plan indicated Resident #45 would be assisted in decision making and care. Observation on 12/09/24 at 10:28 A.M., revealed on the top of Resident #45's nightstand, there were two bottles of saline nasal spray and in the top drawer of the nightstand, there was an opened bottle of Dulcolax (a laxative medication) and two bottles of digestive aid. Review of Resident #45's Physician Order Summary Report with active orders as of 12/10/24, revealed the resident did not have a physician's orders for saline nasal spray, Dulcolax, or a digestive aid. Observation on 12/10/24 at 10:03 A.M., revealed on the top of Resident #45's nightstand were two bottles of saline nasal spray and in the top drawer of the nightstand, there was an opened bottle of Dulcolax and two bottles of a digestive aid. A Certified Nursing Assistant (CNA) was observed in the resident's room to assist the resident with dressing. The CNA did not remove the medications. Observation on 12/10/24 at 3:10 P.M., revealed on the top of Resident #45's nightstand were two bottles of saline nasal spray and in the top drawer of the nightstand, there was an opened bottle of Dulcolax and two bottles of a digestive aid. Observation on 12/10/24 at 12:56 P.M., revealed on the top of Resident #45's nightstand were two bottles of saline nasal spray and in the top drawer of the nightstand, there was an opened bottle of Dulcolax and two bottles of a digestive aid. Interview with Resident #45, at the time of the observation, revealed the resident was able to identify one medication as nasal spray but was unable to recall who had given the medication to them. Resident #45 was unable to verbalize when to use the medications or how to use the medications that were at their bedside, including the nasal spray, Dulcolax, and the digestive aid. Interview on 12/11/24 at 12:59 P.M., with CNA #5 stated she worked the hall on which Resident #45 resided and usually was assigned to care for Resident #45. CNA #5 stated if she found medications at the bedside, she reported to the nurse on the hall and then to the supervisor. CNA #5 stated she had been in Resident #45's room earlier in the day and had not seen the medications in the resident's room. Interview on 12/11/24 at 1:18 P.M., with Licensed Practical Nurse (LPN) #6 acknowledged he was assigned to care for Resident #45. LPN #6 stated if he went into a resident's room and observed over-the-counter medications, he would explain to the resident that they could not have the medications at the bedside. LPN #6 stated he would also remove the medications from the room and notify the Director of Nursing (DON) and the physician. LPN #6 stated he had not found any medications at a resident's bedside during his shift. During the interview, LPN #6 went into Resident #45's room and observed the medications and stated he did not see the medications that day when he gave Resident #45 their medications. Interview on 12/11/24 at 1:28 P.M., with the Director of Nursing (DON) stated with Resident #45's having impaired cognition, the resident was not capable of self-administration of medications. The DON stated prior to any resident being able to self-administer medications there had to be a physician's order for self-administration and an assessment to determine the resident's ability. The DON stated the danger of having medications in a resident's room would be the resident could overdose or someone else could potentially get the medications. Interview on 12/12/24 at 1:51 P.M., with the Administrator, stated she expected medications from any source not to be left at a resident's bedside. The Administrator stated she expected staff to remove medications from a resident's room when the staff member left the room. Review of the policy titled, Self-Administration of Medications, revised December 2016, indicated, staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party.

Based on observation, staff interview, and policy review, the facility failed to maintain infection control procedures when administering medications. This affected one (#111) of four residents observed for medication administration. The facility census was 60. Findings included: Observations on 12/10/24 at 8:14 A.M., during the medication administration, in the presence of Registered Nurse (RN) #2, Licensed Practical Nurse (LPN) #1 removed the following medications from the medication package and place the medications in her bare hands: amlodipine (a high blood pressure medication), Plavix (a medication to help prevent blood clots), Lexapro (an antidepressant medication), Microzide (a blood pressure medication), and Lopressor (a blood pressure medication). Interview on 12/10/24 at 8:23 A.M., with LPN #1 stated she had not been taught anything about touching medication, but stated touching the medication with her hands could contaminate the medication. Interview on 12/10/24 at 8:24 A.M., with RN #2 stated she planned to speak with LPN #1 about touching medications with her hands and had no explanation why she had not immediately stopped LPN #1 from touching the medication and educated her. Interview on 12/12/24 at 12:08 P.M., with the Infection Preventionist (IP) stated she would have expected RN #2 to stop the LPN immediately if the RN observed the LPN touching medications. The IP stated nurses were not allowed to touch medications with their bare hands because that could contaminate the medication. Interview on 12/12/2024 at 1:56 P.M., with the Director of Nursing (DON) stated she did not expect nurses to touch medications with their bare hands due to infection control issues. The DON stated if a mentor (RN #2) watched the medication pass she expected RN #2 to stop the nurse and provide education on why they should not touch the medications with their bare hands. Review of the policy titled, Administering Medications, revised August 2024, revealed Medications are administered in a safe and timely manner, and as prescribed. The policy specified, Staff follows established facility infection control procedures for the administration of medications, as applicable.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's representative was notified of development of new pressure ulcer and treatment plan. This affected one (#75) out of three residents reviewed for pressure ulcers. The facility census was 61. Findings include: Review of the medical record for Resident #75 revealed an admission date of 04/03/24 with medical diagnoses of cerebral atherosclerosis, protein calorie-malnutrition, chronic obstructive pulmonary disease, and obstructive and reflux uropathy. Review of the medical record for Resident #75 revealed a quarterly Minimum Data Set (MDS) assessment, dated 06/17/24, which indicated Resident #75 had severe cognitive impairment and required partial/moderate staff assistance with toilet hygiene, bed mobility, and transfers. The MDS indicated Resident #75 required substantial/maximum staff assistance with bathing and no pressure ulcer/injuries were noted. Review of the medical record for Resident #75 revealed a wound observation evaluation, dated 07/25/24, which stated Resident #75 had a Stage III pressure ulcer to the left heel. The evaluation stated the wound was first observed on 07/25/24, the physician was notified, and a treatment was ordered. Review of the evaluation revealed no documentation to support the facility notified Resident #75's representative of the new pressure ulcer or treatment plan. Interview on 09/11/24 at 10:56 A.M. with Administrator confirmed the medical record for Resident #75 did not contain documentation to support Resident #75's representative was notified of the left heel pressure ulcer and treatment. Review of the facility policy titled, Change in Resident's Condition or Status, revised May 2017 stated the facility shall promptly notify the resident, his/her attending physician, and representative of changes in the resident's medical/mental condition and/or status. This deficiency represents non-compliance investigated under Complaint Number OH00156810.

Based on observation, medical record review, staff and resident interviews, and policy review, the facility failed to follow infection control procedures. This affected one (#22) out of three residents reviewed for wound care. The facility census was 61. Findings include: Review of the medical record for Resident #22 revealed an admission date of 02/21/22 with medical diagnoses of heart failure, diabetes mellitus, severe protein calorie malnutrition, peripheral vascular disease, and hypertension. Review of the medical record for Resident #22 revealed a quarterly Minimum Data Set (MDS) assessment, dated 06/30/24, which indicated Resident #22 was cognitively intact and was independent with eating, bed mobility, and transfers, required supervision with bathing, and set-up assistance with toileting. The MDS did not indicate Resident #22 had any skin areas. Review of the medical record for Resident #22 revealed a wound observation evaluation, dated 08/28/24, which stated Resident #22 had a Stage III pressure ulcer to her sacrum and treatment was in place. Review of the medical record for Resident #22 revealed a physician order dated 08/28/24 for treatment to gluteal cleft which was to apply alginate and cover with bordered foam dressing daily. Review of the medical record including physician orders and care plan revealed there was no documentation to support Enhanced Barrier Precautions (EBP) were ordered or implemented. Interview on 09/10/24 at 8:35 A.M. with Licensed Practical Nurse (LPN) #191 confirmed Resident #22 had a pressure ulcer and received wound care daily. LPN #191 confirmed Resident #22 did not have an order for EBP or a EBP sign posted on her door or personal protective equipment (PPE) cart located near her room. LPN #191 stated staff did not don a gown when providing wound care for Resident #22. Observation with interview on 09/10/24 at 9:00 A.M. revealed Resident #22 lying in bed. Resident #22 confirmed she had an open area to her bottom and staff complete dressing changes daily. Resident #22 confirmed staff did not wear gowns but did wear gloves when providing wound care. Interview on 09/10/24 at 11:20 A.M. with Administrator confirmed the facility had not had EBP in place for the residents with wounds or indwelling devices. Administrator stated the facility identified the issue that morning and entered orders for all residents with wounds, gastrostomy tubes, ostomies, and indwelling or suprapubic catheters. Administrator stated all staff would be educated on EBP and signs would be posted outside of those resident's rooms along with a cart with proper PPE. Review of the facility policy titled, Enhanced Barrier Precautions, stated Enhanced Barrier Precautions (EBP) are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) during high-contact resident care activities both inside and outside the residents' room, which can result in transferring multi-drug resistive organisms (MDRO) to staff hands and clothing. The policy stated PPE was to include gloves and gown and eye protection may be indicated if a splash risk exits. The policy stated EBP's are indicated for residents with infection or colonization with a Center for Disease Control targeted MDRO when contact precautions do not otherwise apply, wounds and/or indwelling medical devices (central lines, urinary catheters, feeding tubes, and tracheostomies). This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review and staff interview, the facility failed to develop a baseline care plan for a resident. This affected one (#76) of three residents reviewed who were new admissions. The census was 74. Findings include: Review of Resident #76's closed medical record revealed an admission date of 05/16/24. Diagnoses listed included osteoarthritis, restless leg syndrome, type two diabetes mellitus, and morbid obesity. Resident #76 was discharged from the facility on 05/19/24. Further review of Resident #76's closed medical record revealed no documentation of baseline careplan being developed. During an interview on 06/05/24 at 10:50 A.M. The Director of Nursing (DON) confirmed a baseline careplan had not been completed for Resident #76. