**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews and policy review, the facility failed to provide activities for a resident in isolation. This affected one (#22) out of one residents reviewed for activities. The facility census was 50. Findings include: Review of the medical record for Resident #22 revealed an admission date of 04/26/24. Diagnoses include chronic obstructive pulmonary disease, chronic diastolic (congestive) heart failure, and dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident with moderate cognitive impairment. Resident required set-up assistance with eating, partial assistance for oral hygiene and bathing, substantial assistance with dressing, personal hygiene, bed mobility, and transfers, and was dependent on staff assistance with toileting hygiene. Review of Resident #22's care plan, dated 05/09/24 revealed the resident has the potential for reduced social interaction and/or reduced activity participation related to dementia and anxiety. With a goal to maintain involvement in cognitive stimulation and activities of choice three to five times weekly as desired/tolerated. Interventions include assist resident to modify / rearrange daily schedule, if possible, to accommodate activities of choice, and assist/direct resident to activity location(s) as needed, encourage and assist resident to choose leisure pursuits daily as needed. Further review of Resident #22's medical record revealed there was a lack of documentation regarding involvement in activities. Interview on 10/07/24 at 11:28 A.M. with Resident #22 revealed she attends bingo for activities but nothing else. Interview with Resident #22 also revealed the activities staff does not bring any activities to her room. Interview on 10/09/24 at 9:25 A.M. with Resident Lifestyle Coordinator #267 confirmed all residents are assessed on admission for likes and dislikes and their participation in community activities. Interview on 10/09/24 at 9:41 A.M. with Resident Lifestyle Coordinator #330 confirmed when a resident attends an activity, it is documented in the progress notes. Resident Lifestyle Coordinator #330 stated one-on-one (1:1) activities in the resident room is also documented in the progress notes. Interview with Resident Lifestyle Coordinator #330 also confirmed Resident #22 doesn't like to attend a lot of activities she is given word search books at times. Resident Lifestyle Coordinator #330 confirmed there was no documentation of Resident #22 attending any activities from 08/17/24 through 10/03/24 and there was no documentation present to indicate that she refused any in room activities. Resident Lifestyle Coordinator #330 confirmed Resident #22 and her roommate had COVID-10 for a long period between 08/17/24 and 10/03/24 and activities did not go into any of the COVID-19 positive rooms. Resident Lifestyle Coordinator #330 confirmed activity packets were left outside of the COVID-19 positive rooms but she could not confirm the residents received any of the activity packets. Review of the facility Infection Control Policy dated 09/2024 revealed the purpose is to ensure the establishment and maintenance of an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Review of the policy also revealed no documentation of there being restrictions of activities when a resident is in isolation. Review of the facility Activities and Social Services Policy dated 10/01/22 revealed the purpose is to ensure the provision of an ongoing activity program that meets physical, mental, emotional, psycho-social well-being and personal interests of patients/residents at varied times of day and on weekends. Based on the patients'/residents' changes in abilities, physical and mental status, timely adjustments in programming shall be made to meet the patients'/residents' needs at all times. Activities shall be an integral component of residents' lives and should be meaningful. Activities are meaningful when they reflect a person' interests and lifestyle, are enjoyable to the person, help the person to feel useful and provide a sense of belonging. Activities will include facility-sponsored group activities, individual activities, and independent activities, and encourage both independence and interaction in the community.