**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #7 revealed the resident was admitted to the facility on [DATE], with diagnoses including: muscle weakness, heart failure, and mood disorder. The resident had a new diagnosis of schizoaffective disorder added on 10/13/22. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/10/24, revealed the resident was assessed to be rarely/never understood. Further record review for Resident #7 revealed no significant change PASSAR was completed following a new diagnosis of schizoaffective disorder. Interview on 11/05/24 at 2:45 P.M., with the Director of Nursing (DON) confirmed a significant change PASSAR was not completed following the new diagnosis of schizoaffective disorder for Resident #7. Based on record reviews and staff interview, the facility failed to ensure a significant change Preadmission Screening and Resident Review (PASARR) was completed following the addition of a new mental health diagnosis. This affected two (#3 and #7) of the four residents reviewed for PASARR during the annual survey. The facility census was 21. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 06/11/20, with diagnoses including: hypertension, dementia, insomnia, chronic respiratory failure, unspecified psychosis, basal cell carcinoma, macular degeneration, peripheral vascular disease, hallucinations, peripheral vascular disease, chronic embolism and thrombosis, insomnia, schizophrenia, atherosclerosis, and delusional disorders. A diagnosis of unspecified psychosis was added on 07/21/22. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had severely impaired cognition . Review of completed PASSAR documents revealed the facility did not complete a new PASSAR designation following the addition of the unspecified psychosis diagnosis on 07/21/22. Interview on 11/06/24 at 10:22 A.M., with Licensed Practical Nurse (LPN) #400 verified a new PASSAR had not been completed with the addition of the new diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a stop date for as needed psychotropic medications. This affected two (#14 and #15) of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 21. Findings include: 1. Record review for Resident #14 revealed the resident was admitted to the facility on [DATE] and had diagnoses including anxiety disorder, allergic rhinitis, and urge incontinence. Review of the 5-Day Minimum Data Set (MDS) assessment, dated 10/16/24, revealed the resident was assessed to have intact cognition. Review of the active physicians order, dated 10/15/24, revealed an order for 25 milligrams (mg) of Hydroxyzine (an antianxiety medication) to be administered every six hours as needed for anxiety. The order did not contain a stop date. Review of the active physicians order, dated 10/17/24, revealed an order for one mg of Xanax (an antianxiety medication) to be administered every 12 hours as needed for anxiety. The order did not contain a stop date. Interview on 11/05/24 at 2:45 P.M., with the Director of Nursing (DON) confirmed Resident #14's orders for Hydroxyzine and Xanax did not contain a stop date despite being ordered on an as needed basis. 2. Record review for Resident #15 revealed the resident was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia with anxiety and agitation, and depression. Review of the admission MDS assessment, dated 09/02/24, revealed the resident was assessed to have moderately impaired cognition. Review of the active physician's order, dated 08/22/24, revealed an order for a topical gel containing a mixture of one mg of Ativan (an antianxiety medication), 25 mg of Benadryl (an antihistamine medication), one mg of Haldol (an antipsychotic medication), and 10 mg of Reglan (an anitiemetic medication) to be administered topically to the wrists every four hours as needed for agitation. The order did not contain a stop date. Interview on 11/05/24 at 2:45 P.M., with the Director of Nursing (DON) confirmed Resident #14's orders for Hydroxyzine and Xanax did not contain a stop date despite being ordered on an as needed basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a self reported incident, staff interview, resident and family interview, and policy review, the facility failed to timely and thoroughly investigate potential resident neglect. This affected one (Resident #1) out of three residents reviewed for neglect. The census was 29. Findings include: Clinical record review revealed Resident #1 was admitted on [DATE] with diagnoses including dementia, traumatic subdural hemorrhage and psychosis. Review of the Minimum Data Set (MDS) assessment, dated 04/18/23, revealed Resident #1 had moderately impaired cognition, ambulated and used the toilet independently, and required the limited assistance of one staff for dressing, hygiene and bathing. Review of an Elopement Evaluation, dated 04/07/23, revealed Resident #1 did not have a history of elopement or elopement attempt and did not express a desire to leave; however, the resident wandered about the facility. The evaluation indicated Resident #1 was at risk for wandering/elopement. Review of a second Elopement Evaluation, dated 05/17/23, revealed the resident had a history of an elopement or attempted to leave the facility without informing the staff. Review of the care plan, dated 05/16/23, revealed there were no interventions to address Resident #1's wandering/elopement risk prior to Resident #1's elopement on 05/12/23. The care plan further revealed Resident #1 was paranoid, manipulative