**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to ensure resident centered comprehensive care plans were in place. This affected two residents (#5 and #77) of 21 residents reviewed for resident centered comprehensive care plans. The facility census was 83. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 07/25/24. Diagnoses included dementia, anxiety, and lewy body dementia. Review of the admission physician orders dated 07/22/24 for Resident #5 revealed she was admitted with an order for Geodon (antipsychotic) 20 milligrams (mg). Review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #5 revealed she was cognitively impaired and was prescribed routine antipsychotic medications. Review of the current physician orders for 10/2024 for Resident #5 revealed the Geodon was discontinued, and Seroquel (antipsychotic) 25 mg was prescribed. Review of the comprehensive care plan initiated 07/2024 for Resident #5 revealed there was no comprehensive care plan in place for psychoactive medications. Interview on 10/10/24 at 11:04 A.M. with the Director of Nursing (DON) verified there was not a comprehensive care plan in place for psychoactive medications for Resident #5. 2. Review of the medical record for Resident #77 revealed she was admitted to the facility on [DATE]. Diagnoses included dementia and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was cognitively impaired and incontinent of bowel and bladder. Review of the comprehensive care plan initiated 04/2024 for Resident #77 revealed there was no comprehensive care plan in place for incontinence care. Interview on 10/09/24 at 10:52 A.M. with State Tested Nursing Assistant (STNA) #220 stated Resident #77 was incontinent of bowel and bladder. Interview on 10/09/24 at 1:37 P.M. with Registered Nurse (RN) #235 verified there was no comprehensive care plan in place for incontinence care for Resident #77. RN #235 stated Resident #77 had been incontinent of bowel and bladder since admission and should have had a care plan for incontinence care since the initiation of her comprehensive care plan. Review of the facility policy titled Good [NAME] Home Comprehensive Care Plans, dated 09/2024 revealed the facility will develop and implement a comprehensive person-centered care plan for each resident. The comprehensive care plan will be developed with seven day after the completion of the comprehensive MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, and review of the facility policy, the facility failed to provide showers timely to residents who were dependent on staff for showers/bathing. This affected one (Resident #8) of three residents reviewed for activities of daily living (ADL). The facility census was 83. Findings include: Review of Resident #8's medical record revealed an admission date of 03/17/23. Diagnosis included severe sepsis without shock, chronic obstructive pulmonary disease, and congestive heart failure. Review of Resident #8's quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a moderate cognitive impairment. Resident #8 required substantial assistance from staff for showers, baths, and personal hygiene. Review of Resident #8's care plan revealed she had an ADL self-care self-care performance deficit related to activity intolerance, impaired gait and balance, limited mobility, musculoskeletal impairment, and neuropathy, Interventions included the resident required substantial assistance from staff with bathing and showering. Review of Resident #8's shower schedule revealed showers were scheduled every Tuesday and Friday. Review of Resident #8's shower documentation dated August 2024 through 10/07/24 revealed Resident #8 did not receive four scheduled showers between 09/03/24 through 09/13/24. Review of Resident #8's nurses notes revealed no documentation of why the showers were missing. Interview with Resident #8 on 10/07/24 at 10:25 A.M. revealed she wished to receive showers timely but the staff failed to assist her regularly. Interview with Licensed Practical Nurse (LPN) #433 on 10/08/24 at 1:01 P.M. verified Resident #8 failed to have showers completed timely between 09/03/24 through 09/13/24 and the medical record was silent as to why. Review of the facility policy titled Good [NAME] Home Resident Showers dated 01/19/23 revealed it is the practice of the facility to assist residents with bathing to promote proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review, the facility failed to ensure wound prevention boots were in place as physician ordered and failed to obtain a resident's weekly weight as physician ordered. This affected one (Resident (#11) of one resident reviewed for wounds and 21 residents reviewed for physician orders. The facility census was 83. Findings include: 1. Review of Resident #11's medical record revealed an admission date of 12/01/22. Diagnoses included cerebral vascular accident, diabetes mellitus, pressure induced deep tissue damage of right heel, and non-pressure chronic ulcer of right ankle with fat layer exposed. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11's cognition was intact. Resident #11 had an open lesion on his foot and required dressings to the feet. Review of the care plan revealed Resident #11 had altered skin integrity related to a right ankle vascular wound, right anterior third toe traumatic wound, and a left posterior ankle wound. Interventions included pressure relieving devices as ordered. Review of Resident #11's physician order dated 10/24/23 revealed an order for a heel lift boot to the right lower extremity every day and night shift. Observations of Resident #11 on 10/07/24 at 9:26 A.M. and 11:33 A.M., and 10/08/24 at 1:02 P.M. revealed Resident #11 was not wearing right heel lift boot. Interview with Resident #11 on 10/08/24 at 1:02 P.M. stated the facility staff did not apply the heel lift boot daily and he was unsure where the boot was located. Interview with the Wound Care Nurse Practitioner #600 on 10/10/24 at 11:58 A.M. stated the right lateral ankle wound was chronic and the main goal was to avoid infection. The wound had not worsened. Interview with Unit Manager (UM) #302 on 10/10/24 at 12:02 P.M. verified Resident #11 was not wearing his right heel boot lift as physician ordered. UM #302 stated she could not locate Resident #11's boot. Observation on 10/10/24 at 3:40 P.M. revealed Resident #11 was in his wheelchair and the heel lift boot was in place. 2. Review of Resident #54's medical record revealed an admission date of 03/26/24. Diagnosis included disease of the pericardium, vitamin deficiency, protein malnutrition, cystic fibrosis, and adult failure to thrive. Review of Resident #54's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a moderate cognitive function. Review of Resident #54's care plan revealed he required tube feeding related to dysphagia, adult failure to thrive, malnutrition, and weight loss. Goals included the resident will maintain adequate nutritional and hydration status as evidenced by a weight stable and no signs of malnutrition. The resident received nothing by mouth and was provided nutrition via a feeding tube. Review of Resident #54's medical record dated 05/24/24 revealed a physician's order for weekly weights every night shift every Friday. Review of Resident #54's weight record from 04/12/24 through 10/01/24 revealed the resident's weight were not obtained on the following dates: on 04/12/24, 04/26/24, 05/03/24, 05/17/24, 05/24/24, 05/31/24, 06/21/24, 06/28/24, 07/19/24, 07/26/24, 08/02/24, 08/16/24, and 09/06/24. Interview with the Director of Nursing (DON) on 10/10/24 at 8:18 A.M. verified Resident #54's weekly weight were not obtained as physician ordered. The DON verified Resident #54's weight was not obtained on 04/12/24, 04/26/24, 05/03/24, 05/17/24, 05/24/24, 05/31/24, 06/21/24, 06/28/24, 07/19/24, 07/26/24, 08/02/24, 08/16/24, and 09/06/24. Interview with the Clinical Operations Director #500 on 10/10/24 at 2:35 P.M. revealed the facility had no policy regarding following physician orders.