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to update a resident's comprehensive care plan for suicide risk/suicidal ideation. This affected one (#59) of three residents reviewed for comprehensive care plans. The census was 74. Findings include: Review of Resident #59's medical record revealed an admission dated of 01/31/23. Diagnoses listed include hypertensive kidney disease, major depressive disorder, bradycardia, impulsiveness, dementia, and congestive heart failure. Review of quarterly Minimum Data Set (MDS) assessment revealed Resident #59 was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of a possible 15. Review of progress notes revealed on 05/09/24 expressed thoughts of harming himself and having plan to do so by telling a state tested nursing assistant (STNA). Resident #59 was placed on one on one (1:1) supervision until a psychiatric evaluation on 05/10/24. On 05/20/24 Resident #59 was found with a call light wrapped around his neck after being found on the floor on his room. Resident #59's was discharged to a local hospital and pink slipped (emergency admitted ) on 05/21/24 for psychiatric evaluation. Resident #59 returned to the facility on [DATE] was placed on 1:1 supervision until psychiatric evaluation on 05/24/24. Review of Resident #59's comprehensive care plan revealed no focus or related interventions interventions for suicide risk/suicidal ideation. During an interview on 06/05/24 at 1:25 P.M. the Director of Nursing (DON), Administrator, and Social Services Director (SSD) #150 confirmed Resident #59 had been evaluated for suicidal ideation on 05/10/24 and 05/24/24. The DON, Administrator, and SSD #150 confirmed Resident #59's comprehensive care plan should have been update to include interventions for suicide risk/suicidal ideation. This deficiency represents non-compliance investigated under Complaint Number OH00154118.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to provide urinary catheter care to a resident. This affected one (#76) of three residents reviewed for urinary catheters. The census was 74. Findings include: Review of Resident #76's closed medical record revealed an admission date of 05/16/24. Diagnoses listed included osteoarthritis, restless leg syndrome, type two diabetes mellitus, and morbid obesity. Resident #76 was discharged from the facility on 05/19/24. Review of a Nursing Administration Evaluation dated 05/16/24 revealed Resident #76 had an indwelling urinary catheter. Further review of Resident #76's closed medical record revealed no documentation of urinary catheter care being provided to Resident #76 from admission [DATE] to discharge 05/19/24. During an interview on 06/05/24 at 9:55 A.M. The Director of Nursing (DON) and Regional Nurse #100 confirmed urinary catheter care was not documented as being provided Resident #76. Urinary catheter care should be completed as least every shift (two times a day). Review of the facility's policy titled Catheter Care, Urinary dated revised September 2014 revealed a resident's urinary catheter care should be documented in the medical record. This documentation should include the date and the time that catheter care was given and the name and the title of the individual(s) giving the catheter care. This deficiency represents non-compliance investigated under Complaint Number OH00154127.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of facility policy, and review of medication information from Medscape, the facility failed to monitor a resident's blood glucose level before administering insulin. This affected one (#76) of three residents reviewed for insulin administration. The census was 74. Findings include: Review of Resident #76's closed medical record revealed an admission date of 05/16/24. Diagnoses listed included osteoarthritis, restless leg syndrome, type two diabetes mellitus, and morbid obesity. Resident #76 was discharged from the facility on 05/19/24. Review of physician orders revealed an order dated 05/16/24 to inject 60 units of insulin glargine subcutaneous solution 100 units per milliliter (unit/ml) subcutaneously (SQ) at bedtime for diabetes mellitus. Review of medication administration records (MAR) revealed 60 units of insulin glargine subcutaneous solution was administered to Resident #76 on 05/17/24 and 05/18/24. No documentation of blood glucose levels checks before administration was documented. Review of documented blood glucose level results revealed no documentation of results being obtained before administration of 60 units of insulin glargine subcutaneous solution to Resident #76 on 05/17/24 and 05/18/24. During an interview on 06/05/24 at 9:55 A.M. The Director of Nursing (DON) and Regional Nurse #100 confirmed Resident #76's blood glucose level was not checked prior to administration of 60 units of insulin glargine subcutaneous solution on 05/17/24 and 05/18/24. Both the DON and Regional Nurse #100 confirmed Resident #76 was admitted on [DATE] and the administration of insulin on 05/17/24 and 05/18/24 would have been the first time Resident #76 had received insulin at the facility. Both the DON and Regional Nurse #100 confirmed Resident #76's blood glucose levels should have been checked before being administered insulin on 05/17/24 and 05/18/24. Review of the facility's policy titled Insulin Administration dated revised September 2014 revealed step #2 in the insulin administration procedure was to check blood glucose per physician order or facility protocol. Documentation included the resident's blood glucose result. Review of Medscape at https://reference.medscape.com/drug/lantus-toujeo-insulin-glargine-999003#91 revealed blood glucose monitoring is essential in all patients receiving insulin therapy. Insulin glargine is a long acting insulin and while taking this insulin patients should monitor their blood sugar on a regular basis. This deficiency represents non-compliance investigated under Complaint Number OH00154127.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews and policy review, the facility failed to provide a resident with timely incontinence care and timely assistance with the use of a bed pan. This affected one (#44) of three residents reviewed for incontinent care. The facility census was 75. Findings include: Review of medical record for Resident #44 revealed admission date of 02/18/24. Diagnoses include diabetes mellitus type two, morbid obesity and hypertension. The resident was scheduled to be discharged [DATE] to another facility. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #44's Brief Interview Mental Status (BIMS) score was 15 indicating intact cognition. Resident #44 required maximum assistance for bed mobility, dependent for transfers and maximum assistance for eating. Review of Resident #44's admission skin assessment dated [DATE] revealed bruising to the right forearm and healed pressure area to the sacrum. Review of Resident #44's Body assessment dated [DATE] revealed Moisture Associated Skin Damage to bilateral thighs and buttocks. In the summary it was documented, Resident #44 voiced complaint of burning skin and being left on bed pan from previous shift. Administrator asked this nurse to perform skin assessment. Interview on 03/06/24 at 9:42 A.M. with Resident #44 revealed about a week or two ago, she had been left on a bed pan throughout the night and was not taken off until the morning staff came in. Resident #44 said the call light had gone unanswered. During the interview with State Tested Nursing Assistant (STNA) #320 who entered the room to provide care. Observation during incontinence care revealed several open areas on her coccyx, right and left posterior thigh. Observation on 03/06/24 at 9:48 A.M. of incontinence care for Resident #44 by STNA #320 revealed Resident #44 incontinence brief was saturated. Resident #44 was turned onto her left side and a strong urine smell filled the room. Further observation revealed a large, yellow tinged stain on Resident #44's bed blanket. Interview on 03/06/24 at 10:02 A.M. with STNA #320 revealed she had not yet provided incontinence care for Resident #44. STNA #320 stated she arrived at the facility and her shift started at 7:00 A.M. STNA #320 stated she was unsure of the last time Resident #44 was provided with incontinence care. Interview on 03/06/24 at 10:06 A.M. with Resident #44 revealed she was unsure the last time she received incontinence care, but it had been during the night shift. Resident #44 further shared night shift would come to the door and ask if she was wet, if she said yes, they would ask if she was wet, wet. Resident #44 added she felt if she was wet at all, she wanted to be provided with care. Interview on 03/06/24 at 11:22 A.M. with STNA #350 revealed she had been informed by another STNA in report Resident #44 had been left on the bed pan all night about a week or two ago. STNA #350 acknowledged she was not working when the incident happened but added she had taken care of Resident #44 prior to the incident, and she did not have any open areas to her coccyx or thighs before the incident. Interview on 03/06/24 at 1:03 P.M. with Registered Nurse (RN) #325 revealed she had been informed in report Resident #44 had been left on the bed pan through the night. RN #325 stated she performed a skin assessment and contacted the Medical Director to provide an update and received an order for barrier cream. Interview on 03/06/24 at 4:15 P.M. with STNA #345 revealed she had arrived to work late, between 8:00 A.M. and 9:00 A.M. on 02/20/24. Resident #44 had her call light on and when she answered, Resident #44 was upset because she needed to be removed from the bed pan. STNA #345 shared the bed pan was overflowing with stool. When she removed Resident #44 from the bed pan, she could tell she had been on it a while and she had several open areas. STNA #345 stated she cleansed her and changed the bed sheet. STNA #345 stated she informed the nurse and was unsure what happened there. Review of the facility policy, Activities of Daily Living, Supporting dated 08/22 documented appropriate care and services would be provided for residents who were unable to carry them out independently. This deficiency represents non-compliance investigated under Master Complaint Number OH00151459 and Complaint Number OH00151261.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and physician interviews, and review of facility policy, the facility failed to notify a resident's physician of abnormal laboratory results. This affected one (#77) of three residents reviewed for notification of change. The census was 74. Findings include: Review of Resident #77's closed medical record revealed an admission dated of 07/29/23. Diagnoses listed included obstructive sleep apnea, muscle weakness, type two diabetes mellitus, urine retention, and chronic kidney disease. Resident #77 was transferred to a local hospital on [DATE]. Resident #77 passed away while at the hospital on [DATE]. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #77 was moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight. Resident #77 had an indwelling catheter. Review of progress notes revealed Resident #77 was noted with penile discharge with a foul odor on 12/19/23. Resident #77 was assessed by physician on 12/19/23 for the penile discharge. Physician ordered an urinalysis (UA ) with culture and urology consult. The urologist was notified on 12/19/23. Resident #77 was transferred to a local hospital on [DATE] by emergency squad for low oxygen saturation levels and decreased level of consciousness. Resident #77 passed away at a local hospital on [DATE]. Review of physician orders revealed an order dated 12/19/23 to obtain an UA with culture. Review of laboratory results revealed the sample for for UA and culture was obtained on 12/20/23. UA results dated 12/21/23 revealed abnormal bacteria levels were present at too numerous to count (TNTC) when normal level was absent. Culture results dated 12/24/23 revealed the presence of two bacterial organisms (proteus mirabilis and enterococcus faecalis) at greater than 100,000 colony forming units per milliliter cfu/ml. Further review of Resident #77's closed medical record revealed no documentation of UA results dated 12/21/23 or culture dated 12/24/23 being addressed by staff. There was no documentation of Resident #77's physician or urologist being notified of the UA or culture results. There was no documentation of any treatment being ordered. During an interview on 02/07/24 at 2:45 P.M. the Director of Nursing (DON) and Administrator confirmed Resident #77's UA and culture results were not reported to a physician and a treatment was not started before Resident #77 was transferred to a local hospital on [DATE]. Both the DON and Administrator confirmed Resident #77's culture results were reported 48 hours before he was transferred. During a phone interview on 02/07/24 at 2:55 P.M. Physician #100 confirmed either the urologist or himself should have been notified of Resident #77's UA and culture results. Physician #100 stated he was not notified of the results. Physician #100 confirmed Resident #77's culture results would have warranted a change in treatment. Physician #100 stated that there were concerns with how the laboratory company was reported results to the facility. Review of the facility's policy titled Change in a Resident's Condition or Status revised September 2022 revealed the facility will notify the resident, his or her attending physician, and the resident representative in changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there is a need to alter the resident's medical treatment significantly. Except in medical emergencies notifications will be made within 24 hours of a change occurring. This deficiency represents non-compliance investigated under Complaint Number OH00149971.