and made false allegations against female peers and male staff members. Resident #1 was anxious and agitated at times and made delusional comments that were sexual in nature to others, especially female peers. Review of the progress note, dated 05/12/23 at 4:53 P.M., revealed Resident #1 was outside with the activity director and female peers. He was agitated and was making delusional comments regarding female peers and a male staff member. The staff attempted to redirect him without success and his agitation increased. He sat with his female peers for the evening meal in the dining area. Review of the progress note on 05/12/23 at 7:42 P.M. revealed Registered Nurse (RN) #40 responded to the alarm sounding, and the outside courtyard gate was open and Resident #1 was entering a hall where he did not belong and stated he had paperwork the girls needed. The resident became agitated and was redirected to his room. The progress note on 05/14/23 at 5:57 P.M. revealed Resident #1's family reported Resident #1 stated he left the facility out his window, walked to the gas station (roughly 0.3 miles and a six minute walk from the facility) from the facility and called the police the other night. RN #40 noted the window screen was removed from the window when he was escorted back to his room the night of 05/12/23. RN #40 assured the family member Resident #1 did not leave the facility the evening of 05/12/23. Review of the facility Self Reported Incident (SRI) dated 05/17/23, revealed on 05/16/23, Resident #1's family reported Resident #1 went out his window to the gas station and had a still photo of the gas station security camera showing Resident #1 wearing a large brimmed hat. The SRI did not include the date or time of the still photo in the investigation. Resident #1 was interviewed and stated he left the facility to report a rape involving no specific people to the sheriff. The resident was assessed with no injuries. The facility completed wellness checks and interviews with three female residents Resident #1 usually associated with in the facility which all revealed no injuries or concerns. On 05/17/23, the police were called regarding the rape report and spoke to Resident #1 as well as Resident #3 however the police did not file a report. The nurses notes were included in the investigation but there were no staff statements regarding the elopement. The investigation determined neglect was unsubstantiated. Interview with Licensed Practical Nurse (LPN) #5 on 05/24/23 at 11:35 A.M. verified there was no mention of the date or time of the still photo from the gas station in the SRI dated 05/17/23. LPN #5 verified there were no staff statements regarding the elopement and there were only nurses notes included in the facility investigation of Resident #1's elopement and possible neglect. LPN #5 verified the facility elopement investigation was not initiated until the family provided the still photo of Resident #1 at the gas station despite the family stating on 05/14/23 that Resident #1 indicated he had left the facility through the window and walked to the gas station. She verified it was unknown how long Resident #1 was outside of the facility on 05/12/23. Interview with Resident #1 on 05/24/23 at 12:40 P.M. revealed he left out of the window in order to talk to the Sheriff, then came back to the facility through the window. The resident stated he was a machinist and could fix or get out of anything. Interview with RN #40 on 05/24/23 at 3:05 P.M. verified on 05/12/23 around 7:20 P.M. the gate alarm sounded and she thought Resident #1 was attempting to leave the courtyard gate and had wet shoulders due to the rain. RN #40 indicated Resident #1 was agitated and was on the wrong hall. RN #40 indicated when she redirected him back to his room after the alarm sounded, she noticed the screen to his window was out of place. RN #40 verified she did not investigate the missing screen from the window. Phone interview with Resident #1's sister in law on 05/24/23 at 4:05 P.M. verified the still photo of Resident #1 at the gas station was from 05/12/23 at 5:18 P.M. She stated Resident #1 had a long history of making false allegations against his former wives and love interests when he saw them near another man. Review of the policy titled Investigation of Abuse, dated 12/2022, revealed the facility thoroughly and timely investigated all allegations or suspicions of abuse and neglect. Statements from witnesses were reviewed as part of the investigation. The policy further revealed neglect included a lack of supervision or care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a self reported incident, staff interview, resident and family interview, and policy review, the facility failed to ensure residents were adequately supervised to prevent elopement. This affected one (Resident #1) out of three residents reviewed for elopement. The census was 29. Findings include: Clinical record review revealed Resident #1 was admitted on [DATE] with diagnoses including dementia, traumatic subdural hemorrhage and psychosis. Review of the Minimum Data Set (MDS) assessment, dated 04/18/23, revealed Resident #1 had moderately impaired cognition, ambulated and used the toilet independently, and required the limited assistance of one staff for dressing, hygiene and bathing. Review of an Elopement Evaluation, dated 04/07/23, revealed Resident #1 did not have a history of elopement or elopement attempt and did not express a desire