Based on record review, observation, staff interview, and policy review, the facility failed to prepare pureed foods per the recipe and follow the dietician recommendations for serving sizes. This had the potential to affect six residents (#2, #37, #38, #46, #47, and #68) who received pureed meals and had to the potential to affect 77 residents who received regular or mechanical soft meals from the kitchen. The facility census was 83. Findings include: 1. Review of the Dining Manager's recipe for pureed vegetables revealed the recipe called for one quart of vegetables with one-fourth cup of melted margarine. Observation on 10/08/24 at 10:48 A.M. revealed Chef #282 was preparing the vegetable for the pureed diets. The chef placed the vegetables in the food processor then began pouring in a butter tasting substance used for grilling, sauteing, and pan frying. Chef #282 failed to measure the vegetables nor the butter substance. He poured at least one cup of butter substance in the food processor. Interview with Culinary Director #251 on 10/08/24 at 10:44 A.M. verified Chef #282 did not follow the Dietary Manager's recipe for pureed vegetables. 2. Review of the facility menu spreadsheet for the week of 10/07/24 revealed the residents should be served three four ounce meatballs per serving. Observation on 10/09/24 between 11:03 A.M. and 11:15 A.M. revealed Dietary Assistants #273 and #384 were plating spaghetti and meatballs. Dietary Assistants #273 and #384 were serving between three and six meatballs on the plates. Interview with Dietary Assistant #384 on 10/09/24 at 11:13 A.M. revealed he was unaware of the serving sizes and not necessarily following the facility's menu spreadsheet. Interview with Culinary Director #251 on 10/09/24 at 11:24 A.M. verified Dietary Assistants #273 and #384 were not serving the portion size of meatballs as stated in the facility's menu spreadsheet. Review of the facility's undated policy titled Good [NAME] Home Puree Food Preparation revealed each resident must receive and the facility must provide food that is prepared by methods that conserve nutritive value, flavor, and appearance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record for Resident #14 revealed she was admitted on [DATE] with diagnoses of anxiety, cerebral vascular accident (CVA) (stroke), anemia, anxiety, thyrotoxicosis, gastroesophageal reflux disease (GERD), osteoarthritis, hypertension (HTN), chronic kidney disease (CKD), visual loss, and metabolic encephalopathy. Review of the current physician orders from 10/24 for Resident #14 revealed she was prescribed a acetaminophen 500 milligrams (mg), potassium chloride 10 milliequivalence (meq), metoprolol 12.5 mg (HTN), areds2 preservision (visual loss), amlodipine 10 mg, pantoprazole 40 mg (GERD), glucosamine chondroitin (osteoarthritis), folic acid 400 micrograms (mcg), Buspar 2.5 mg (anxiety), Plavix 75 mg (CVA), and iron supplement 325 mg (anemia). Observation on 10/09/24 at 8:07 A.M. during medication pass observation of Medication Aide (MA) #290 revealed she did not use hand hygiene prior to pulling the medications for administration for Resident #14. MA #190 removed metoprolol 25 mg from the pill bottle and broke the pill in half (for a dose of 12.5 mg as prescribed) and handled the medication without gloves and placed the other half of the pill back into the medication bottle. Further observation at 10/09/24 at 8:16 A.M. of MA #290 revealed to count the number of pills in the medication cup, MA #290 poured the entire cup of pills onto the top of medication cart without a barrier and picked up each pill to count without gloved hands and placed them back into the medication cup for administration. Interview on 10/09/24 at 8:18 A.M. with MA #290 verified she did not complete hand hygiene prior to preparing the medications for administration for Resident #14. MA #290 verified she broke the metoprolol in half without using gloves and poured pills directly onto the medication cart without a barrier and continued to touch the medication for Resident #14 with ungloved hands and then administered the medications to Resident #14. Review of the facility policy titled, Medication Administration Guidelines, dated 02/2019 revealed medications are to be administered per physician order to promote positive resident outcomes. Wash hands prior to handling medications, after administering medication, and after direct resident contact. Based on observations, medical record review, staff interview, facility policy, and review of the Centers of Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) in COVID-19 positive resident's rooms. This had the potential to affect all nine (#48, #49, #65, #67, #73, #76, #82, #88, and #189) residents in the 200 hall who were not COVID-19 positive. In addition, the facility failed to ensure four (#1, #11, #54, and #79) residents with a wound or indwelling medical device had enhanced barrier precautions in place. The facility identified an additional nine (#17, #30, #45, #48, #52, #53, #55, #68, and #189) residents who required enhanced barrier precautions. Additionally, the facility failed to ensure hand hygiene prior to administering medications to Resident #14. The facility census was 83. Findings include: 1. Review of the medical record revealed Resident #188 was admitted on [DATE]. Diagnoses included COVID-19 (10/03/24). Review of the social service progress note, dated 10/04/24, revealed Resident #188 had been diagnosed with COVID-19 and remained in isolation. Review of Resident #188's physician order, dated 10/08/24, revealed an order for a single room contact droplet isolation for ten days with all services brought to the resident in room. Observation on 10/07/24 at 11:34 A.M. revealed Registered Nurse (RN) #213 was in Resident #188's room assisting the resident . RN #213 was wearing a N-95 mask over a surgical mask and gloves. RN #213 was not wearing a gown or eye protection. Interview on 10/07/24 at 11:40 A.M. with RN #213 verified she was not wearing eye protection and a gown. RN #213 verified she was assisting Resident #188 with care as he needed assistance. RN #213 stated there was no gown in the PPE cart. 2. Review of the medical record revealed Resident #30 was initially admitted on [DATE]. Diagnoses included COVID-19 (09/29/24). Review of the Minimum Data Set (MDS) assessment, dated 08/09/24, revealed Resident #30 was cognitively intact. Review of Resident #30's physician orders, dated 09/29/24 to 10/09/24 revealed an order for single room contact/droplet isolation for ten days with all services brought into the resident room. Observation on 10/07/24 at 11:52 A.M. revealed Registered Nurse (RN) #235 entered Resident #30's room. RN #235 donned a N-95 mask placed over the surgical mask and no eye protection in place prior to entering the resident's room. Interview on 10/07/24 at 12:07 P.M. with RN #235 verified Resident #30 was COVID-19 positive. RN #235 verified the N-95 mask was placed over the surgical mask and no eye protection was worn. RN #235 stated the resident was not coughing or spewing saliva; therefore the eye protection was not necessary. Observation on 10/08/24 at 2:30 P.M. revealed State Tested Nursing Assistant (STNA) #338 entered Resident #30's room after donning gloves, a N95 mask over a surgical mask, and a gown. No eye protection was worn in the resident's room. Interview on 10/08/24 at 2:36 P.M. with STNA #338 verified a N-95 mask was donned over the surgical mask and no eye protection was worn. STNA #338 stated there was no eye protection available in the PPE cart outside Resident #30's room. Review of CDC's guidance titled Infection Control Guidance: SARS-CoV-2, found at https://www.cdc.gov/covid/hcp/infection-control/?CDC_AAref_Val=https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, dated 06/24/24 revealed healthcare professionals who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a N-95 mask or higher, gloves, gowns, and eye protection. Review of CDC's guidance titled How to Use your N95 Mask Respirator, found at https://www.cdc.gov/niosh/topics/publicppe/use.html#:~:text=Place%20the%20N95%20respirator%20under,Do%20not%20crisscross%20the%20straps, dated 05/16/23, revealed N95 respirators must form a seal to the face to work properly. This is especially important for people at increased risk for severe disease. 3. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnosis included pressure induced deep tissue damage of right heel, and non-pressure chronic ulcer of right ankle with fat layer exposed. Review of Resident #11's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had an open lesion on his foot and required dressings to the feet. Review of the medical record revealed Resident #54 was admitted on [DATE]. Diagnoses included protein malnutrition, adult failure to thrive, and dysphagia. Review of the most recent care plan revealed Resident #54 required tube feeding due to dysphasia, adult failure to thrive, malnutrition, and weight loss. Review of the medical record revealed Resident #1 was admitted on [DATE]. Review of the MDS assessment, dated 09/20/24, revealed Resident #1 had a feeding tube. Review of the medical record revealed Resident #79 was admitted to the facility on [DATE]. Diagnoses included retention of urine and neuromuscular dysfunction of bladder. Review of the MDS assessment, dated 09/16/24, revealed Resident #79 had an indwelling catheter. Observations on 10/08/24 at 4:10 P.M. revealed Residents #1, #11, #54, and #79 did not have enhanced barrier precautions in place. Interview on 10/08/24 at 4:15 P.M. with State Tested Nursing Assistance (STNA) #341 verified when providing care to residents with a catheter or tube feed, gloves were worn but no additional PPE such as a gown have been donned. Interview on 10/08/24 at 4:22 P.M. with STNA #362 verified when providing care to residents with a catheter or tube feed, gloves were worn but no additional PPE such as a gown have been donned. Interview on 10/08/24 at 4:32 P.M. with the Director of Nursing (DON) verified no residents in the facility had enhanced barrier precautions in place. Review of the policy titled Enhanced Barrier Precautions, dated 2024, revealed an order for enhanced barrier precautions will be obtained for residents with any of the following: wounds (chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g. central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with MDRO (multidrug-resistant organisms). Review of the CDC guidance titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO), reviewed 07/12/22 and located at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html revealed enhanced barrier precautions apply to all residents with any of the following infections or colonization with MDRO (when contact precautions do not apply): wounds and/or indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status.