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, pharmacy staff and Nurse Practitioner (NP) interviews and review of medication information from Medscape, the facility failed to ensure a resident received a cardiac medication as as ordered resulting in significant medication errors. This affected one (#207) out of one residents reviewed for medication errors. The facility census was 50. Findings include: Review of the medical record for Resident #207 revealed an admission date of 10/04/24. Diagnoses include intervertebral disc degeneration, lumbar region without mention of lumbar back pain or lower extremity pain, chronic respiratory failure with hypoxia, and acute on chronic diastolic (congestive) heart failure. Review of the Minimum Data Set (MDS) revealed no information was available due to Resident #207 being a new admission. Review of Resident #207's physician orders revealed an order dated 10/04/24 for Entresto Oral Tablet 24-26 milligrams (mg) (Sacubitril-Valsartan), give one (1) tablet by mouth two times a day related to acute on chronic diastolic (congestive) heart failure. Review of the Medication Administration Record (MAR) for October 2024 revealed an entry for Entresto Oral Tablet 24-26 mg (Sacubitril-Valsartan), give one (1) tablet by mouth two times a day related to acute on chronic diastolic (congestive) heart failure. Further review of the MAR revealed Resident #207's Entresto orally was not administered on the following dates/times: on 10/04/24 at 9:00 P.M.; on 10/05/24 at 9:00 A.M.; on 10/05/24 at 9:00 P.M.; on 10/06/24 at 9:00 A.M.; on 10/06/24 at 9:00 P.M.; on 10/07/24 at 9:00 A.M.; on 10/07/24 at 9:00 P.M.; and on 10/08/24 9:00 A.M. Further review of Resident #07's medical record revealed there was no further documentation as to why the Entresto was not administered. Interview on 10/07/24 at 2:10 with Licensed Practical Nurse (LPN) #238 confirmed Resident #207 had an order for Entresto orally two times a day related to acute on chronic diastolic (congestive) heart failure and this was ordered on admission [DATE]. LPN #238 confirmed Resident #207 has not received the Entresto since admission. LPN #238 stated the facility has not approved the medication due to a cost issue. Interview on 10/08/24 at 2:12 P.M. with Pharmacy Technician #403 confirmed the pharmacy has not sent Entresto Oral Tablet 24-26 MG (Sacubitril-Valsartan) out for Resident #207 due to cost and the facility has not approved the cost. Pharmacy Technician #403 confirmed the facility received a fax on 10/04/24 to approve the cost for Residents #207's medication. Interview on 10/08/24 at 4:26 P.M. with NP #350 confirmed the facility did not notify the physician or NP of Resident #207 not receiving the Entresto since admission. NP #350 confirmed Resident #207's Entresto is ordered for heart failure. Review of medication information from Medscape at https://reference.medscape.com/drug/entresto-sacubitril-valsartan-1000010?_gl=1*imy860*_gcl_au*MTU0MDAzODMxNC4xNzI2NTk1Nzgz#91 revealed Entresto is used to treat heart failure. Patients taking Entresto should not start, stop, or change the dosage of the medicine without doctor's approval.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure the physician was notified of abnormal blood glucose and blood pressure levels. This affected one (Resident #08) of one resident reviewed for notification. The facility census was 40. Findings include: Review of the medical record of Resident #08 revealed the resident admitted to the facility on [DATE] with diagnoses including anemia, anxiety disorder, peripheral vascular disease, major depressive disorder, heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease, hyperlipidemia, gastro-esophageal reflux disease, chronic atrial fibrillation, and pulmonary hypertension. Review of the quarterly minimum data set (MDS) assessment dated [DATE] the resident had intact cognition. Review of the physician's orders revealed orders dated 04/06/21 to check blood glucose before meals and at bedtime and call the attending practitioner and follow the Abnormal Glucose Policy if glucose is over 350 mg/dL (milligrams per deciliter) and to call the physician for systolic blood pressure (SBP) greater than 180 and/or diastolic blood pressure (DBP) greater than 90 or SBP less than 90 and/or DBP less than 40. Review of the September 2021 medication administration record revealed, on 09/10/21 at 11:08 A.M., the resident's blood sugar was 377 mg/dL. On 09/14/21 at 12:49 P.M., the resident's blood sugar was 399 mg/dL. On 09/21/21 at 5:41 P.M., the Resident's blood sugar was 443 mg/dL. On 09/21/21 at 9:51 P.M., the resident's blood sugar was 379 mg/dL. On 09/25/21 at 9:52 P.M., the Resident's blood sugar was 359 mg/dL. On 09/01/21 at 10:19 P.M., the resident's blood pressure was 126/94 mm/Hg. On 09/29/21 at 8:39 A.M., the resident's blood pressure was 110/38 mm/Hg . Review of the progress notes dated 09/01/21 through 09/30/21 revealed no evidence of physician notification of blood glucose greater than 350 mg/dL on 09/10/21, 09/14/21, 09/21/21, nor 09/25/21 and no evidence of physician notification of a DBP greater