to leave; however, the resident wandered about the facility. The evaluation indicated Resident #1 was at risk for wandering/elopement. Review of the care plan, dated 05/16/23, revealed there were no interventions to address Resident #1's wandering/elopement risk prior to Resident #1's elopement on 05/12/23. Review of the progress note, dated 05/12/23 at 4:53 P.M., revealed Resident #1 was outside with the activity director and female peers. He was agitated and was making delusional comments regarding female peers and a male staff member. The staff attempted to redirect him without success and his agitation increased. He sat with his female peers for the evening meal in the dining area. Review of the progress note on 05/12/23 at 7:42 P.M. revealed Registered Nurse (RN) #40 responded to the alarm sounding, and the outside courtyard gate was open and Resident #1 was entering a hall where he did not belong and stated he had paperwork the girls needed. The resident became agitated and was redirected to his room. The progress note on 05/14/23 at 5:57 P.M. revealed Resident #1's family reported Resident #1 stated he left the facility out his window, walked to the gas station (roughly 0.3 miles and a six minute walk from the facility) from the facility and called the police the other night. RN #40 noted the window screen was removed from the window when he was escorted back to his room the night of 05/12/23. RN #40 assured the family member Resident #1 did not leave the facility the evening of 05/12/23. Review of a Self Reported Incident (SRI) revealed on 05/16/23, Resident #1's family reported Resident #1 went out his window to the gas station and Resident #1's family had a still photo of the gas station security camera showing Resident #1 wearing a large brimmed hat. There was no mention in the SRI of the date or time of the still photo. Resident #1 was interviewed and stated he left the facility to report a rape, involving no specific people, to the sheriff. Resident #1 was assessed with no injuries. Wellness checks and interviews with the three female peers Resident #1 usually associated with in the facility revealed no injuries or concerns. The nurses notes were included in the SRI but there were no staff statements regarding the elopement. The SRI determined neglect was unsubstantiated. Interview with Licensed Practical Nurse (LPN) #5 on 05/24/23 at 11:35 A.M. revealed it was unknown how long Resident #1 was outside of the facility on 05/12/23. Interview with Resident #1 on 05/24/23 at 12:40 P.M. revealed he left out of the window of the facility in order to talk to the Sheriff, then came back thru the window. The resident stated he was a machinist and can fix or get out of anything. Interview with RN #40 on 05/24/23 at 3:05 P.M. verified on 05/12/23 around 7:20 P.M. the gate alarm sounded and she thought Resident #1 was attempting to leave the courtyard gate and had wet shoulders due to the rain. RN #40 indicated Resident #1 was agitated and was on the wrong hall. RN #40 indicated when she redirected him back to his room after the alarm sounded, she noticed the screen to his window was out of place. RN #40 verified she did not investigate the missing screen from the window. Phone interview with Resident #1's sister in law on 05/24/23 at 4:05 P.M. verified the still photo of Resident #1 at the gas station was from 05/12/23 at 5:18 P.M. She stated Resident #1 had a long history of making false allegations against his former wives and love interests when he saw them near another man. Review of the policy titled Wandering Residents dated 02/2019 revealed the facility shall take all reasonable measures to prevent elopement and assure resident safety from elopement. Nursing shall assess all residents for potential wandering within the first twenty-four hours of admission, with any pertinent significant change, after any new elopement attempts and as needed. Appropriate measures shall be put in place immediately after identifying a resident with moderate to high risk for wandering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to timely report to the State Survey Agency an allegation of sexual abuse. This affected two (#4 and #23) of three residents reviewed for abuse. The facility census was 26. Findings include: Record review for Resident #4 revealed an admission date of 05/24/22. Diagnoses included Alzheimer's disease, anxiety disorder, restlessness and agitation, psychosis, amnesia, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was sometimes understood and sometimes understands others. Resident #4 has physical behaviors one to three days, others behaviors daily and wandering daily. Record review for Resident #23 revealed an admission date of 05/14/21. Diagnoses included dementia with behaviors. Review of the quarterly MDS assessment dated [DATE] revealed Resident #23 was severely cognitively impaired and has severely impaired vision. Review of the facilities Self Reported Incident Control Number 229793 dated 12/05/22 revealed on 12/02/22, Resident #23 was groping/rubbing Resident #4's private area. Resident #4 alerted staff, staff separated peers, and monitored for safety. Facility shall continue to keep Resident #23 away from Resident #4 however they enjoy each others company and often appropriately interact. Staff will assure no inappropriate touching occurs as the peers will maintain safe distance. Interview with Licensed Practical Nurse (LPN) #10 on 12/13/22 at 12:45 P.M. revealed Resident #23 