Based on observation, staff interview, and policy review, the facility failed to store foods properly in the refrigerator and failed to discard expired food items. This had the potential to affect all 83 residents who the facility identified received food from the kitchen. The facility census was 83. Findings include: 1. Observation of the main kitchen refrigerator on 10/07/24 at 8:10 A.M. revealed there was a container of thickened pudding dated 09/23/24 and a container of thickened juice dated 09/23/24 which were outdated and failed to be discarded. Observation of the walk in refrigerator on 10/07/24 at 8:23 A.M. revealed a box of sliced mushrooms were on a wire shelf and were open to air. The cardboard lid failed to be secured to the box. Interview with Culinary Director #251 on 10/07/24 at 8:25 A.M. verified the thickened pudding and thickened juice were outdated and not discarded and the mushrooms were not stored properly. 2. Observation of the pureed food preparation on 10/08/24 at 10:45 A.M. revealed Chef #282 was preparing pureed beef stroganoff. After placing the stroganoff in the food processor, he mixed hot water with beef base to use as the thinning agent. Observation of the beef base jar revealed it had a best if used by date of 08/22/24. Interview with Chef #282 and Culinary Director #251 on 10/07/24 at 10:47 A.M. verified the chef was utilizing the beef base past the expiration date. The beef stroganoff mixture was then discarded and a new mixture was prepared. Review of the facility policy titled Date Markings dated 11/2005 revealed the facility should discard all food past their used by date. Date marking is required for foods that are considered held under refrigeration for more than a cumulative total of 24 hours before service. If the food is maintained at a temperature of 41 degrees Fahrenheit or less, mark the foods use by date for seven calendar days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to serve meals to residents in a dignified manner. This affected two residents (#1 and #21) of four residents reviewed for dining. The facility census was 89. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 06/10/20. Diagnoses included type II diabetes mellitus and gout. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition and required limited assistance of one person for eating. Review of an order dated 01/05/22 revealed Resident #1 received a no added salt diet with pureed food and thin liquids. Observation on 05/09/22 at 11:40 A.M. revealed Resident #1 and Resident #89 sitting together at a dining table. Resident #89 was served her meal at that time, Resident #1 was not. Observation on 05/09/22 at 12:25 P.M. revealed Resident #1 received her meal 45 minutes after Resident #89 received her meal. Interview on 05/09/22 at 12:25 P.M. the Culinary Director #507 confirmed Resident #1 received her meal after Resident #89 had been served and consumed her meal at the same table. 2. Review of the medical record for Resident #21 revealed an admission date of 02/19/21. Diagnoses included dementia and hypertension. Review of the MDS assessment dated [DATE] revealed Resident #21 had moderately impaired cognition and was independent with setup help only for eating. Review of an order dated 02/22/21 revealed Resident #21 received a no added salt diet with regular textures and thin liquids. Observation on 05/11/22 at 11:57 A.M. revealed Resident #21 and Resident #57 sitting together at a dining table. Resident #57 was served her meal at that time, Resident #21 was not. Observation and interview on 5/11/22 at 12:10 P.M. with Dietary Assistant #365 confirmed Resident #57 received and was consuming her meal while Resident #21 had not still not received a meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to provide a comfortable wheelchair for Resident #30. This affected one resident of four reviewed for accommodation of needs. The facility census was 89. Findings include: Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cellulitis (infection of the skin), type two diabetes, gout, lack of coordination, unsteadiness on feet, and dementia with lewy bodies. Assessment completed on 02/20/22 indicated Resident #30 had severe cognitive impairment. The resident's record additionally revealed they were admitted to hospice care on 02/07/22. Observations throughout the afternoon on 05/09/22 found Resident #30 sitting in a geriatric (geri) chair. They were positioned properly but did not appear comfortable as evidenced by his head and shoulders were approximately one foot above the back of the chair. Resident #30 appeared to be sitting stiffly trying to support his head. His face appeared strained. The geri chair appeared to be too small for the resident. Observations throughout the morning on 05/10/22 revealed Resident #30 sitting forward in a geri chair. Their back was not against the back of the chair. Resident #30 did not appear comfortable as evidenced by restlessness and straining. Observation on 05/10/22 at 11:07 A.M. revealed Resident #30 seated in a geri chair against the back rest. The back rest ended at the resident's shoulders with no support for their head or neck. Observation on 05/11/22 at 7:42 A.M. revealed Resident #30 asleep in a geri chair with their ankles and feet over the end of the footrests. Interview on 05/11/22 at 7:45 A.M. Registered Nurse (RN) #356 verified Resident #30 did not fit comfortably in the geri chair. RN #356 stated this chair was provided by hospice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, family interview, and review of facility policy, the facility failed to provide a copy of the baseline care plan to Resident #46 or Resident #46's family. This affected one resident (#46) out of seven residents reviewed for care planning. The facility census was 89. Findings include: Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including muscle weakness, macular degeneration, dementia, anxiety, heart disease and major depressive disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 was severely cognitively impaired. Resident #46 required extensive assistance of two people for bed mobility, toilet use and transfers. Review of the baseline care plan for Resident #46 revealed the baseline care plan was developed on 01/19/22, however was the baseline care plan had not been not signed or dated by Resident #46 or by Resident #46's family. Interview on 05/12/22 at 2:35 P.M. the Director of Nursing (DON) verified baseline care plans were to be developed and signed and dated when shared with the resident and or the resident's family. At the time of the interview, the DON verified a copy of the care plan was not provided to Resident #46 or her family. Interview on 05/11/22 at 3:05 P.M. Resident #46's family reported no baseline care plan was shared or received from the facility upon Resident #46's admission in January 2022. Review of the facility's undated policy titled, Care Plan Policy, revealed the facility was to develop and implement a comprehensive person centered care plan for each resident that included measurable objectives.

**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 review and revise a resident's care plan. This affected one resident (#30) out of seven residents reviewed for care plannning. The census was 89. Findings include: Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cellulitis (infection of the skin), type two diabetes, gout, lack of coordination, unsteadiness on feet, and dementia with lewy bodies. Assessment completed on 02/20/22 indicated Resident #30 had severe cognitive impairment. The resident's record additionally revealed admission to hospice care on 02/07/22. Further review of the medical record revelaed Resident #30 had falls on 05/01/22 and 05/03/22. Review of progress notes revealed both falls happened when the resident attempted to stand up from a geriatric (geri) chair. No major injuries were noted for either fall. Review of the care plan for Resident #30 revealed an update on 03/11/22 recommending a geri chair for comfort if the resident was restless in other chairs as an intervention for falls. No additional fall interventions were added to the care plan after 03/11/22, verifying the care plan had not been updated with additional fall interventions after Resident #30 suffered falls on 05/01/22 and 05/03/22. Interview on 05/11/22 at 1:35 P.M. the Director of Nursing (DON) stated a new intervention of assiting Resident #30 to the restroom was initiated after Resident #30's fall on 05/01/22. The DON verified no additional interventions to prevent future falls were added to the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure dependent residents received assistance with shaving and fingernail care. This affected one resident (#83) of four residents reviewed for activities of daily living. The facility census was 89. Findings Include: Review of Resident #83's medical record revealed an admission date of 01/04/21. Diagnoses included history of COVID-19, dementia, and weakness. Review of Resident #83's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine indicating Resident #83 was moderately cognitively impaired. Resident #83 required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #83 displayed no behaviors during the review period. Review of Resident #83's care plan revised 04/11/22 revealed supports and interventions for risk for having behaviors of rejection of care and getting up unassisted, risk for mood problems, resident preferences for personal care, and self-care deficit. Supports for self-care deficit included to provide assistance with activities of daily living. Staff were to check nail length, trim, and clean Resident #83's nails on bath day and as necessary. Resident #83 was totally dependent on staff to provide a bath or shower. Resident #83 required extensive assistance of one to two staff to maximize independence with personal hygiene. Observation on 05/09/22 at 10:09 A.M. of Resident #83 found him lying in bed. Resident #83's fingernails were long with a yellowish brown substance under them. Resident #83 had facial hair growth of approximately a centimeter long. Interview on 05/09/22 at 10:11 A.M. with Resident #83 found he was alert and orientated. Resident #83 reported he needed assistance with shaving and trimming his nails. Resident #83 stated he had told staff he wanted to be shaved and have his nails trimmed, but no one who would do it for him. Observation on 05/10/22 at 8:06 A.M. of Resident #83 found him up in his wheelchair. Resident #83's fingernails continued to untrimmed and dirty. Resident #83 continued to have facial hair. Interview on 05/10/22 at 8:10 A.M. with State Tested Nursing Assistant (STNA) #328 verified Resident #83 had not been shaven and his nails were not trimmed. STNA #328 stated Resident #83 was to have his nails trimmed and his facial hair shaved with his weekly shower and as needed or requested. Review of the facility policy titled, Grooming a Resident's Facial Hair, dated 2022 revealed it was the facility's practice to assist residents with grooming facial hair to help maintain proper hygiene as per current standards of practice. Review of the facility policy titled, Fingernail Care, dated July 2001 revealed residents would be given proper nail care by staff to ensure the nails were kept clean, trimmed, and healthy. This deficiency substantiates Complaint Number OH00132162.