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and physician interviews, and review of Centers for Disease Control and Prevention (CDC) information, the facility failed to timely treat a resident's urinary tract infection (UTI). This affected one (#77) of three residents reviewed for UTI's. The census was 74. Findings include: Review of Resident #77's closed medical record revealed an admission dated of 07/29/23. Diagnoses listed included obstructive sleep apnea, muscle weakness, type two diabetes mellitus, urine retention, and chronic kidney disease. Resident #77 was transferred to a local hospital on [DATE]. Resident #77 passed away while at the hospital on [DATE]. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #77 was moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight. Resident #77 had an indwelling catheter. Review of progress notes revealed Resident #77 was noted with penile discharge with a foul odor on 12/19/23. Resident #77 was assessed by physician on 12/19/23 for the penile discharge. Physician ordered an urinalysis (UA ) with culture and urology consult. The urologist was notified on 12/19/23. Resident #77 was transferred to a local hospital on [DATE] by emergency squad for low oxygen saturation levels and decreased level of consciousness. Resident #77 passed away at a local hospital on [DATE]. Review of physician orders revealed an order dated 12/19/23 to obtain an UA with culture. Review of laboratory results revealed the sample for for UA and culture was obtained on 12/20/23. UA results dated 12/21/23 revealed abnormal bacteria levels were present at too numerous to count (TNTC) when normal level was absent. Culture results dated 12/24/23 revealed the presence of two bacterial organisms (proteus mirabilis and enterococcus faecalis) at greater than 100,000 colony forming units per milliliter cfu/ml. Further review of Resident #77's closed medical record revealed no documentation of UA results dated 12/21/23 or culture dated 12/24/23 being addressed by staff. There was no documentation of Resident #77's physician or urologist being notified of the UA or culture results. There was no documentation of any treatment being ordered. During an interview on 02/07/24 at 2:45 P.M. the Director of Nursing (DON) and Administrator confirmed Resident #77's UA and culture results were not reported to a physician and a treatment was not started before Resident #77 was transferred to a local hospital on [DATE]. Both the DON and Administrator confirmed Resident #77's culture results were reported 48 hours before he was transferred. During a phone interview on 02/07/24 at 2:55 P.M. Physician #100 confirmed either the urologist or himself should have been notified of Resident #77's UA and culture results. Physician #100 confirmed Resident #77's culture results would have a warranted treatment for UTI. Physician #100 stated that there were concerns with how the laboratory company was reported results to the facility. Review of CDC literature titled Urinary Tract Infection (UTI) Event for Long-term Care Facilities revealed catheter-associated symptomatic urinary tract infections (CA-SUTI) events occur when a resident develops signs and symptoms localizing to the urinary tract while having an indwelling urinary catheter in place or removed within the two calendar days prior to the date of event. Residents with one or more of the following with no alternate source: fever, rigors, new onset hypotension, with no alternate site of infection, new onset confusion/functional decline and leukocytosis, new costovertebral angle pain or tenderness, new or marked increase in suprapubic tenderness, acute pain, swelling or tenderness of the testes, epididymis or prostate, or purulent discharge from around the catheter, and a positive culture with equal to 100,000 cfu//ml of any microorganisms from an indwelling catheter specimen are diagnosed with a CA-SUTI. This deficiency represents non-compliance investigated under Complaint Number OH00149971.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, and policy review, the facility failed to ensure pressure ulcer treatments were completed as prescribed and failed to ensure pressure ulcer assessment were completed. This affected two (Residents #10 and #12) of three residents reviewed for pressure ulcers. The facility census was 73. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 02/20/23. Diagnoses included peripheral vascular disease and cognitive communications deficit. The resident was cognitively impaired. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 required assistance with eating, toileting, bed mobility, and transfers. Review of the 12/13/23 wound evaluation revealed a Suspected Deep Tissue Injury (SDTI) (purple or maroon localized area of discolored intact skin due damage of underlying soft tissue from pressure) on the left proximal foot measuring 1.5 centimeters (cm) by (x) 1.5 cm and left proximal foot SDTI measuring 2.3 cm x 1.1 cm. Documents revealed Physician #114 was contacted. Review of the weekly wound assessments revealed no documentation a weekly assessment was completed on 12/20/23 for the left distal or proximal left foot wounds. Review of physician orders revealed an order with a start date of 12/21/23 to cleanse with normal saline, pat dry, apply xeroform and cover with dry, clean dressing every day shift. Review of the December and January Treatment Administration Record (TAR) revealed no documentation the treatment was provided as ordered on 12/12/23, 12/28/23, or 01/03/24. Interview on 01/09/24 at 3:30 P.M. with the Director of Nursing verified there was no documentation of a wound assessment for the distal and/or proximal wound to the left foot on 12/20/23. 2. Review of the medical record for Resident #12 revealed an admission date of 12/07/23. Diagnoses included rhabdomyolysis, type two diabetes mellitus, and anxiety. The resident was cognitively impaired. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 required assisstance with activities of daily living. Further review revealed the resident had two stage four pressure ulcers and three unstageable pressure ulcers all of which were documented present upon admission. Review of the admission skin assessment revealed wounds were documented to right elbow, left elbow, coccyx and left trochanter. There was no documentation of the type of wound, measurements, and/or staging of the wounds. Interview on 01/09/24 at 12:17 P.M. with the Administrator verified there was no description, staging and/or measurements of Resident 12's wounds upon admission. Review of the Prevention of Pressure Injuries policy revised 09/22 revealed to assess the resident upon admission for existing pressure injury risk factors, and to identify any signs of developing pressure injuries. Review of the Wound Care policy revised 09/22 revealed documentation which should be included in the resident record all assessment data (wound bed color, size, drainage, etc.) obtained when inspecting the wound. This deficiency represents non-compliance investigated under Complaint Number OH00149752.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #53 revealed admission date of 07/01/12. The resident was admitted with diagnoses including depression and anxiety. On 12/31/19, Resident #53 received a new diagnosis of unspecified psychosis not due to a substance or known physiological condition and on 02/06/20, a new diagnosis of a mood disorder due to physiological condition. The medical record did not have a PASARR assessment for Resident #53. Interview on 08/02/22 at 3:36 P.M. with Social Worker #173 revealed she was unsure if a PASARR was completed after the diagnosis of mood disorder due to known physiological condition was added on 02/06/20 or unspecified psychosis not due to a substance or known physiological condition was added on 02/31/19. She was unable to provide Resident #53's PASARR assessment at the time of exit. Based on staff interview and record review, the facility failed to ensure an updated and accurate pre-admission screening and resident review (PASARR) assessment was completed for the residents. This affected three (Residents (#39, #45, and #53) of six resident reviewed for the PASARR program. The facility census was 72. Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 09/28/16. Diagnoses included respiratory failure with hypoxia, encephalopathy, psychosis, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact. Review of the PASARR assessment dated [DATE] revealed Resident #39 has no mental health diagnoses. Interview on 08/03/22 at 1:33 P.M. with Social Services (SS) #173 confirmed the PASARR assessment was not accurate for Resident #39 to reflect Resident #39 had a mental health diagnosis. SS #173 stated she would complete a new PASARR assessment for Resident #39. 2. Review of the medical record for the Resident #45 revealed an admission date of 09/11/20. Diagnoses included anxiety, depression, and psychosis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was cognitively intact. Review of the PASARR assessment dated [DATE] revealed Resident #45 did not have anxiety documented as a diagnosis, but was prescribed medication for anxiety. Interview on 08/03/22 at 1:33 P.M. with Social Services (SS) #173 confirmed the PASARR assessment did not include anxiety for Resident #45. SS #173 stated she would complete a new PASARR assessment for Resident #45.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, review of the facility's policy, and record review, the facility failed to ensure Resident #39 who required assistance with activity of daily living (ADL) care received adequate and timely nail care. This affected one (Resident #39) of two residents reviewed for ADL care. The facility identified 71 residents who required assistance with bathing. The facility census was 72. Findings include Review of the medical record for the Resident #39 revealed an admission date of 09/28/16. Diagnoses included respiratory failure with hypoxia, cerebrovascular disease, hemiplegia and hemiparesis, diabetes mellitus, psychosis, tremor, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively impaired and required extensive assistance of one staff for hygiene care and required extensive assistance of two staff for bathing. Review of the plan of care dated 06/22/22 revealed Resident #39 had impaired activity of daily living (ADL) requiring assistance with ADLs and self-care. Intervention included to assist Resident #39 with baths and showers. Review of the shower sheets revealed Resident #39 was offered and refused a bath on 07/03/22, 07/14/22, 07/21/22, and 07/28/22. Resident #39 received a bath on 07/07/22, 07/10/22, 07/17/22, and 07/24/22. Observation and interview on 08/01/22 at 10:40 A.M. with Resident #39 revealed the resident's fingernails were long and jagged and black substance under the nails. Resident #39 stated he would like his nails cut. Subsequent observations on 08/02/22 at 9:20 A.M. and 3:35 P.M. and on 08/03/22 at 11:30 A.M. revealed Resident #39's nails had not yet been trimmed. Interview on 08/03/22 at 11:40 A.M. with Licensed Practical Nurse (LPN) #117 revealed Resident #39 does frequently refuse showers but typically agrees after some encouragement. Interview and observation on 08/03/22 at 4:20 P.M. with LPN #127 confirmed Resident #39 had long nails with some jagged edges and dirt under the nails. LPN #127 reported she will request the state tested nursing aide to come in and trim Resident #39's nails. Resident #39 confirmed to LPN #127 during observation he would like his nails trimmed. Review of the facility's undated policy titled Shower Bath Policy and Procedures, revealed the facility will provide comfort to the resident and to observe the condition of the resident's skin and nails. A shower or bath should be completed at least once weekly per resident preferences. Observe the skin for any areas redness, rashes, broken skin, tender places, pressure point, blisters or skin breakdown, provide nail care during shower or bath. Notify the unit manager or charge nurse if the resident refuses the shower or tub bath or nail care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record reviews, review of the facility's policy, and staff interviews, the facility failed to ensure the resident's skin assessments were completed as physician ordered, failed to monitor a resident's wounds routinely, and failed to timely identify new wounds. This affected two (Residents #39 and #56) of two residents reviewed for skin. The facility census was 72. Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 09/28/16. Diagnoses included respiratory failure with hypoxia, cerebrovascular disease, hemiplegia and hemiparesis, malnutrition, diabetes mellitus, tremor, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact and required extensive assistance of two staff members for transfers and bed mobility. Resident #39 had no wounds or skin conditions. Review of the plan of care dated 06/22/22 revealed Resident #39 was at risk for impaired skin integrity with interventions to provide routine skin care and apply lotion as needed. Review of Resident #39's physician's orders dated 01/08/22 revealed an order for weekly skin check on Saturdays from 7:00 A.M. to 3:00 P.M. Review of Resident #39's skin assessments dated 01/01/22 to 08/01/22 revealed weekly skin assessments were missed on 01/01/22, 01/08/22, 01/15/22, 01/29/22, 02/05/22, 02/12/22, 03/05/22, 04/16/22, 04/23/22, 04/30/22, 05/07/22, 05/14/22, 05/21/22, 07/09/22, 07/16/22, 07/23/22, and 07/30/22. Review of the skin assessment dated [DATE] revealed Resident #39 had no new skin impairments and it did not describe any history of active wounds or healing stages of wounds. Review of the progress notes dated 04/01/22 to 08/04/22 revealed no mention of skin wounds or sores to feet. Observation on 08/01/22 at 10:46 A.M. revealed Resident #39 had several cuts and wounds to his feet especially his right foot which had two wounds slightly larger than a pencil eraser on the top of the toes that have a scabbed and dried blood appearance. No treatments appeared to be in place. Observation and interview on 08/03/22 at 4:20 P.M. with Licensed Practical Nurse (LPN) #127 confirmed Resident #39 had dried feet with flaking skin and scabbed wounds on several toes. LPN #27 stated the foot wounds were not new and verified Resident #39 had no treatment orders in place for the wounds on his feet. Interview on 08/04/22 at 10:20 A.M. with the Director of Nursing (DON) revealed Resident #39's foot wounds were scratches which was why their was no documentation in the skin assessments. The DON provided documents from admission skin assessments (09/28/16) stating wounds on all extremities were superficial scratches and were chronic skin impairments. Observation and interview on 08/04/22 on 9:20 A.M. with State Tested Nursing Aide (STNA) #107 stated Resident #39 had foot wounds. STNA #107 stated the areas appeared to be scabbed over and had dried blood on them. STNA #107 stated Resident #39 had these areas from hitting the footboard with his feet and continuously re-opening up old wounds on his feet. Interview on 08/04/22 at 9:50 A.M. with LPN #117 revealed a weekly skin assessment entails checking all areas of the resident's skin from head to toe and document status of skin impairments and wounds including scratches, open wounds, bruising, rashes and scabbed areas. LPN #117 stated the wounds on Resident #39's foot have been there a long time, but they start to heal and then were re-opened from hitting the foot board. LPN #117 was unsure if the facility had looked into alternatives such as padded footwear or making changes with the footboard. 2. Review of the medical record for Resident #56 revealed an admission date of 05/13/21. Diagnoses included Parkinson's disease and altered mental status. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was cognitively impaired and required extensive assistance of two staff members for bed mobility and transfers. Resident #56 had no wounds or skin conditions. Review of the plan of care dated 07/14/22 revealed Resident #56 had a potential for impaired skin integrity with interventions to assist the resident with turning and repositioning, provide routine skin care, and apply lotion as needed. Review of Resident #56's physician orders dated 01/03/22 revealed an orders for weekly skin check every Monday during evening shift. Review of the progress notes dated 04/11/22 revealed Resident #56 was found on the floor after a fall and was assessed by the nurse and found to have an abrasion on his right knee and left lower back. There was no mention of wounds of skin impairments in any progress notes since 04/11/22 until 08/02/22 revealed skin tear to left forearm, secondary to the clip on the call light. Review of Resident #56's skin assessments dated 04/04/22, 04/18/22, and 05/23/22 revealed no concerns or skin issues were noted. Weekly skin assessments were missed on 04/25/22, 05/02/22, 05/09/22, 05/16/22, and 08/01/22. Observation on 08/01/22 at 3:07 P.M. of Resident #56 revealed Resident #56 had a wound and bruising on his left upper extremity. Interview on 08/02/22 at 3:37 P.M. with State Tested Nursing Aide (STNA) #106 revealed she noticed the wound and bruising on Resident #56's arm earlier in the day but revealed she had not worked with Resident #56 for several days and was unsure when the wound and bruise developed. Interview on 08/02/22 at 5:00 P.M. with the Director of Nursing (DON) verified the facility staff just observed the wound on his arm that day (08/02/22). Interview on 08/03/22 at 11:40 A.M. with Licensed Practical Nurse (LPN) #117 stated wound healing progress should be documented in the medical record and if residents had a previous wound that healed, it should be documented as a healed. Interview on 08/04/22 at 4:20 P.M. with the Director of Operations (DO) #200 stated non-pressure wounds would follow the same policy for wound management as the pressure wound policy for monitoring, assessing, and documentation. DO #200 stated the facility had no additional policies on wound monitoring. Review of the facility's policy titled Pressure Ulcers and Skin Breakdown - Skin and Wound Management, dated 02/2014, revealed when a wound was observed, the nurse and physician shall assess and document a full assessment including location and size, a pain assessment, and treatments. The physician should identify risk factors for skin breakdown. The policy does not mention how wounds would be followed and documented on an ongoing basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of the National Pressure Injury Advisory Panel (NPIAP) resources, the facility failed to have documented timely treatment and interventions for a resident who was admitted to the facility with deep tissue injuries (DTIs). This affected one (Resident #23) of two residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 72. Finding include: Review of Resident #23's medical record revealed an admission date of 05/22/22. Diagnoses included anxiety disorder, hypertension, rhabdomyolysis, stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) of left ankle, and unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) of left hip. Review of Resident #23's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was moderately cognitively impaired and required extensive assistance with bed mobility, was at risk for pressure ulcers, and did not have any unhealed pressure ulcers. Review of Resident #23's admission skin assessment dated [DATE] revealed bruising to the left hip measuring 76 centimeters (cm) in length by 49 cm wide, bruising to the left outer ankle measuring 12 cm by 10 cm, and bruising to front right lower leg measuring 30 cm by 18 cm. Review of the facility's wound tracking documentation revealed on 05/22/22, a DTI to right anterior leg measuring 28 cm x 10 cm, a DTI to left lateral ankle measuring 12 cm x 10 cm, and a DTI to the left hip measuring 76 cm x 49 cm. Interventions listed in place for each DTI included to encourage turn and position, pad and protect, and positioning with pillows. There was no documentation of these interventions being implemented from 05/22/22 through 06/08/22 was found in Resident #23's medical record. Review of the completed physician's orders revealed treatments to the left hip, right lower leg, and left ankle wounds were first ordered on 06/08/22. Physician orders included cleanse the left ankle with normal saline (NS), apply wound gel (moisture providing gel), and bordered foam dressing, cleanse left hip with NS, apply wound gel, and bordered foam dressing, and cleanse lower right calf with NS, apply triple antibiotic ointment, and cover with 3 x 3 (gauze) dressing. Review of Resident #23's care plan revealed an impaired skin integrity related to pressure ulcer to left hip and left ankle was initiated on 07/15/22. There were no care plan interventions for an actual impaired skin integrity before 07/15/22. Review of the initial wound physician note dated 07/26/22 revealed Resident #23's right anterior leg pressure ulcer was noted as healed. The left lateral ankle wound was a stage three pressure ulcer measuring 0.5 cm x 0.3 x 0.1 cm with 100% granulation and was noted as healing. The left hip pressure ulcer was now a stage four measuring 3.6 cm x 1.7 cm x 0.8 cm with 100% granulation and was noted as healing. Review of the physician's orders dated 07/26/22 revealed an order to cleanse the left ankle with NS, apply wound gel to wound bed, cover with dampened gauze, and cover with dry dressing. An order dated 07/26/22 was to cleanse the left hip with NS, apply wound gel to wound bed, cover with dampened gauze, and cover with dry dressing. Observations of wound care provided to Resident #23 on 08/02/22 at 3:30 P.M. revealed a round wound with serous drainage to the left hip. Observation of wound care provided to Resident #23 on 08/03/22 at 2:32 P.M. revealed a small round healing wound with no drainage to the left lateral heal. A wound to Resident #23's right anterior leg had healed and a reddened scar remained. During an interview on 08/03/22 at 11:58 A.M., the Director of Nursing (DON), Administrator, and Regional Director of Clinical Services (RDCS) #177 confirmed there was no documentation of treatments or interventions being completed for three deep tissue injuries identified on Resident #23 from admission on [DATE] through 06/08/22. The DON, Administrator, and RDCS #177 confirmed Resident #23 was not assessed by a wound care physician until 06/28/22. The DON, Administrator, and RDCS #177 also confirmed Resident #23's care plan was not updated for actual skin impairments until 07/15/22. Review of the NPIAP website revealed a deep tissue pressure injury was persistent non-blanchable deep red, maroon or purple discoloration intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage III or Stage IV).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview and review of Medscape guidance, the facility failed to ensure the residents were free from unnecessary medication use. This affected one (Resident #58) of five residents reviewed for unnecessary medication use. The facility census was 72. Findings include: Medical record review for Resident #58 revealed an admission date of 12/27/19. Diagnoses included chronic obstructive pulmonary disease and stroke. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 had impaired cognition and was dependent on staff for toileting. Review of the physician's orders dated 07/08/22 revealed Resident #58 had an order for Miralax (laxative) 17 grams by mouth daily. Review of the bowel record for Resident #58 revealed loose/diarrhea was noted on 07/07/22, 07/09/22, 07/10/22, 07/11/22, 07/12/22, 07/13/22, 07/14/22, 07/15/22, 07/16/22, 07/19/22, 07/20/22, 07/21/22/ 07/23/22, 07/24/22, 07/25/22, 07/27/22, 07/29/22, 07/30/22, 07/31/22, 08/01/22, 08/02/22, and 08/03/22. Interview on 08/01/22 at 11:28 A.M. with Resident #58 stated she had loose bowel movements one to two times daily. Interview with the Director of Nursing (DON) on 08/04/22 at 8:12 A.M. verified Resident #58 had a lot of loose stools/diarrhea documented in the last month. The DON stated he spoke to the physician regarding Resident #58's loose stools and the physician order changed to as needed. Review of the medication information from Medscape (https://reference.medscape.com/drug/golytely-miralax-polyethylene-glycol-342026#0) revealed Miralax is a osmotic laxative and is used to treat constipation. Miralax causes water retention in stool, causing increase in stool frequency and can cause diarrhea.