was delusional on 12/02/22 and Resident #23 grabbed Resident #4 in her private area. Staff intervened and separated them immediately. Interview with the Administrator on 12/13/22 at 11:35 A.M. revealed he received a call around 4:00 P.M. on 12/02/22 about the incident. The Administrator verified the incident happened on 12/02/22 and he did not report the allegation of sexual abuse to the State Survey Agency until 12/05/22. The Administrator stated he had COVID-19 and thought he had 24 business hours to report and since the incident happened on Friday 12/02/22 he thought he had until Monday 12/05/22 to report to the State Survey Agency. Review of the facility's Abuse Reporting policy dated 06/01/19 revealed the facility will not tolerate any of the following; abuse, neglect, and or misappropriation of resident's property. The Administrator or designee shall report abuse as soon as possible to Ohio Department of Health (ODH) and shall assure ODH was notified within less than 24 hours. This was an incidental finding during the course of the self-reported incident investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the online Resident Assessment Instrument (RAI) manual, the facility failed to complete required Minimum Data Set (MDS) assessments. This affected 10 (#1, #6, #9, #10, #12, #116, #117, #118, #164, and #166) of 17 residents reviewed for completed MDS assessments. The facility census was 23. Findings include: 1. Record review for Resident #1 revealed no MDS assessments had been completed for the resident since the annual MDS assessment dated [DATE]. 2. Record review for Resident #6 revealed no MDS assessments had been completed for the resident since the quarterly MDS assessment dated [DATE]. 3. Record review for Resident #9 revealed no MDS assessments had been completed for the resident since the quarterly MDS assessment dated [DATE]. 4. Record review for Resident #10 revealed no MDS assessments had been completed for the resident since the quarterly MDS assessment dated [DATE]. 5. Record review for Resident #12 revealed no MDS assessments had been completed for the resident since the quarterly MDS assessment dated [DATE]. 6. Record review for Resident #116 revealed no MDS assessments had been completed for the resident since the admission MDS assessment dated [DATE]. 7. Record review for Resident #117 revealed no MDS assessments had been completed for the resident since the quarterly MDS assessment dated [DATE]. 8. Record review for Resident #118 revealed no MDS assessments had been completed for the resident since the Medicare-30 Day/End of Therapy MDS assessment dated [DATE]. 9. Record review for Resident #164 revealed no MDS assessments had been completed for the resident since the annual MDS assessment dated [DATE]. 10. Record review for Resident #166 revealed no MDS assessments had been completed for the resident since the quarterly MDS assessment dated [DATE]. Interview with Facility Manager #5 on 04/13/22 at 1:30 P.M. verified MDS assessments had not been completed for Resident #1, #6, #9, #10, #12, #116, #117, #118, #164, and #166 due to facility staff not having time for which to do so. Review of the online Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility RAI 3.0 User's Manual (https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_October_2019.pdf), dated 10/2019, revealed quarterly MDS assessments were to be completed within 92 days of the most recent annual or quarterly MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the online Resident Assessment Instrument (RAI) manual, the facility failed to timely complete and submit the Minimum Data Set (MDS) assessments. This affected eight (#1, #3, #4, #13, #116, #117, #164, and #166) of 17 residents reviewed for completed and submitted MDS assessments. The facility census was 23. Findings include: 1. Record review for Resident #1 revealed the quarterly MDS assessment, dated 12/10/21, was in in progress and had not been submitted. 2. Record review for Resident #3 revealed the quarterly MDS assessment, dated 02/06/22, was in progress and had not been submitted. 3. Record review for Resident #4 revealed the annual MDS assessment, dated 02/02/22, was in progress and had not been submitted 4. Record review for Resident #13 revealed the admission MDS assessment, dated 03/28/22, was in progress and had not been submitted. 5. Record review for Resident #116 revealed the entry MDS assessment, dated 12/17/21, and the admission MDS, dated [DATE], were in progress and had not been submitted. 6. Record review for Resident #117 revealed the quarterly MDS assessment, dated 11/11/21, was in progress and had not been submitted. 7. Record review for Resident #164 revealed the annual MDS assessment, dated 11/10/21, was in progress and had not been submitted. 8. Record review for Resident #166 revealed the quarterly MDS assessment, dated 12/10/21, was in progress and had not been submitted. Interview on 04/13/22 at 1:30 P.M. with Facility Manager #5 verified the MDS assessments had not been completed or submitted for Resident #1, #3, #4, #13, #116, #117, #164, and #166 due to facility staff not having enough time for which to do so. Review of the online Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility RAI 3.0 User's Manual (https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_October_2019.pdf), dated 10/2019, revealed MDS assessments should be completed and submitted no later than 14 days after the assessment was initiated.