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide wound treatments as ordered. This affected one resident (#67) out of five residents reviewed for wound care. The facility census was 89. Findings include: Review of the medical record for Resident #67 revealed an admission date of 11/09/09 with medical diagnoses of abnormal posture and anxiety disorder, and non-pressure chronic ulcer of right ankle with unspecified severity. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #67 had intact cognition and required extensive assistance of two people for bed mobility, dressing, toilet use, personal hygiene, and required total dependence of two people for transfers. Resident #67 used a wheelchair for mobility. Review of Resident #67's orders revealed daily treatment orders for his right outer ankle wound from 12/12/21 through 05/11/22. Review of Resident #67's Treatment Administration Record (TAR) for February 2022 revealed four treatments for his right outer ankle were not documented in the record on 02/12/22, 02/17/22, 02/21/22, and 02/25/22. Review of Resident #67's TAR for March 2022 revealed four treatments for his right outer ankle were not documented in the record on 03/13/22, 03/14/22, 03/26/22, and 03/27/22. Review of Resident #67's TAR for April 2022 revealed four treatments for his right outer ankle were not documented in the record on 04/08/22, 04/12/22, 04/15/22, and 04/23/22. Interview on 05/12/22 at 1:45 P.M. the Director of Nursing (DON) confirmed Resident #67's TARs for February, March, and April 2022 were missing documentation of wound treatments to his right outer ankle for four days each month. Review of the wound care consult notes for Resident #67 dated 05/04/22 revealed the wound was vascular, and was improved and healing. This deficiency substantiates Master Complaint Number OH00132531 and Complaint Number OH00132162.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview the facility failed to ensure residents received timely care and treatment for vision and audiology. This affected one resident (#83) out of one resident reviewed for ancillary services. The facility census was 89. Findings Include: Review of Resident #83's medical record revealed an admission date of 01/04/21. Diagnoses included personal history of COVID-19, dementia and weakness. Review of Resident #83's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine indicating Resident #83 was moderately cognitively impaired. Resident #83 had adequate vision and hearing at the time of the review. Review of Resident #83's care plan revised 04/11/22 revealed supports and interventions for risk for having behaviors of rejection of care, preferences for personal care, and self-care deficit. Review of Resident #83's ancillary services consent form revealed on 07/08/21 Resident #83's representative consented to vision services, dental services, podiatry services, and audiology services to be arranged by the facility. Further review of Resident #83's medical record found no evidence Resident #83 was seen by the audiologist or optometrist since admission on [DATE]. Interview on 05/09/22 at 10:11 A.M. with Resident #83 found Resident #83 was alert and aware. Resident #83 reported he had not seen an eye doctor or anyone for his hearing for a very long time. Resident #83 stated he would like to be checked out. Interview on 05/11/22 at 9:48 A.M. the Administrator #496 verified Resident #83 had not had any ancillary services appointments for hearing or vision. Administrator #496 provided evidence of upcoming scheduled appointments. Review of Resident #83's scheduled appointments revealed Resident #83 was scheduled on 05/25/22 for an audiology appointment, and on 06/22/22 for a vision appointment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interview, the facility failed to implement ordered treatments to potentially prevent pressure ulcers. This affected one resident (#30) of four residents reviewed for pressure ulcers. The census was 89. Findings include: Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cellulitis (infection of the skin), type two diabetes, gout, lack of coordination, unsteadiness on feet, and dementia with lewy bodies. Assessment completed on 02/20/22 indicated Resident #30 had severe cognitive impairment. The resident's record additionally revealed Resident #30 admitted to hospice care on 02/07/22. Review of physician orders for Resident #30 revealed an order to, keep elbow protectors in place at all times, dated 01/28/22. It also revealed an order for, bilateral heel lift boots at all times, dated 01/27/22. Observation of Resident #30 throughout the afternoon on 05/09/22 found the resident sitting up in a geriatric (geri) chair in the common area next to the nurse's station. Resident #30 did not have heel protectors or elbow protectors in place. There were no visible wounds observed. Observation of Resident #30 throughout the morning on 05/10/22 found the resident sitting in a geri chair by the nurses station. Resident #30 did not have heel protectors or elbow protectors in place and no visible wounds. Interview on 05/10/22 at 1:45 P.M. State Tested Nurse Aide (STNA) #338 verified Resident #30 had orders for heel protectors and elbow protectors. STNA #338 stated Resident #30 refused to wear the heel and elbow protectors. STNA #338 was unaware of the last time staff attempted to put heel protectors or elbow protectors on the resident. Observation of Resident #30's room on 05/10/22 at 1:49 P.M. found his heel protector boots were kept in a chair in his room. Resident #30 had no elbow protectors available for use. Observation of Resident #30 on 05/11/22 throughout the morning revealed the resident sitting in a geri chair in the main living area with heel protectors and elbow protectors on. Resident #30 appeared calm and was not attempting to remove the treatments. Further review of Resident #30's medical record revealed no pressure areas or skin concerns in the past 30 days. This deficiency substantiates Master Complaint Number OH00132531 and Complaint Number OH00132162.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to provide range of motion as ordered. This affected one resident (#7) of four residents reviewed for positioning and range of motion. The facility census was 89. Findings Include: Review of Resident #7's medical record revealed an admission date of 02/03/22. Diagnoses included adjustment disorder, Alzheimer's disease, and wedge compression fracture of first lumbar vertebra (at admission). Review of Resident #7's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of one indicating Resident #7 was severely cognitively impaired. Resident #7 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #7 was totally dependent on staff for eating. Resident #7 was receiving therapy services at the time of the review. Resident #7 had delusions during the review period and displayed physical and verbal behavioral symptoms directed toward others one to three days during the review period. Review of Resident #7's care plan revised 04/08/22 revealed supports and interventions for risk for falls, verbal and physical behaviors, and impaired cognitive function. Review of Resident #7's therapy orders revealed an order dated 03/29/22 for Restorative Nursing to start on 03/30/22. Resident #7 was to get right lower extremity and left lower extremity range of motion. It was noted Resident #7 required extensive verbal, tactile, and visual cues to participate. Resident #7's range of motion (ROM) exercises included a seated march, seated long arc quad, seated ankle dorsiflexion active range of motion, seated heel raise, and seated hip abduction. Review of Resident #7's State Tested Nursing Assistant (STNA) Tasks for the last 30 days revealed Resident #7 was provided range of motion (ROM) six times. ROM was provided on 04/17/22, 04/19/22, 04/28/22, 05/01/22, 05/02/22 and 05/07/22. Resident #7 was documented as refused ROM 11 times, on 04/12/22, 04/15/22, 04/18/22, 04/24/22, 04/26/22, 04/29/22, 04/30/22, 05/03/22, 05/04/22, 05/08/22 and 05/10/22. Resident #7 was not offered ROM services 13 times on 04/11/22, 04/13/22, 04/14/22, 04/16/22, 04/20/22, 04/21/22, 04/22/22, 04/23/22, 04/25/22, 04/27/22, 05/05/22, 05/06/22, and 05/09/22. Interview on 05/09/22 at 9:31 A.M. with Resident #7's wife revealed Resident #7 was no longer receiving therapy services because he was not cooperative. Resident #7's wife reported Resident #7 was to be receiving ROM services from the STNAs daily and they were not doing anything with him. She said they maybe did ROM a handful of times since he had been on the secured unit. Interview on 05/09/22 at 11:08 A.M. with State Tested Nursing Assistant (STNA) #447 verified Resident #7's ROM was to be completed daily as indicated in Resident #7's therapy order. STNA #447 stated Resident #7 was often noncompliant with care. STNA #447 reported all refusals and minutes of ROM completed were documented in the electronic medical record under tasks. Review of Resident #7's ROM tracking with STNA #447 verified there were 13 times in the last 30 days Resident #7 was not provided ROM. Review of the undated facility policy titled, Range of Motion, revealed a range of motion program was to be developed based on the residents unique risk factors. Nursing's primary responsibility was to preserve the resident's range of motion.