Based on observations, staff interviews, and recipe review, the facility failed to ensure therapeutic texture diets were made according to a recipe and maintained palatability. This had the potential to affect 13 residents who received a puréed diet. The facility census was 72. Findings include: Observation and interview on 08/02/22 at 11:08 A.M. with Dietary Staff (DS) #185 revealed DS #185 was preparing mixed vegetables of 14 servings. DS #185 stated the vegetables already had liquid in the can and she added chicken broth. DS #185 put in several unmeasured scoops of vegetables in the roboku and blended for several seconds. DS #185 then dumped an unmeasured amount of liquid from the container in the roboku (estimated around half to three-fourths cup). The vegetables and liquid were blended to a tomato soup consistency. DS #185 stated she needed to add thickener to the mixture. DS #185 added four unmeasured spoonfuls (about one tablespoon each) of thickener then blended the mixture. DS #185 stated the mixture was still too thin and Kitchen Manager (KM) #180 added a large scoop (about one-fourth cup of thickener) to the mixture. After blending the mixture, DS #185 placed the vegetable mixture in a metal tin and in a warmer. Observation on 08/02/22 at 12:02 P.M. during tray line revealed the vegetable pureed was an applesauce consistency and did not hold a form. The mixture took the shape of the dish it was placed in. Observation and interview on 08/02/22 at 2:00 P.M. with KM #180 during the test tray revealed the pureed food was a thin consistency and had a heavy taste of starch from the thickener agent. KM #180 confirmed the texture concerns and the taste of starch while also tasting from the test tray. Review of the pureed food recipe revealed oriental blend vegetables included instructions to make one, five, 10 and 15 servings. The recipe revealed a ratio for 15 servings to include three tablespoons of liquid plus three-fourths cup. The recipe has notes including gradually add liquid starting with the smallest amount and only add more liquid if needed to use the least amount of liquid and thickener.

Based on observations, staff interviews, review of manufacturer's guide, policy review, and record review, the facility failed to ensure food was safely and properly stored in the kitchen. The facility also failed to ensure the dishwasher was in safe working order. This had the potential to a affect all residents except three (Residents #5, #39 and #54) who do not eat food from the kitchen. The facility census was 72. Findings include: Observations and interview on 08/01/22 from 9:05 A.M. to 9:20 A.M. with Kitchen Manager #180 revealed pancakes and bratwurst were left undated in the freezer. In addition, a box of green beans, chicken breast, and cut up sausage were left open to air and undated in the freezer. Many items in the freezer appeared to have freezer burn and were covered in frost. The refrigerator had an employee lunch that was left undated and four gallons of milk dated 07/27/22 and 07/28/22. The dry storage area included three bags of pasta, two bags of brownie mix, and three bags of yellow cake mix that was unsealed and undated. The dry storage also contained a pack of gingersnap cookies and about 20 bags of quinoa that were left undated. Kitchen Manager #180 confirmed food storage concern for all named items above. Observation on 08/02/22 at 2:00 P.M. revealed the dishwasher temperature gauges were not working properly. The wash gauge stayed in the 165 Fahrenheit (F) range even when the washer was not running and the rinse gauge was not displaying any temperature. Staff were rinsing off the plate and running them through the dishwasher even knowing the temperature gauges were not working properly. Staff were not using temperature testing strips to measure temperatures. Interview on 08/02/22 at 2:00 P.M. with Dietary Staff #185 stated the dishwasher had been broken for awhile and works only when it wants to. Interview on 08/03/22 at 4:08 P.M. with the Administrator revealed the kitchen has no current temperature log for the dishwasher and revealed the former kitchen manager had no record of a log for the dishwasher temperatures. The Administrator revealed the dishwasher had been broken ever since she started which was a month ago. Review of the facility's list of diets revealed Residents #5, #39 and #54 diet's were nothing by mouth. Review of the dishwasher's manufacturer guide revealed the wash temperature should be at least 150 degrees F and the rinse setting should be over 180 degrees F. Review of the facility's policy titled Preventing Foodborne Illness - Food Handling, dated 12/2012, revealed food will be stored, prepared, handled and served so that the risks for foodborne illness was minimized. All food service equipment and utensils will be sanitized according to current guidelines and manufacture recommendations.

Based on review of the facility's policy, record review, observations, review of online resources for the Centers for Disease Control and Prevention (CDC) and the Center for Medicare and Medicaid Services (CMS), and staff interview, the facility failed to ensure staff wore Personal Protective Equipment (PPE) while caring for residents to the prevent the potential spread of COVID-19. In addition, the facility failed to have a Legionella management plan in place. This had the potential to affect all 72 residents residing in the facility. Findings include: 1. Observation on 08/02/22 at 1:26 P.M. revealed there were two staff members supervising five residents smoking. Residents were spaced approximately six feet apart. Activity Aide #168 was sitting at a table with two residents, within six feet with his mask pulled down to his chin. This was verified by Licensed Practical Nurse (LPN) #125. Observation on 08/03/22 at 8:29 A.M. revealed State Tested Nursing Assistant (STNA) #163 went into Resident #63's room while he was present, with her mask pulled down to her chin and her goggle on top of her head. STNA #163 verified this when she exited the room. Observation on 08/03/22 10:51 A.M. revealed Activity Aide #168 was standing/walking in the smoking area with approximately five residents with his mask pulled down to his chin. This was verified with LPN #300. Review of an online resource from CMS titled COVID-19 Nursing Home Data at https://data.cms.gov/covid-19/covid-19-nursing-home-data revealed the county in which the facility was situated was experiencing a high (red) community transmission rate of COVID 19. Review of an online resource per the CDC titled Infection Control Guidance for Healthcare Professionals about Coronavirus (COVID-19) at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html, dated 06/03/22, revealed the use of eye protection in healthcare facilities is recommended in areas with moderate to substantial community transmission and staff should don eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area. Review on an online resource per the CDC titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the COVID-19 Pandemic found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, last updated 02/02/22, revealed the recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic to implement source control measures. Source control refers to the use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control options for healthcare professionals include: A NIOSH-approved N95 or equivalent or higher-level respirator or a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators or a well-fitting facemask. 2. Review of the facility's policy titled Legionella Water Management Program, dated July 2017, revealed the facility will have a Legionella water management program with specific measures used to control the introduction and/or spread of Legionella (e.g., temperature,disinfectants), the control limits or parameters that are acceptable and that are monitored, a diagram of where control measures are applied, a system to monitor the control limits and the effectiveness of the control measures, a plan for when control limits are not met and/or control measures are not effective, and documentation of the program. The facility was unable to provide a Legionella management plan with control measures. Interview with the Director of Nursing (DON) on 08/04/22 at 2:15 P.M. confirmed the facility did not have a Legionella management plan with documented control measures and corrective actions. This deficiency substantiates Complaint Number OH00134364.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility staff interview and resident interview and review of facility policy the facility failed to complete a comprehensive care plan that addressed resident individual needs. This affected two (#5 and #47) of 19 residents care plans reviewed. The total facility census was 63. Findings include: 1. Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included respiratory failure with hypoxia, cerebrovascular accident, hemiplegia, hyperkalemia, atrial fibrillation, hypertension, hyperlipdiemia, dysarthria, diabetes type two, anxiety, depression, alcohol abuse, obesity and deconditioning. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had cognitive impairment, had no hallucinations or delusions; however, did have rejection of care one to three days of the review period. The resident was coded as requiring extensive assist for bed mobility, dressing, eating, toileting and, dependent on staff for transfer. The resident was coded as having hypertension, hemiplegia, anxiety, and depression included as diagnosis, however there is no coding of dementia. Review of the resident care plan from a prior admission with an initiation date of 11/15/16 revealed the resident had mood problem related to his cognitive decline. The resident had diagnoses of depression and anxiety. The care plan did not reflect that the resident's mood problems were related to the medical diagnosis of anxiety and depression. During an interview with on 07/31/19 at 10:31 A.M. with Registered Nurse (RN) #442 it was verified the resident care plan was not updated since the prior admission and did not reflect the resident's diagnoses. 2. Record review revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included fracture of the left humerus, repeated falls, hearing loss and major depression. Review of the assessment dated [DATE] revealed the resident required extensive assistance of staff for bed mobility, transfer, and all activities of daily living. Review of the notification of discharge from therapy dated 05/28/19 revealed she would be discharged from physical therapy (PT) and occupational therapy (OT), and referred to restorative. Review of the plan of care (POC) dated 05/28/19 revealed the restorative plan was not in place. Review of the quarterly assessment dated [DATE] revealed she had improved in only one area (eating), which was documented as supervision. Review of the nursing notes dated 07/31/19 revealed she was evaluated and was going to be placed on a restorative nursing program for range of motion and was to begin a transfer program. The residents goal was to go home. Interview on 07/31/19 at 9:13 A.M., Resident #5 stated she wanted to be able to stand by herself so she could go home. She said her daughter had been calling the facility trying to get her some more therapy, but since she had been cut from therapy she had not received anything else. She figured since she was on Medicaid that was why she wasn't receiving therapy. She also stated someone was supposed to be helping each day to complete strengthening and no one had been doing this for her. She also stated she did not want to be in the facility long term and was firm with this. Interview on 07/31/19 at 10:20 A.M., Therapy Director (TD) #501 stated the resident was cut from services on 05/28/19 due to her reaching a plateau. She was in the process of appealing because her goal was to go home. TD #501 said she had referred the resident to a restorative program to continue until she got the appeal process complete. TD #501 said the daughter was willing to pay for the therapy but she did not know what had happened to her receiving more therapy. TD #501 said the resident had been at another facility and exhausted her 100 days. The resident did not progress before she was admitted . Interview on 07/31/19 at 10:34 A.M., RN #462 stated she had not placed the resident in the restorative program or formulated a plan for her. She also stated she had received phone calls from the resident's family and was going to put her on the restorative schedule this week, but the survey started. Review of the policy titled Restorative Nursing Services date revised July 2017, documented restorative goals and objectives are individualized and resident centered, and are outlined in the residents POC. The resident or representative will be included in determining goals and the POC.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and facility staff interview the facility failed to update care plans timely. This affected one (#47) of 19 residents' care plans reviewed. The total facility census was 63. Findings include: Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included respiratory failure with hypoxia, cerebrovascular accident, hemiplegia, hyperkalemia, atrial fibrillation, hypertension, hyperlipdiemia, dysarthria, diabetes type two, anxiety, depression, alcohol abuse, obesity and deconditioning. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] the resident had cognitive impairment, had no hallucinations or delusions; however, did have rejection of care one to three days of the review period. The resident was coded as requiring extensive assist for bed mobility, dressing, eating, toileting and, dependent on staff for transfer. The resident is coded as having hypertension, hemiplegia, anxiety, and depression included as diagnosis, however there is no coding of dementia. Review of the resident's current orders revealed a current diet order of regular pureed food with no salt, and honey consistency liquids with no straws, must be spoon fed all liquids and meals by staff. The resident was to have gastronomy tube flushed with water every four hours with 350 milliliter (ml) of water. Review of the care plan from a prior admission with an initiation date of 11/15/16 revealed the resident was at risk for dehydration related to dementia and or altered mental status with decreased awareness of fluid need. The resident was listed with a diet of nothing by mouth with tube feed and flushes. Review of the care plan from a prior admission with an initiation date of 11/15/16 and revised on 04/06/17 for for hypertension etiology as life style choices and stroke. Intervention included to educate the resident family and care giver about the importance of regular exercise, limiting salt intake, the adverse effects of tobacco and alcohol. The resident was receiving nothing by mouth the last time the care plan was revised and the resident required extensive assist from staff for mobility, the interventions were not specific to the resident and the resident capabilities. Review of the fall care plan revealed the resident was at risk for falls with interventions to assist resident with wheel chair or walker for mobility. During an interview with the resident on 07/30/19 at 5:11 P.M. it was revealed the resident was not able to walk or to propel a wheelchair. During an interview with Licensed Practical Nurse (LPN) #402 on 07/30/19 at 3:57 P.M. it was confirmed the resident was unable to move his own arms and legs. The LPN further stated he was dependent on staff and staff feed the resident, she believed he could move his hands. During an interview with on 07/31/19 at 10:31 A.M. with Registered Nurse #442 it was verified the resident care plans were not updated and did not reflect the resident abilities and individual needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff and resident interview and policy review, the facility failed to timely refer a resident for restorative nursing care. This affected one Resident (#5) of 24 reviewed. The facility census was 63. Findings include: Record review revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included fracture of the left humerus, repeated falls, hearing loss and major depression. Review of the assessment dated [DATE] revealed the resident required extensive assistance of staff for bed mobility, transfer, and all activities of daily living. Review of the notification of discharge from therapy dated 05/28/19 revealed she would be discharged from physical therapy (PT) and occupational therapy (OT), and referred to restorative. Review of the plan of care (POC) dated 05/28/19 revealed the restorative plan was not in place. Review of the quarterly assessment dated [DATE] revealed she had improved in only one area (eating), which was documented as supervision. Review of the nursing notes dated 07/31/19 revealed she was evaluated and was going to be placed on a restorative nursing program for range of motion and was to begin a transfer program. The residents goal was to go home. Interview on 07/31/19 at 9:13 A.M., Resident #5 stated she wanted to be able to stand by herself so she could go home. She said her daughter had been calling the facility trying to get her some more therapy, but since she had been cut from therapy she had not received anything else. She figured since she was on Medicaid that was why she wasn't receiving therapy. She also stated someone was supposed to be helping each day to complete strengthening and no one had been doing this for her. She also stated she did not want to be in the facility long term and was firm with this. Interview on 07/31/19 at 10:20 A.M., Therapy Director (TD) #501 stated the resident was cut from services on 05/28/19 due to her reaching a plateau. She was in the process of appealing because her goal was to go home. TD #501 said she had referred the resident to a restorative program to continue until she got the appeal process complete. TD #501 said the daughter was willing to pay for the therapy but she did not know what had happened to her receiving more therapy. TD #501 said the resident had been at another facility and exhausted her 100 days. The resident did not progress before she was admitted . Interview on 07/31/19 at 10:34 A.M., RN #462 stated she had not placed the resident in the restorative program or formulated a plan for her. She also stated she had received phone calls from the resident's family and was going to put her on the restorative schedule this week, but the survey started. Review of the policy titled Restorative Nursing Services date revised July 2017, documented restorative goals and objectives are individualized and resident centered, and are outlined in the residents POC. The resident or representative will be included in determining goals and the POC.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff and resident interview and policy review, the facility failed to provide timely weights, reweighs and acknowledge a significant weight loss. This affected one Resident (#5) of 24 reviewed. The facility census was 63. Findings include: Record review revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included fracture of the left humerus, repeated falls, hearing loss and major depression. Review of the Treatment Administration Record (TAR) dated April 2019 revealed weekly weights were ordered times four weeks. There were no weekly weights documented for Resident #5. Review of the admission dietary assessment dated [DATE] documented her current body weight (CBW) on 04/02/19 was 139.7 pounds, her usual body weight (UBW) was 136 pounds per resident. Resident #5 was alert and oriented and stated she had no recent weight changes, she had been on ensure at the former facility and was explained she would be placed on a similar product three times daily for weight maintenance due to she was at risk for poor nutrition due to age, wounds, fair intake (50-75 percent), and difficulty chewing. Review of the assessment dated [DATE] revealed the resident required extensive assistance of staff for bed mobility, transfer, and eating. Review of the Plan of Care (POC) dated 04/09/19 revealed she was at nutritional risk due to age, wounds, fair intake, and difficulty chewing. Interventions included supplements as ordered, weights, and assistance with meals as necessary. Review of the weekly/daily weight book revealed 04/15/19 was the first weight taken for Resident #5 since admission and her weight was 123.6 pounds. Review of the dietary note dated 04/19/19 revealed the resident had a 11.4 percent weight loss since admission her CBW was 118.8 and a re-weight of 123.6 pounds obtained by Registered Dietician (RD) #502, she spoke to the resident and daughter about the weight loss and the daughter felt like the resident was not eating as well as she normally did prior to admission. Resident #5 also had complaints of sore gums from her dentures. Discussion occurred to provide more foods the resident enjoyed. Her basal metabolic index (BMI) was adequate and they would continue to monitor her intakes and she showed healing progression of wounds. The daughter also requested she have two slices of wheat bread with each meal and pudding for lunch and dinner in addition to her supplement three times daily and multivitamin. Review of the Dietetic Technician note dated 04/30/19 documented CBW of 123.8 pounds, and her previous weight was 123.6 pounds. She documented her admission weight was likely an error and crossed it out as she documented a UBW of 129 from her doctors office (Office weight was 129 on 03/16/19), however intakes decreased to 25-75 percent. Review of the quarterly assessment dated [DATE] revealed she had improved in only one area (eating), which was documented as supervision. Review of the weights dated 07/30/19 revealed the residents CBW was 132.9. Interview on 07/31/19 at 9:13 A.M., Resident #5 stated she was not eating very well when she first arrived because she really did not like the food and she was in a sling. She was eating more and was back at her CBW around 135 pounds. She said she was not always drinking the supplements but she tried. She said she really just wanted to be able to stand so she could go home to live out the rest of her days. Interview on 07/31/19 at 9:44 A.M., Dietetic Technician (DT) #500 stated she had stricken out the admission weight on 05/07/19 due to it being an error. She had no re-weights on admission and the first weekly weight was completed on 04/15/19. She further stated she pulled the weight from a doctors office visit for her UBW. She did not answer how or why she discredited RD #502's nutritional assessments and follow ups weeks after they had occurred. She also confirmed weights were not completed weekly as ordered. She further could not speak to why re-weights were not conducted if she felt the admission weight was in error almost one month after it was obtained. Observation on 07/31/19 at 12:08 P.M., Resident #5 was in the dining room with her lunch meal in front of her, she had no utensils at this time and she was trying to reach her food, she began asking Certified Nursing Assistant (CNA) #450 to scoot her closer to the table. CNA #450 never scooted her closer and then left to go to the kitchen. Resident #5 continued to try and reach her food and scoot up her wheelchair without success. At 12:12 P.M., Registered Nurse (RN) #462 was alerted she needed to be scooted in, and then she observed Resident #5 still did not have utensils to eat and said she told CNA #450 to get clean utensils. When Resident #5 was scooted up to the table and had utensils she was able to eat the food items she liked on her plate. Review of the policy titled Weight Management dated August 2017, revealed it was to provide guidelines for obtaining and monitoring a residents weight status up admission, re-admission, and monthly and as needed weekly. The residents weight will be obtained weekly for the first four weeks after admit or readmit. Once monthly weights have been completed weights will be reviewed for the need to reweigh the resident to verify weight accuracy. It may be necessary to reweigh a couple of times to verify accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and facility staff interview the facility failed to the monitor the dialysis access site. This affected one Resident (#21) of one reviewed. The facility identified three residents who were receiving dialysis services. The total facility census was 63. Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic ischemic heart disease, end stage renal disease, paroxysmal atrial fibrillation, and diabetes mellitus. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had cognitive impairment, had no delusions or hallucinations, but did have rejection of care one to three days. The resident was coded as receiving dialysis services. Review of Resident #21's care plans revealed the resident had a care plan in place that identified the dialysis center where dialysis occurred, the address and contact information. The care plan also indicated the staff were to check the bruit and thrill of the resident's arteriole venous (AV) fistula every shift. Review of Resident #21's current orders and Treatment Administration Record (TAR) revealed there was no order to monitor the residents AV fistula for bruit and thrill. Further review of the resident's orders revealed the resident's order to check bruit and thrill was discontinued on 07/05/18. Review of Resident #21's TAR's for the last year confirmed the order was discontinued as there was no documentation of the bruit and thrill being monitored. During an interview with Registered Nurse (RN) # 442 on 07/31/19 at approximately 2:00 P.M., confirmed Resident #21 had an order to check bruit and thrill discontinued on 07/05/18. RN #442 verified the medical record was silent to the facility monitoring for bruit and thrill form 07/05/18-07/25/19. RN #442 confirmed the standard nursing practice would be to check thrill and bruit on a resident with an AV fistula at least daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and facility staff interview the facility failed to have required medications available. This affected one (#20) of four observed during medication administration. The total facility census was 63. Findings include: Review of Resident #20's medical record revealed the resident was admitted on [DATE]. Diagnoses included type two diabetes, hypertension, chronic obstructive pulmonary disease, chronic kidney disease, hypokalemia, major depressive disorder, angina pectoris, Parkinson's disease, encephalopathy, disorder of calcium metabolism, hypercholesterolemia, constipation, gastro-esophageal reflux disease, retention of urine and schizoaffective disorder Bi Polar type. Review of the progress notes dated 07/30/19 revealed the notes were silent to the resident being administered the medication, the medication being signed as given in error, or the physician or family being notified of the missing dose of medication. During observation on 07/30/19 at 8:35 A.M., Licensed Practical Nurse (LPN) #402 administered medications to Resident #20. The resident was to receive an Arnuity Ellipta aerosol powder breath activated 100 micrograms (mcg) one puff orally one time a day related to chronic obstructive pulmonary disease. The medication was not available in the medication cart. During an interview with the LPN #402 at the time of the observation, it was verified the medication was not available from the pharmacy to administer to the resident. During a follow up interview with LPN #402 on 07/30/19 at 3:57 P.M. it was verified the inhaler had not been sent by the pharmacy. Review of the 07/2019 Medication Administration Record (MAR) revealed Arnuity Ellipta aerosol was signed off as administered on 07/30/19.