Based on observation and interview, the facility failed to provide residents with knives during meals. This affected three residents (Residents #4, #5 and #141) of 15 residents observed eating in the dining room. The facility census was 21. Findings include: During observation of the main dining room on 07/02/19 at 11:51 A.M., residents were served paper plates, plastic forks, regular spoons, and no knives. During interview on 07/02/19 at 11:51 A.M., [NAME] #141 stated the residents were served paper plates and plastic forks because there was a leak in the kitchen and the dishes were not all clean. She verified they had plastic forks and no knives. During observation on 07/02/19 at 12:11 P.M., Resident #4 and Resident #17 were trying to cut their burritos with their plastic forks, which did not work. No staff offered to cut them. During interview on 07/02/19 at 12:11 P.M., Resident #5 had eaten the contents of her burrito only, but not the tortilla. She stated it would have been better if she had a knife to cut her burrito. During interview on 07/02/19 at 12:25 P.M., both Resident #4 and Resident #17 stated it was too hard to cut burritos with a plastic fork. During interview on 07/02/19 at 12:30 P.M., [NAME] #141 stated residents were not given knives, only spoons and forks.

Based on observation, interview and policy review, the facility failed to store, label, date, and serve food properly to avoid food borne illnesses. This had the potential to affect all 21 residents in the facility. Findings include: Initial tour of the kitchen completed on 07/01/19 from 9:15 A.M. to 9:45 A.M. revealed the following items in the refrigerator were being stored opened and undated: A bag of celery with celery stalks exposed; a bag of carrots; a bag of red grapes with some grapes exposed; and a bag of romaine lettuce hearts During interview on 07/01/19 at 9:30 A.M., [NAME] #141 verified all of the above items were opened and did not have a date on it. Review of the freezer on 07/01/19 at 9:32 A.M. revealed the following items were being stored in opened bags and undated: A bag of sausage patties; a bag of white shrimp; a bag of fish sticks were opened with some of the fish sticks exposed; a bag of pepperoni; a bag of french fries; and a bag of shredded cheddar cheese. An interview with the Administrator on 07/01/19 at 9:37 A.M. verified the above items were being stored in opened bags and were not dated. Observation of [NAME] #141 preparing and serving lunch meal on 07/01/19 at 12:02 P.M. revealed [NAME] #141 pulled three plates from the top of a stack of plates that were visibly wet with water on them and used them to serve the lunch meal to residents. [NAME] #141 also provided a tray cover to an aide that visibly had water still in it. [NAME] #141 dumped the water out of the tray cover into the sink and then provided the tray cover to the aide. The aide used the tray cover to cover a resident's meal and then delivered the meal to the resident's room at 12:04 P.M. Interview with [NAME] #141 on 07/01/19 at 12:05 P.M. confirmed the above observations. Observation of [NAME] #141 at 12:20 P.M. revealed tongs were used to serve chicken breasts to the residents. The tongs fell completely into the serving dish and were completely covered in chicken broth. [NAME] #141 used the serving spoon from the broccoli to get the tongs out of the chicken broth and then continued to use the same spoon to serve broccoli to the residents. Interview with [NAME] #141 on 07/01/19 at 12:23 P.M. confirmed the above observation. Review of the facility policy titled Food Purchasing, Receiving, and Storage, dated September 2014, stated food will be dated and stored promptly. All food supplies will be stored in areas protected from contamination by condensation, leakage, drainage, rodents, and vermin. Food will be purchased, received, and stored in such a manner as to assure quality and safe food, prevent contaminations and spoilage, assure proper billing, and promote health.