**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 address the nutritional needs of residents with significant weight loss. This affected two residents (#30 and #39) of five residents reviewed for significant weight loss. The census was 89. Findings include: 1. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cellulitis (infection of the skin), type two diabetes, gout, lack of coordination, unsteadiness on feet, and dementia with lewy bodies. Assessment completed on 02/20/22 indicated Resident #30 had severe cognitive impairment. The resident's record additionally revealed the resident was admitted to hospice care on 02/07/22. Review of Resident #30's weights revealed a weight of 185 pounds on 12/22/21 and 157 pounds on 05/04/22, indicating a significant (15%) weight loss over five months. Resident #30 weighed 173 pounds on 02/09/22 indicating a 12-pound weight loss prior to hospice admission. Review of a progress note dated 02/19/22 written by Registered Dietitian (RD) #514 revealed Resident #30 weighed 171 pounds and had significant weight loss. The progress note also revealed intake of oral fluids was less than optimal. No interventions were noted in the progress notes at that time. Review of a progress note dated 05/09/22 written by RD #514 revealed Resident #30 weighed 157 pounds and had significant weight loss. The progress note also said, Could consider use of supplement if it would provide comfort overall. No interventions were recommended in the note. Interview with RD #514 on 05/11/22 at 3:10 P.M. revealed RD #514 did not recommend aggressive interventions for residents receiving hospice care. RD #514 also verified Resident #30 lost 12 pounds prior to being admitted to hospice care and stated their nutrition intervention was hospice. Interview with RD #514 on 05/12/22 at 9:00 A.M. stated RD #514 did not communicate which residents had significant weight loss with the interdisciplinary team. 2. Review of the medical record for Resident #39 revealed an admission date of 07/02/19 and medical diagnoses of type II diabetes mellitus and paranoid schizophrenia. Review of the quarterly MDS dated [DATE] revealed Resident #39 had intact cognition and required extensive assistance of one person for transfers, dressing, toileting, and hygiene, and required only supervision with setup for eating. Review of an order dated 09/23/21 revealed Resident #39 received a regular diet with low fiber, regular textures and thin liquids. Review of Resident #39's current care plan revealed he had a nutritional problem or potential nutritional problem. Interventions included monitoring, recording, and reporting to the physician as needed any signs or symptoms of malnutrition, including weight loss greater than 7.5% in three months and greater than 10% in six months, discourage sweets/donuts, and limit to one entree per meal. Review of the meal intakes for Resident #39 from 04/15/22 to current revealed he consumed 95-100% of his meals. Review of Resident #39's weights over the past six months revealed an 8.7% weight loss over the last three months and a 15% weight loss over the last six months. His weight on 05/09/22 was 199.0 pounds and his body mass index (BMI) was 28.6. Review of a nutrition progress note dated 03/08/22 revealed Resident #39 had significant weight loss from the previous six months, was eating well, and was well above his weight from three years prior. The dietitian did not make any recommendations to offset the weight loss. Review of a nutrition progress note dated 05/09/22 revealed Resident #39 had a significant weight loss over the past six months, though meal intake was good. The dietitian indicated a supplement may be considered in the future to offset the weight loss, and further noted Resident #39's weight was higher than his weight in 2019. Observation on 05/09/22 at 11:48 A.M. revealed Resident #39 consumed 100% of his noon meal. Interview on 05/10/22 at 7:57 A.M. with Resident #39 revealed he thought he had lost weight because he just did not feel like eating. Interview on 05/11/22 at 3:07 P.M. with the RD #514 confirmed Resident #39 had significant weight loss over the past six months beginning in March 2022. The RD #514 further confirmed Resident #39 did not receive nutrition supplements, and was not on an ordered weight loss program. RD #514 revealed he did not meet with facility staff to discuss weight changes and would notify the physician of significant weight changes through his documentation in the medical record. Further interview revealed RD #514 did not feel a supplement would be nutritionally valuable to Resident #39, though he did want Resident #39's weight to stabilize. Continued interview with RD #514 revealed he did not speak with Resident #39 regarding his most recent weight loss. Interview on 05/12/22 at 3:22 P.M. with the Director of Nursing (DON) revealed nursing staff was responsible for notifying the physician of significant weight changes. Further interview revealed the facility relied on the dietitian to recommend interventions when residents had significant weight changes. Review of facility policy titled, Dietary Weight Monitoring Program, revised 01/2018, stated in the event of significant or patterned weight loss, The dietician will assess the resident, document the assessment, and make recommendations in the resident's medical record. Orders may be obtained for nutritional supplements or other interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure pharmacy recommendations were timely addressed by the physician. This affected one resident (#7) of five residents reviewed for unnecessary medications. The facility census was 89. Findings Include: Review of Resident #7's medical record revealed an admission date of 02/03/22. Diagnoses included type II diabetes, adjustment disorder, dementia, major depressive disorder, and Alzheimer's disease. Review of Resident #7's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of one, indicating Resident #7 was severely cognitively impaired. Resident #7 had delusions during the review period and displayed physical and verbal behavioral symptoms directed toward others one to three days during the review period. Review of Resident #7's care plan revised 04/08/22 revealed supports and interventions for risk for falls, chronic pain, verbal and physical behaviors, impaired cognitive function, use of psychotropic medications, antidepressant use, and risk for drug related complications. Review of Resident #7's physician orders revealed an order dated 02/02/22 with a discontinuation date of 05/03/22 for Quetiapine Fumarate (antipsychotic) 25 milligrams (mg) give one tablet at bedtime related to dementia without behavioral disturbance. An order dated 05/03/22 for Seroquel 25 mg at bedtime for psychosis. Review of Resident #7's monthly pharmacy reviews revealed Resident #7's medications were reviewed on 02/04/22, 03/18/22, and 04/16/22. Review of Resident #7's pharmacy recommendations revealed on 02/04/22 the pharmacist reviewed Resident #7's Quetiapine and recommended an active diagnosis be added to the electronic medical record to support the therapy. It was noted an antipsychotic should only be uses for schizophrenia, schizoaffective disorder, delusional disorder, mood disorders, schizophreniform disorder, psychosis not otherwise specified, atypical psychosis, brief psychotic disorder, dementing illnesses with associated behavioral symptoms, medical illnesses or delirium with manic or psychotic symptoms. The physician checked the disagree box on the pharmacist recommendation form on 03/01/22 and noted I will evaluate. No diagnoses was added to Resident #7's electronic medical record. Review of Resident #7's Mental Health New Patient Progress Note dated 04/07/22 revealed Resident #7's medications were reviewed by the Physician Assistant and a diagnosis of unspecified psychosis was added. The plan was to monitor for psychosis and continue Seroquel at the same dose. Resident #7's physician orders and Medication Administration Record (MAR) were not updated with the new diagnosis in the electronic medical record. Interview on 05/12/22 at 1:30 P.M. with the Director of Nursing (DON) verified Resident #30's electronic medical record was updated on 05/03/22 with the diagnosis of psychosis. The DON reported she thought Resident #7 was also seen by a mental health provider and his mental health provider added the diagnoses at an earlier date. Interview on 05/12/22 at 3:23 P.M. with the DON