Based on observation, facility staff interview and review of package insert the facility failed to store ophthalmic solution correctly in one of two medication carts observed. The facility had a total of four medication carts. This directly affected two (#26 and #41) residents who medications were stored in the 400 hall medication cart. The total facility census was 63. Findings include: Observation on 07/31/19 at 9:35 A.M. of the 400 hall medication cart with Licensed Practical Nurse (LPN) # 482 revealed there was Latanopros ophthalmic solution 0.005% for Resident #26 with an opened date of 05/25/19 and the attached sticker indicated to discard 42 days after opening. The 42nd day would have been 7/06/19. At the time of the observation LPN #482 confirmed the resident was still receiving the eye drops and that was the only bottle available. Additionally there was Olopathadine 0.1% ophthalmologist solution for Resident #41 without an open date on the medication. The bag the medication was stored in had a deliver date from the pharmacy of 04/25/19. LPN #482 confirmed the resident had current orders for the medication and this was the bottle of medication the staff was using to supply the medication to the resident as it was the only bottle in the medication cart. Review of package insert for olopathadine revealed the manufacture indicated this medication must be discarded four weeks after it is opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide a copy of the notification of bed hold status, or transfer and discharge notice to the resident, their representative or the Ombudsman for residents that discharged to the hospital. This affected seven (#20, #21, #26, #44, #58, #106 and #256) of seven residents reviewed for hospitalization. The facility identified 24 residents who had an unplanned discharge to the hospital in the past six months who additionally did not receive these notifications. The facility census was 63. Findings include: 1. Review of the record for Resident #20 revealed she was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes, hypertension, chronic obstructive pulmonary disease, chronic kidney disease, hypokalemia, major depressive disorder, angina pectoris, Parkinson's disease, encephalopathy, disorder of calcium metabolism, hypercholesterolemia, constipation, gastro-esophageal reflux disease, retention of urine and schizoaffective disorder, bipolar type Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired and required supervision with eating, dressing, toileting and transfers and extensive assistance with personal hygiene. Further review of Resident #20's record revealed she was hospitalized on [DATE] for psychiatric stabilization and was readmitted to the facility on [DATE]. The record was silent for Resident #20 receiving bed hold notification or transfer and discharge information and there was no evidence the Ombudsman received transfer and discharge information. 2. Review of the record for Resident #44 revealed he was admitted [DATE] with diagnoses to include abdominal aortic aneurysm, congestive heart failure, malignant neoplasm of prostate with secondary malignant neoplasm of bone, acute kidney failure, hydronephrosis, epilepsy, dysphagia, anorexia, atherosclerotic heart disease, presence of urogenital implants, neuromuscular dysfunction of bladder, major depressive disorder, hyperlipidemia, hypertension, gastro-esophageal reflux disease, aphasia, obstructive and reflux uropathy and hemiplegia and hemiparesis following cerebrovascular disease. Review of Resident #44's quarterly MDS assessment dated [DATE] revealed he was severely cognitively impaired and required supervision with eating and extensive assistance with activities of daily living, bed mobility and transfers. Further review of Resident #44's record revealed he was hospitalized on [DATE] from a doctor's appointment due to a concern identified during the appointment and he was readmitted to the facility on [DATE]. The record was silent for Resident #44 receiving bed hold notification or transfer and discharge information and there was no evidence of Ombudsman the Ombudsman received transfer and discharge information. 3. Review of the closed record for Resident #58 revealed he was admitted on [DATE] with diagnoses to include cerebrovascular disease, dysphagia, thyrotoxicosis, atrial fibrillation, atherosclerotic heart disease, hyperlipidemia, pain in left hip, epilepsy, glaucoma, personal history of pulmonary embolism, person history of transient ischemic attack, hemiplegia, gastro-esophageal reflux disease, major depressive disorder, generalized anxiety disorder and vascular dementia without behavioral disturbance. Review of Resident #58's quarterly MDS assessment dated [DATE] revealed he was severely cognitively impaired and required supervision with eating and extensive assistance with activities of daily living, bed mobility and transfers. Further review of Resident #58's record revealed he was hospitalized on [DATE] due to having a seizure lasting 20 minutes with no relief and he did not return to the facility. The record was silent for Resident #44 receiving bed hold notification or transfer and discharge information and there was no evidence the Ombudsman received transfer and discharge information. 4. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses to include weakness, lack of coordination, dysphagia, respiratory failure, anxiety, chronic ischemic heart disease, end stage renal disease, hyperlipidemia, protein calorie malnutrition, myocardial infarction, lack of coordination, paroxysmal atrial fibrillation, diabetes, bacterial pneumonia, unsteadiness on feet, dementia , psychotic disorder with delusions, overactive bladder depression, hypertension, heart failure, adult failure to thrive, and quadriplegia. Review of the most recent MDS revealed the resident had cognitive impairment, the resident had no delusions, hallucinations, but did have rejection of care one to thee days of the review period. The resident required extensive assist from staff for bed mobility, dressing, and toileting and is dependent on staff for transfers. Further review of the medical record revealed the resident was transferred to the hospital on the following dates for unplanned discharges due to changes in medical condition. The medical record was silent for each occurrence of the resident, resident responsibility party and Ombudsman receiving in writing a notice of the transfer in language that they could understand. discharge date s included: 05/03/19 related to cardiac pulmonary arrest the facility had initiated emergency cardiac pulmonary resuscitation. 05/16/19 the resident was sent to the to the hospital and admitted with low oxygenation saturation upon return from dialysis. 06/27/19 the resident was sent to the hospital and admitted for low blood sugar. 07/23/19 the resident was sent to the hospital from dialysis for respiratory distress during treatment and admitted to the hospital. 5. Review of Resident #26's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses to include hypercholesterolemia, constipation, kidney disease osteoporosis, atrial fibrillation, hypertension, Raynaud's syndrome, dysphagia, and Alzheimer's disease. The diagnoses of anorexia and gastrostomy status were added during the resident stay. Review of the most recent significant change MDS dated [DATE] revealed the resident was not able to answer questions, had no hallucinations, delusions or behaviors, required extensive assist for transfers, bed mobility and toileting and was dependent on staff for personal hygiene, eating and dressing. The resident was coded for having 51% or more of total calories through enteral feeding and more than 501 cubic centimeter (cc) of fluid a day through tube feeding. The resident was coded as having hospice services. The resident was coded as having one deep tissue injury upon admission from the hospital and no other wounds were coded. Review of the interact transfer form dated 05/11/19 revealed the resident was sent to the outlying hospital on [DATE] for diagnosis of altered mental status. The narrative note revealed the resident was noted to have altered mental status and the fingertips and toe nails were blue. Family requested for the resident to go to the outlying hospital and the resident was transferred. The medical record was silent to the resident , responsible party or ombudsman being notified of the the resident's transfer in writing and there was no evidence of the resident or responsible party being informed of the bed hold information. 6. Review of Resident #256's medical record revealed the resident was admitted to the facility on [DATE] with a most recent re-admission date of 07/19/19. Resident diagnoses included biliary tract disease, malignant neoplasm of prostate, type two diabetes mellitus, congenital stenosis of aortic value, non rheumatic tricuspid valve, atrioventricular block first degree, hypertension, retention of urine, dysphagia, anorexia, falls, constipation, chronic pain syndrome, hypercholesterolemia, depression, chest pain, mass in the common bile duct, and chronic ischemic heart disease. Further review of the medical record revealed the resident most recent discharge to the hospital occurred on 07/03/19 and a return to the facility was anticipated. The MDS correlation to this date revealed the resident was not cognitively intact, had no delusions, hallucinations or behaviors, required extensive assist from staff for daily cares with the exception of eating which is supervision. The resident was coded as frequently incontinent of bladder and always incontinent of bowel. The resident had no pressure ulcers. Review of progress note dated 07/03/19 at 3:05 P.M. revealed the resident had nausea and vomiting, and yellow skin noted around her mouth and eyes and the physician was called. A new order was received to send the resident to be evaluated at the hospital. Further review of the medical record revealed it was silent to the resident, representative or Ombudsman being notified in writing of the transfer and bed hold policy in language they could understand. During an interview with the Administrator on 07/31/19 at 7:38 A.M., she reported she had identified providing bed hold notices, transfer and discharge notices and Ombudsman notification when residents were discharged to the hospital as a concern they were working to correct. She verified bed hold notices, transfer and discharge notices and notification to the Ombudsman were not being completed for residents who were discharged to the hospital. 7. Review of the medical record revealed Resident #106 was admitted on [DATE] with diagnoses that included weakness, malignant neoplasm of oropharynx perforation of esophagus, hypertension, gastrostomy, malignant neoplasm of lymph nodes, dysphagia, lack of coordination, difficulty walking and weakness. Review of the admission MDS dated [DATE] revealed the resident cognition was intact, the resident had no hallucinations, delusions, or behaviors. The resident required extensive assist with all daily cares with the exception of eating which was dependent. Review of the progress notes dated 07/30/19 at 8:24 A.M. revealed the resident's room was entered by the nurse and the resident was noted in bed with emesis on the side of the bed and the resident's gown. The resident's breathing was labored and oxygen saturation was 78%. The resident was documented as being unresponsive to verbal stimuli and rales were auscultated in all fields of the lungs. The resident was supplied oxygen via a non rebreather mask, and the resident was suctioned. The progress note indicated the physician was notified and a new order was received to send the resident to the hospital for evaluation and treatment. The responsible party was attempted to be contacted, but the number was out of service. The resident was transported via squad to the hospital. Progress note from 07/30/19 at 6:54 P.M. revealed the resident was in intensive care unit unit with a possible necrotic bowel. Further review of the medical record was silent to the resident, responsible party, or ombudsman receiving notification of the transfer to the hospital or any information regarding holding the resident's bed. During an interview with the administrator on 08/01/19 10:03 AM revealed the resident/responsible party was not given a transfer notice in language they could understand nor were they issued a bed hold notification. The ombudsman also was not sent notification of the resident's transfer to the hospital. The Administrator stated the resident was not Medicaid so he did not require the bed hold notice. The Administrator stated the resident did not get a transfer notice as the facility had identified they were not in compliance with issuing the transfer and bed hold notices and were still in the process of correcting the problem and working through the quality assurance performance improvement (QAPI) plan the facility had set up. The Administrator verified the facilities QAPI indicated residents, and responsible parties were to receive transfer notice and bed hold notification within 24 hours of a transfer and confirmed Resident #106 had transferred to the hospital greater than 24 hours ago and the notifications still had not been sent as stated in the QAPI plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide a copy of the notification of bed hold status, or transfer and discharge notice to the resident, their representative or the Ombudsman for residents that discharged to the hospital. This affected seven (#20, #21, #26, #44, #58, #106 and #256) of seven residents reviewed for hospitalization. The facility identified 24 residents who had an unplanned discharge to the hospital in the past six months who additionally did not receive these notifications. The facility census was 63. Findings include: 1. Review of the record for Resident #20 revealed she was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes, hypertension, chronic obstructive pulmonary disease, chronic kidney disease, hypokalemia, major depressive disorder, angina pectoris, Parkinson's disease, encephalopathy, disorder of calcium metabolism, hypercholesterolemia, constipation, gastro-esophageal reflux disease, retention of urine and schizoaffective disorder, bipolar type Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired and required supervision with eating, dressing, toileting and transfers and extensive assistance with personal hygiene. Further review of Resident #20's record revealed she was hospitalized on [DATE] for psychiatric stabilization and was readmitted to the facility on [DATE]. The record was silent for Resident #20 receiving bed hold notification or transfer and discharge information and there was no evidence the Ombudsman received transfer and discharge information. 