found Resident #7's mental health provider reviewed Resident #7's medications on 04/07/22 and added the diagnosis of unspecified psychosis. The diagnoses was added two months after the pharmacy recommendation and was not added into Resident #7's electronic medical record as requested by the pharmacist. Review of the facility policy titled, Documentation and Communication of Consult Pharmacist Recommendations and Pharmacy Services, dated 07/01/12 revealed recommendations were to be acted upon and documented by the facility and/or the prescriber within 30 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview the facility failed to ensure residents received timely dental services. This affected one resident (#83) of one resident reviewed for ancillary services. The facility census was 89. Findings Include: Review of Resident #83's medical record revealed an admission date of 01/04/21. Diagnoses included personal history of COVID-19, dementia and weakness. Review of Resident #83's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine, indicating Resident #83 was moderately cognitively impaired. Resident #83 had no oral concerns at the time of the review. Review of Resident #83's care plan revised 04/11/22 revealed supports and interventions for risk for having behaviors of rejection of care, preferences for personal care, and self-care deficit. Review of Resident #83's ancillary services consent form revealed on 07/08/21 Resident #83's representative consented to vision services, dental services, podiatry services, and audiology services to be arranged by the facility. Further review of Resident #83's medical record found no evidence Resident #83 was seen by a dentist since admission on [DATE]. Interview on 05/09/22 at 10:11 A.M. with Resident #83 found Resident #83 was alert and aware. Resident #83 reported he had not seen a dentist for a very long time. Resident #83 stated he would like to be checked out. Interview on 05/11/22 at 9:48 A.M. with Administrator #496 verified Resident #83 had not had any ancillary services appointments for dental care. Review of Resident #83's scheduled appointments revealed Resident #83 was not scheduled for a dental appointment due to him being private pay. No evidence was found of the facility attempting to assist with arrangements for dental services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interviews, and staff interviews, the facility failed to ensure resident rooms and wheelchairs were kept in a clean and sanitary manner. This affected eight residents (#2, #32, #39, #50, #52, #56, #60, and #87) out of eight residents reviewed for environmental concerns. The facility census was 89. Findings include: 1. Observation on 05/10/22 at 8:20 A.M. revealed Resident #39's room smelled of urine. Resident #39 was not in the room at the time. Interview on 05/10/22 at 8:20 A.M. with Medication Aide #513 confirmed Resident #39's room smelled of urine. Observation of Resident #50's room on 05/10/22 from 11:15 A.M. to 11:21 A.M. revealed an unmade bed, dirty linen on the sink and dirty clothing in a pile on the floor in the left hand corner of the room. There was dark, sticky debris on the floor in four of four corners of the room and on the metal threshold between the room and the hallway and the dark, sticky debris rubbed off when scuffed with the Surveyor's shoe. There was also a sticky substance on the floor in front of sink which caused the Surveyor's shoes to stick to the floor. Observation of Resident #87's room on 05/10/22 at 11:27 A.M. revealed dark discoloration to four of four corners in the room along with a dark sticky substance built up on the metal threshold between the hallway and room. The dark sticky substance on the metal threshold scuffed off with the Surveyor's shoe. Observation of Resident #52's room on 05/10/22 at 11:34 A.M. revealed a tile floor with a change in color from light to dark from the bathroom to the room and had multiple scuff marks. The line of change was uneven and sticky when walked on. There was a maroon colored reclining chair in the corner of room with white substance on the cushion of chair. There was an opened wound dressing package, four inches by four- and three-quarter inches sitting on the right side of the sink with a notation on the package which indicated the dressing was sterile. Interview with Licensed Practical Nurse #439 (LPN) on 05/10/22 at 11:40 A.M. stated the Resident #52 had been transferred to the hospital two days ago. Interview with Housekeeper #413 at 05/10/22 at 11:52 A.M. verified Resident #52's room had not been cleaned since the resident discharged two days ago. Housekeeper #413 further added rooms were to be cleaned daily. Housekeeper #413 stated she was unable to complete her work each shift. Housekeeper #413 stated she was required to clean staff areas, the break room and then nurses stations prior to resident rooms, further, Housekeeper #413 admitted she does not get to all resident rooms every day. Observation of Housekeeper #413 cleaning cart on 05/10/22 at 11:52 revealed a full unlabeled spray bottle with purple liquid. Interview with Housekeeper #413 at the time of the observation verified the spray bottle containing the purple liquid was unlabeled. Housekeeper #413 was unable to provide the name of liquid in the spray bottle. Observation on 05/10/22 at 11:53 A.M. of Resident #32 and Resident #56's room revealed scuff marks on the tile floor and a dirty, used glove on the floor next to an empty trash can. Observation on 05/10/22 at 12:21 P.M. of Resident #60's room revealed a tile floor with dark colored build up in four of four corners of room and on the floor around the wood vanity. The transition from the carpeted hallway with a metal transition strip contained dark debris which rubbed off with the Surveyor's shoe. There was also additional dark sticky areas on the tile floor next to the bed with scuff marks on the floor throughout the room. Interview on 05/12/22 at 11:23 A.M. Resident #60 stated the housekeeping staff do not sweep or mop her bedroom floor often enough and stated her room was not as clean as she would like it. Interview on 05/12/22 at 3:15 P.M. Housekeeping Supervisor #400 verified the discoloration, debris and scuff marks on the floors of Resident (#32, #50 #52, #56, #60 and #87) rooms. Housekeeping Supervisor #400 further added he received complaints about the condition of the floors in the Vineyard Unit from both residents and resident's family members. 2. Review of Resident #2's medical record revealed an admission date of 08/07/18. Diagnoses included restlessness and agitation, dementia, major depressive disorder, and cerebral infarction. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating Resident #2 was severely cognitively impaired. Resident #2 was totally dependent on staff for transfer, and locomotion. Resident #2 required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. Review of Resident #2's care plan revised 04/28/22 revealed supports and interventions for self-care deficit, and impaired physical mobility. Resident #2 was noted to slide down nearly out of his customized specialty wheelchair. A wheelchair provider recommended the use of a seatbelt. Observation on 05/09/22 11:47 P.M. found Resident #2 seated in his customized wheelchair in the dining room for lunch. Resident #2 was found to have dried bacon and dirt and debris built up on the brakes and connecting bars of his wheelchair. Observation and attempted interview on 05/09/22 at 11:56 A.M. found Resident #2 was not able to be interviewed. Resident #2 had been provided his lunch meal and was observed feeding himself bite size pieces using his hands. Resident #2 was observed having some difficulty getting the food from his plate to his mouth and was observed dropping pieces of chicken onto his lap. Interview on 05/09/22 at 12:01 P.M. with State Tested Nursing Assistant (STNA) #380 verified Resident #2's wheelchair had dried bacon as well as built up dirt and debris on his wheelchair. STNA #380 stated resident wheelchairs were to be cleaned at the end of the day. STNA #380 verified Resident #2's wheelchair did not appear to have been cleaned. Interview on 05/09/22 at 12:08 P.M. with Dietary Staff #498 verified the dried bacon on Resident #2's wheelchair was from breakfast. Dietary Staff #498 was not able to determine what the other built up debris was and verified the wheelchair was dirty. This deficiency substantiates Master Complaint Number OH00132531.

Based on observation, staff interview, review of manufacturer's instructions, and review of facility policy, the facility failed to ensure staff properly cleaned and disinfected the blood glucometer per manufacturer's recommendations. This had the potential to affect eight residents (#8, #23, #28, #31, #39, #41, #74 and #75) receiving blood sugar checks in the Meadows Unit. Facility census was 89. Findings include: Observation on 05/10/22 at 7:36 A.M. revealed Licensed Practical Nurse (LPN) #376 administering medications on the Meadows Unit and cleaned the blood glucometer with two alcohol wipes. Interview with LPN #376 at the time of the observation on 05/10/22 at 7:36 A.M. verified blood glucometer's are cleaned with alcohol. Interview with LPN #376 on 05/10/22 at 2:30 P.M. verified LPN #376 used alcohol to clean the blood glucometer before and after the morning blood sugar check for Resident #74, with LPN #376 further stating she should have used a disinfectant wipe. Review of facility policy titled, Glucometer Disinfection, with a review date of 02/21 verified blood glucometer should be cleaned and disinfected after each use and according to manufacturer instructions. Review of the undated manufacturer's instructions for blood glucometer used revealed any disinfectant product with the Environmental Protection Agency (EPA) number 67619-12 was to be used on the device for cleaning and disinfection. This deficiency substantiated Complaint Number OH00132162.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure foods were stored properly, staff prepared food in a sanitary manner, and failed to ensure the dishmachine reached appropriate temperatures. This had the potential to affect 88 residents in the facility. The facility identified one resident (#32) did not receive oral nutrition. The facility census was 89. Findings include: 1. Observations on 05/09/22 beginning at 8:33 A.M. revealed an open bag of chicken, an open box of hashbrowns, and individual flatbread lying loose on the shelf in the walk-in freezer, and one large can of mandarin oranges and one large can of raspberry filling dented near the seal stored with the in-use canned food items. Interview on 05/09/22 at 8:46 A.M. with the Culinary Director #507 confirmed the chicken, hashbrowns and flatbread were stored inappropriately, and the dented cans should be removed from use. Observation and interview on 05/09/22 at 8:52 A.M. with the Culinary Director #507 revealed two opened, undated bags of hardboiled eggs with cloudy fluid inside, leaked when they were picked up, and were inappropriately stored in an additional walk-in refrigerator. Observation and interview on 05/09/22 at 8:58 A.M. with the Culinary Manager #507 confirmed deli ham dated 05/01/22 was in the refrigerator of the kitchen on the locked unit. The Culinary Manager #507 confirmed the ham was beyond the date of use. Observation and interview on 05/09/22 at 9:03 A.M. with the Culinary Manager #507 confirmed personal food and expired chocolate milk were in the stand-up refrigerator on the 200-hall. The Culinary Manager #507 further confirmed the coleslaw located in the low reach-in refrigerator on the 200-hall was expired. Review of the facility policy titled, Date Marking for Food Safety, dated 03/28/22, revealed food items should be marked to indicate the date by which the food shall be consumed or discarded, and refrigerated food items should be held for a maximum of seven days. 2. Observation on 05/09/22 at approximately 8:56 A.M. revealed Dietary Assistant #388 wearing disposable gloves and used a handle to open a compartment, removed a clean plate, closed the compartment, put a toasted sandwich on the plate, opened another compartment, removed bacon slices with her gloved hands, and placed the bacon on the plate. Interview on 05/09/22 at approximately 8:57 A.M. with the Dietary Assistant #388 confirmed she did not change gloves between touching handles and touching consumable food. Further interview revealed the sandwich and bacon was for Resident #88. Interview on 05/09/22 at approximately 8:57 A.M. with the Culinary Director #507 confirmed the Dietary Assistant #388 did not practice appropriate hand sanitation while plating the sandwich. Observation on 05/09/22 at 8:48 A.M. revealed the sandwich and bacon was delivered to Resident #88. 3. Observation on 05/11/22 at 1:35 P.M. of the dishmachine revealed the wash temperature ranged from 100 degrees fahrenheit to 105 degrees fahrenheit. Further observation of the dishmachine revealed posted guidelines for washing temperatures to be at least 120 degrees fahrenheit. Interview on 05/11/22 at 1:55 P.M. revealed Dietary Assistant #365 was running the dishmachine, but did not know who was required to complete the dishmachine temperature log. Interview on 05/11/22 at 1:53 P.M. with the Chef Manager #475 confirmed the washing temperature of the dishmachine ranged between 100 to 105 degrees fahrenheit. Interview and observation of the dishmachine on 05/12/22 at 12:35 P.M. with the Culinary Director #507 revealed the wash temperature was 93 degrees fahrenheit. Further interview revealed the dishmachine was a chemical sanitizer and a high temperature machine. Continued interview revealed most of the kitchen staff was new and had not been trained on monitoring and completing the logs for the dishmachine. Review of the facility policy titled, Good [NAME] Home Dishwasher Temperature, dated 2021, revealed the wash temperature should be 120 degrees fahrenheit for a chemical sanitizing machine, and should be 150-165 degrees fahrenheit for a high temperature machine. Review of the Infection Control logs from October 2021 to current revealed no foodborne illness had occurred at the facility.

Based on review of facility beneficiary notices and staff interview, the facility failed to ensure Medicare beneficiaries received the appropriate notices informing them of their rights when discharged from skilled services. This affected two (Resident #53 and #91) of three residents reviewed for beneficiary notices. The facility census was 112. Findings include: 1. Review of Resident #53's skilled nursing facility beneficiary protection notification form revealed her last covered day of skilled service under Medicare Part A was on 05/02/19. The resident remained in the facility after being discharged from skilled services. Review of the resident's beneficiary notices revealed she did not receive the skilled nursing facility advanced beneficiary notice (SNF ABN) form as required. Interview with the Director of Nursing (DON) on 06/25/19 at 5:55 P.M. verified Resident #53 did not receive a SNF ABN form completed as required. 2. Review of Resident #91's skilled nursing facility beneficiary protection notification form revealed her last covered day of skilled service under Medicare Part A was on 06/20/19. The resident remained in the facility after being discharged from skilled services. Review of the resident's beneficiary notices revealed she did not receive the SNF ABN form as required. Interview with the DON on 06/25/19 at 5:55 P.M., verified Resident #91 did not receive a SNF ABN form completed as required. She stated the facility implemented a plan of action with monitoring on 06/25/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident, resident's representative, and the ombudsman were notified in writing when a resident was transferred to the hospital. This affected one (Resident #103) of one residents reviewed for hospitalization. The facility census was 112. Findings include: Review of Resident #103's medical record revealed an admission date of 09/25/18. She was transferred to the hospital on [DATE]. Medical diagnoses included candidal cystitis and urethritis, sepsis, osteomyelitis of vertebra, hypertension, end stage renal disease, acute and subacute infective endocarditis, diabetes mellitus, iron deficiency anemia, spinal stenosis, and chronic obstructive pulmonary disease. Continued review of the resident's medical record revealed no indication the resident, the resident's representative, or the ombudsman were notified in writing of the reason for the resident's transfer to the hospital. Interview with the Director of Nursing (DON) on 06/26/19 at 12:23 P.M., verified the facility did not notify the resident, the resident's representative, or the ombudsman in writing of the reason for transfer when she was transferred to the hospital. She stated the facility did not currently have a policy as they were not aware of this requirement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview the facility failed to ensure all treatments were completed as ordered. This affected two residents, (Resident #10 and Resident #92) out of five residents reviewed for treatments. The current census is 112. Findings include: 1. Record review of Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #10 include abnormal findings in the lung field, infection of the skin, non-pressure ulcer of the left lower leg, chronic kidney disease, diabetes, edema, and normal pressure hydrocephalus. Review of Resident #10's care plans dated 09/08/15 revealed a focus for impaired skin integrity due to cellulitis and abscess of legs. Interventions for the focus include treatments per order. Review of Resident #10's quarterly Minimum Data Set, (MDS), dated [DATE] revealed the resident had impaired cognition. Per the assessment the resident was documented as having an unhealed, unstageable pressure ulcer and received non-surgical dressing, ointments, and medications as treatment. Further review of Resident #10's medical record revealed the resident had a non-pressure ulcer on her left lower leg. Per the record the resident was being seen by the facility's Wound Nurse Practitioner for care and treatment of the wound. Review of physician orders for Resident #10 revealed on 03/12/19 the resident was ordered to have the left anterior shin cleansed with normal saline, apply Medihoney to wound bed, calcium alginate dressing, and to be covered with foam dressing daily and as needed, the order was discontinued on 05/27/19. On 05/30/19, the resident was ordered to have the left anterior shin washed with normal saline, apply Vashe moistened fluffed gauze to wound, lightly pack and cover with ABD pad twice a day and as needed, the order was discontinued of 06/10/19. On 06/10/19, the resident was ordered to have the wound cleansed with normal saline on the left anterior shin skin wound, pack the wound with Vashe moistened fluffed gauze. Please avoid putting gauze on good, intact skin, cover with ABD pad and Kerlix twice a day and as needed. There were no orders for the dressing change from 05/27/19 to 