2. Review of the record for Resident #44 revealed he was admitted [DATE] with diagnoses to include abdominal aortic aneurysm, congestive heart failure, malignant neoplasm of prostate with secondary malignant neoplasm of bone, acute kidney failure, hydronephrosis, epilepsy, dysphagia, anorexia, atherosclerotic heart disease, presence of urogenital implants, neuromuscular dysfunction of bladder, major depressive disorder, hyperlipidemia, hypertension, gastro-esophageal reflux disease, aphasia, obstructive and reflux uropathy and hemiplegia and hemiparesis following cerebrovascular disease. Review of Resident #44's quarterly MDS assessment dated [DATE] revealed he was severely cognitively impaired and required supervision with eating and extensive assistance with activities of daily living, bed mobility and transfers. Further review of Resident #44's record revealed he was hospitalized on [DATE] from a doctor's appointment due to a concern identified during the appointment and he was readmitted to the facility on [DATE]. The record was silent for Resident #44 receiving bed hold notification or transfer and discharge information and there was no evidence of Ombudsman the Ombudsman received transfer and discharge information. 3. Review of the closed record for Resident #58 revealed he was admitted on [DATE] with diagnoses to include cerebrovascular disease, dysphagia, thyrotoxicosis, atrial fibrillation, atherosclerotic heart disease, hyperlipidemia, pain in left hip, epilepsy, glaucoma, personal history of pulmonary embolism, person history of transient ischemic attack, hemiplegia, gastro-esophageal reflux disease, major depressive disorder, generalized anxiety disorder and vascular dementia without behavioral disturbance. Review of Resident #58's quarterly MDS assessment dated [DATE] revealed he was severely cognitively impaired and required supervision with eating and extensive assistance with activities of daily living, bed mobility and transfers. Further review of Resident #58's record revealed he was hospitalized on [DATE] due to having a seizure lasting 20 minutes with no relief and he did not return to the facility. The record was silent for Resident #44 receiving bed hold notification or transfer and discharge information and there was no evidence the Ombudsman received transfer and discharge information. 4. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses to include weakness, lack of coordination, dysphagia, respiratory failure, anxiety, chronic ischemic heart disease, end stage renal disease, hyperlipidemia, protein calorie malnutrition, myocardial infarction, lack of coordination, paroxysmal atrial fibrillation, diabetes, bacterial pneumonia, unsteadiness on feet, dementia , psychotic disorder with delusions, overactive bladder depression, hypertension, heart failure, adult failure to thrive, and quadriplegia. Review of the most recent MDS revealed the resident had cognitive impairment, the resident had no delusions, hallucinations, but did have rejection of care one to thee days of the review period. The resident required extensive assist from staff for bed mobility, dressing, and toileting and is dependent on staff for transfers. Further review of the medical record revealed the resident was transferred to the hospital on the following dates for unplanned discharges due to changes in medical condition. The medical record was silent for each occurrence of the resident, resident responsibility party and Ombudsman receiving in writing a notice of the transfer in language that they could understand. discharge date s included: 05/03/19 related to cardiac pulmonary arrest the facility had initiated emergency cardiac pulmonary resuscitation. 05/16/19 the resident was sent to the to the hospital and admitted with low oxygenation saturation upon return from dialysis. 06/27/19 the resident was sent to the hospital and admitted for low blood sugar. 07/23/19 the resident was sent to the hospital from dialysis for respiratory distress during treatment and admitted to the hospital. 5. Review of Resident #26's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses to include hypercholesterolemia, constipation, kidney disease osteoporosis, atrial fibrillation, hypertension, Raynaud's syndrome, dysphagia, and Alzheimer's disease. The diagnoses of anorexia and gastrostomy status were added during the resident stay. Review of the most recent significant change MDS dated [DATE] revealed the resident was not able to answer questions, had no hallucinations, delusions or behaviors, required extensive assist for transfers, bed mobility and toileting and was dependent on staff for personal hygiene, eating and dressing. The resident was coded for having 51% or more of total calories through enteral feeding and more than 501 cubic centimeter (cc) of fluid a day through tube feeding. The resident was coded as having hospice services. The resident was coded as having one deep tissue injury upon admission from the hospital and no other wounds were coded. Review of the interact transfer form dated 05/11/19 revealed the resident was sent to the outlying hospital on [DATE] for diagnosis of altered mental status. The narrative note revealed the resident was noted to have altered mental status and the fingertips and toe nails were blue. Family requested for the resident to go to the outlying hospital and the resident was transferred. The medical record was silent to the resident , responsible party or ombudsman being notified of the the resident's transfer in writing and there was no evidence of the resident or responsible party being informed of the bed hold information. 6. Review of Resident #256's medical record revealed the resident was admitted to the facility on [DATE] with a most recent re-admission date of 07/19/19. Resident diagnoses included biliary tract disease, malignant neoplasm of prostate, type two diabetes mellitus, congenital stenosis of aortic value, non rheumatic tricuspid valve, atrioventricular block first degree, hypertension, retention of urine, dysphagia, anorexia, falls, constipation, chronic pain syndrome, hypercholesterolemia, depression, chest pain, mass in the common bile duct, and chronic ischemic heart disease. Further review of the medical record revealed the resident most recent discharge to the hospital occurred on 07/03/19 and a return to the facility was anticipated. The MDS correlation to this date revealed the resident was not cognitively intact, had no delusions, hallucinations or behaviors, required extensive assist from staff for daily cares with the exception of eating which is supervision. The resident was coded as frequently incontinent of bladder and always incontinent of bowel. The resident had no pressure ulcers. Review of progress note dated 07/03/19 at 3:05 P.M. revealed the resident had nausea and vomiting, and yellow skin noted around her mouth and eyes and the physician was called. A new order was received to send the resident to be evaluated at the hospital. Further review of the medical record revealed it was silent to the resident, representative or Ombudsman being notified in writing of the transfer and bed hold policy in language they could understand. During an interview with the Administrator on 07/31/19 at 7:38 A.M., she reported she had identified providing bed hold notices, transfer and discharge notices and Ombudsman notification when residents were discharged to the hospital as a concern they were working to correct. She verified bed hold notices, transfer and discharge notices and notification to the Ombudsman were not being completed for residents who were discharged to the hospital. 7. Review of the medical record revealed Resident #106 was admitted on [DATE] with diagnoses that included weakness, malignant neoplasm of oropharynx perforation of esophagus, hypertension, gastrostomy, malignant neoplasm of lymph nodes, dysphagia, lack of coordination, difficulty walking and weakness. Review of the admission MDS dated [DATE] revealed the resident cognition was intact, the resident had no hallucinations, delusions, or behaviors. The resident required extensive assist with all daily cares with the exception of eating which was dependent. Review of the progress notes dated 07/30/19 at 8:24 A.M. revealed the resident's room was entered by the nurse and the resident was noted in bed with emesis on the side of the bed and the resident's gown. The resident's breathing was labored and oxygen saturation was 78%. The resident was documented as being unresponsive to verbal stimuli and rales were auscultated in all fields of the lungs. The resident was supplied oxygen via a non rebreather mask, and the resident was suctioned. The progress note indicated the physician was notified and a new order was received to send the resident to the hospital for evaluation and treatment. The responsible party was attempted to be contacted, but the number was out of service. The resident was transported via squad to the hospital. Progress note from 07/30/19 at 6:54 P.M. revealed the resident was in intensive care unit unit with a possible necrotic bowel. Further review of the medical record was silent to the resident, responsible party, or ombudsman receiving notification of the transfer to the hospital or any information regarding holding the resident's bed. During an interview with the administrator on 08/01/19 10:03 AM revealed the resident/responsible party was not given a transfer notice in language they could understand nor were they issued a bed hold notification. The ombudsman also was not sent notification of the resident's transfer to the hospital. The Administrator stated the resident was not Medicaid so he did not require the bed hold notice. The Administrator stated the resident did not get a transfer notice as the facility had identified they were not in compliance with issuing the transfer and bed hold notices and were still in the process of correcting the problem and working through the quality assurance performance improvement (QAPI) plan the facility had set up. The Administrator verified the facilities QAPI indicated residents, and responsible parties were to receive transfer notice and bed hold notification within 24 hours of a transfer and confirmed Resident #106 had transferred to the hospital greater than 24 hours ago and the notifications still had not been sent as stated in the QAPI plan.

Based on review of the facilities legionella risk assessment and control plan and facility staff interview the facility failed to implement control measures to ensure the facility water source was free from legionella bacteria. This had the potential to affect all 63 residents who reside in the facility. Findings include: Review of the facilities legionella risk assessment and control plan revealed the facility would test the water for the presence of legionella bacteria when there was a risk presented to the facility's water source, to ensure the water was free of legionella bacterium. The facility had the water tested after recent tornado activity as the water was shut off for a week. The facility was under a boil advisory for the water after the water was turned back on by the municipal water supplier. The test the facility had conducted was for Escherichia coli (E.Coli) and for Coliform, both were negative. During an interview with the Administrator on 08/01/19 at 2:45 P.M. it was verified the facility called the local county health department and received guidance to test the water for E.Coli and Coliform bacterium to ensure the water was safe. The Administrator stated she informed the Health department the facility needed to ensure the water also did not have legionella bacterium and was instructed these two test were the tests needed to ensure the water was safe. The Administrator also indicated she had spoken with a sister facility in the area who had also performed water testing for legionella and these were the same two tests the facility completed as well. The facility risk assessment was reviewed with the Administrator on 08/01//19 at 2:45 P.M. and it was determined the facility maintained the water in the holding tanks at 140 degrees to ensure there was no growth of the legionella bacterium. The Administrator was unable to provide monitoring where the facility was ensuring the water lines including the cold water line and the end of the water lines had water that was flushed through then that was at the 140 degrees to ensure no legionella bacterium or biofilm was present or remained in the lines. The Administrator confirmed there was no monitoring.