05/30/19. Review of Resident #10's Treatment Administration Record, (TAR), dated 05/2019 revealed no documentation of the treatment to the left anterior shin completed on 05/11, 05/12, 05/16, 05/17, 05/21, 05/25, 05/26, 05/27/19. Per the TAR dated 06/2019 there was no documentation for the left anterior shin treatment completed on 06/03/19 P.M., on 06/04/19 A.M., on 06/05/19 A.M., 06/07/19 A.M., 6/08/19 A.M. and P.M., 06/09/19 A.M., 06/18/19 A.M., 06/19/19 A.M. and P.M., 06/21/19 A.M., 06/22/19 A.M. and P.M., 06/23/19 A.M., and 06/26/19 P.M. treatments were not documented as completed. Review of Resident #10's progress notes dated from 05/2019 to 06/2019 revealed no corresponding progress notes for the missing documentation noted on the TARs. Interview on 06/26/19 at 9:26 A.M., with Licensed Practical Nurse, (LPN), #550 verified the missing documentation in Resident #10's MARs and TARs. Interview on 06/ 26/19 at 4:30 P.M. with the Director of Nursing, (DON), verified there was missing documentation in Resident #10's MARs and TARs and no documentation in the progress notes for the dates missed on the MARs and TARs. 2. Record review for Resident #92 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #92 include unspecified dementia, diabetes, hypertension, weakness, Parkinson's disease, muscle weakness, and Alzheimer's disease. Review of Resident #92's care plans dated 08/24/18 revealed a focus for impaired physical mobility. Interventions for the focus include up to geri-chair for comfort and out of room mobility, Review of Resident #92' physician orders revealed on 08/24/18 the resident was ordered to have her feet elevated by a pillow while in bed and in the resident's geri-chair. On 10/03/18, the physician ordered for a soft palm cone splint to wear during the day except for meals. Review of Resident #92's quarterly MDS assessment dated [DATE] revealed the resident has intact cognition and was an extensive assist with all Activities of Daily Living, (ADL). Observation and interview on 06/24/19 at 10:03 A.M., revealed Resident #92 was sitting in the geri-chair in the resident's room. Resident #92 stated she was supposed to have her feet elevated while sitting in her chair. Interview on 06/27/19 at 9:30 A.M., with Resident #92 revealed the resident stated her feet were again not elevated on a pillow while she was sitting in her chair. Resident #92 also verified she did not have her hand cone in her hand during the observation. Interview on 06/27/19 at 10:00 A.M. with Registered Nurse, (RN), #540 revealed she was the nurse unit manager for Resident #92's unit. RN #540 verified Resident #92's feet were not elevated on a pillow and the resident did not have her hand cone per the physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy, record review, and staff interview, the facility failed to ensure the proper care and treatment was completed for resident's with tube feedings. This affected one (Resident #41) of one resident reviewed for tube feedings. The current census was 112. Findings include: Record review of Resident #41 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #41 included hypertension, hemiplegia, aphasia, dysphagia, diabetes, convulsions, apraxia, and cerebral vascular accident. Review of Resident #41's physician orders revealed on 03/06/19 an order to check placement and residual of the feeding tube five times a day, to check the placement and residual with each feed five times a day, and to cleanse the peg tube site with normal saline and apply gauze to the site twice a day. Review of Resident #41's care plan dated 03/07/19 revealed a focus feed tube was in place. Interventions included to check tube placement per order and dressing changes per order. Review of Resident #41's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition and was documented as having a feeding tube. Observation on 06/25/19 at 3:45 P.M., of LPN #500 administering a tube feeding to Resident #41 revealed the nurse did not check the residual or placement prior to administered a flush of the tube. LPN #500 was observed taking a paper towel, wetting it with tap water, and cleansing the peg tube site after administering the tube feeding. Interview on 06/25/19 at 3:55 P.M., with LPN #500 verified the nurse did not check the resident's tube residual or check the placement of the tube prior to administering the flush and the tube feeding. LPN #500 verified it was facility policy to check the placement and residual of the tube prior to administering medications and tube feedings. LPN #500 verified she did not use gauze or normal saline to cleanse the peg site per physician order. Review of the facility policy titled, Medication Administration, dated 02/2019 revealed the facility staff was to check patency and placement of tube feeding prior to administering medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure an appropriate indication for a resident's antibiotic use. This affected one (Resident #103) of five residents reviewed for unnecessary medications. The facility identified one resident on antibiotic medication. The facility census was 112. Findings include: Review of Resident #101's medical record revealed an admission date of 03/25/19. Medical diagnoses included generalized muscle weakness, insomnia, delusional disorder, cardiac arrhythmia, hemiplegia and hemiparesis following cerebral infarction, atrial fibrillation, cognitive communication deficit, cerebral infarction, and low back pain. Review of the resident's minimum data set assessment dated [DATE] revealed she had moderately impaired cognition. Review of the resident's physician's orders revealed she was started on keflex (antibiotic) 250 milligrams (mgs) three times daily for seven days for a urinary tract infection (UTI) on 06/24/19. Continued review of the resident's medical record revealed she received the keflex from an emergency room visit on 06/24/19. Review of the hospital documentation revealed a urinary culture was in progress. Review of the resident's laboratory record revealed no evidence of results of the urinary culture. Interview with Licensed Practical Nurse (LPN) Unit Manager #520 on 06/27/19 at 11:14 A.M., verified the resident was receiving an antibiotic for a UTI and her urinary culture results had not been obtained by the facility. After speaking with the surveyor, LPN Unit Manager #520 called to obtain the results of the urine culture, which was negative on 06/25/19. Review of a facility policy titled Antibiotic Stewardship Program Policy dated 05/18 revealed at 72 hours after empiric antibiotic initiation or first dose in the facility resident will be reassessed for consideration of antibiotic need, duration, and selection of antibiotic.

Based on observation, staff interview, puree recipes, list of residents who received a puree diet and policy and procedures, the facility failed ensure puree menu items were prepared in a manner to conserve the nutritional value. This affected five Residents (#47, #67, #69, #73 and #108) of five resident who received a puree diet in a facility census of 112. Findings include: On 6/26/19 at 10:02 A.M. until 10:22 A.M., [NAME] #200 was observed preparing puree menu items. The first item prepared was stuffing. She was observed preparing a little over five servings of dressing. As she was pureeing the dressing she added approximately a little over two cups of water to reach the desired puree consistency. She then prepared the pork with gravy as a listed menu item for this day. She was observed preparing the five serving of pork chops with five slice of bread. She then added approximately two cups of water and an unmeasured amount of thickener to reach the appropriate puree consistency. On 06/26/19 at 10:22 A.M., interview with [NAME] #200 verified she was not aware of any recipes to follow for preparing puree meal items. She then verified it was her regular practice to use water and thickener at times to obtain the desired constancy of the pureed menu items. On 06/26/19 at 11:32 A.M., interview with Dietary Director (DD) #300 verified the puree recipes for dressing and pork chops did not call to use water or thickener to ensure the appropriate puree consistency. Review of undated pureed diet list provided by the facility documented Residents (#47, #67, #69, #73 and #108) received puree diets during the annual survey. Review of recipe for pureed dressing undated documented to prepare measure amount of dressing to be pureed from the regular menu item, add chicken broth and process until smooth in texture. Further review documented to use two and half cups of low sodium chicken broth for five servings of dressing. Review of recipe for pureed pork chops undated documented to prepare pork chops as directed, measure amount of meat needed as documented on the regular recipe, add hot broth or gravy until smooth consistency, add one slice of bread per portion and process until mixed. Further review documented to use two and half cups of no salt chicken base or low salt gravy for five servings of the pork chops. Review of policy and procedure for puree food preparation dated 2018 documented it was the policy of the facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor and attractive appearance.

Based on review of the facility's legionnaires prevention documentation and staff interview, the facility failed to implement a legionella control plan with identified control measures and documentation. This had the potential to affect all the residents residing in the facility. The census was 112. Findings include: Review of a facility policy titled Water Management Plan dated 02/25/18 revealed the facility would conduct a hazard analysis of the water systems and determine which ones present a significant risk of Legionella growth and transmission. Further review revealed the facility would establish control locations where Legionella control measures could be applied. The facility would then establish and implement control measure with performance limits, monitoring, and corrective action. The facility would establish and implement documentation of control measures. Further review of the facility legionnaires documentation revealed no facility assessment which determined specific risk areas for Legionella. The facility had implemented daily tasks, monthly tasks, and yearly tasks to control Legionella, however the documentation of these control measures was incomplete. Interview with Plant Operations Director #700 on 06/27/19 at 2:54 P.M., stated the facility does not have a flowsheet indicating what areas of concern should be monitored. He verified they have not implemented and monitored all of control measure per their plan.