than 90 on 09/01/21 and DBP less than 40 on 09/29/21. During interview on 09/29/21 at 4:30 P.M., the Director of Nursing (DON) stated the facility policy is for the nurse to call they physician when a resident's blood sugar is greater than 450, however the physicians write orders for their own parameters. During interview on 09/30/21 at 2:30 P.M., the DON verified the chart lacked evidence of physician notification of abnormal blood pressure readings on 09/01/21 and 09/29/21 and abnormal blood sugar levels on 09/10/21, 09/15/21, 09/21/21, and 09/25/21. Review of the facility policy titled Change in Condition, updated 11/17/20, revealed the physician should immediately be notified of clinical complications and the notification should be documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure there was ongoing communication, coordination and collaboration between the facility and the dialysis center. This affected one (Resident #35) of one resident who received dialysis in the facility. The census was 40. Findings include: Review of medical record for Resident #35 revealed an original admission date of 07/14/21. Additional admissions /discharges included resident was discharged with a return not anticipated on 07/21/21 and readmitted on [DATE]. Diagnosis included hypertensive emergency, hypertension, diabetes mellitus, chronic kidney disease with end stage renal disease with dependence on renal dialysis and congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 08/20/21, revealed Resident #35 was cognitively intact, had no behaviors, did not reject care, was a one-person physical assist, required limited assistance and/or supervision for activities of daily living and received dialysis. Review of plan of care for Resident #35 reveled resident was dependent on renal dialysis related to end stage renal failure and risk for adverse effects of medications due to diuretic usage. Interventions included monitor document any signs of renal insufficiency, obtain vital signs and weight per protocol and report any significant changes and medicate as ordered per physician's orders. Review of physician orders for Resident #35 dated 07/14/21 revealed resident was ordered to receive hemodialysis on Tuesdays, Thursdays, and Saturdays at an off-site location. Review of electronic medical record and paper medical record for Resident #35 revealed no documented evidence of ongoing communication, coordination and collaboration between the nursing home and the dialysis staff. During interview on 09/29/21 at 4:00 P.M., the Director of Nursing (DON) stated the facility had no documented communication or collaboration notes with dialysis facility. During telephone interview 09/29/21 at 4:23 P.M. with dialysis center staff, they stated the facility called them an hour ago and requested all information from resident's admission on [DATE]. The dialysis center verified there was no documented communication between them and the facility. Review of the facility policy titled Dialysis Policy, dated 09/25/20, revealed the facility would assure resident received care and services for the provision of hemodialysis consistent with profession standards of practice including the ongoing assessment of the resident condition and monitoring for complications before and after dialysis treatments received and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, policy review, review of online resources from Centers for Disease Control (CDC) guidance, and review of the Centers for Medicare and Medicaid Services (CMS) memorandums, the facility failed to initiate immediate outbreak testing when an employee tested positive for COVID-19, failed to ensure visitation was suspended when an employee tested positive for COVID-19, failed to ensure staff wore personal protective equipment (PPE) in the facility to prevent the potential spread of Coronavirus (COVID-19), and failed to ensure staff administered medications utilizing proper infection control practices to prevent the potential spread of infectious disease. This had the potential to affect all 40 residents residing in the facility. Findings include: 1. Review of the COVID-19 employee testing revealed, on 09/24/21, Licensed Practical Nurse (LPN) #82 tested positive for COVID-19 and on 09/28/21 and LPN #18 tested positive for COVID-19. Review of the nursing schedule revealed LPN #18 worked on 09/14/21 on the facility's [NAME] wing, and 09/15/21, 09/16/21, and 09/28/21 on the facility's [NAME] wing and LPN #82 worked on 09/19/21 on the facility's [NAME] wing. Review of the punch detail report for LPN #18 revealed she clocked in on 09/28/21 at 6:32 A.M. and clocked out at 10:00 A.M. Interview on 09/28/21 at 10:51, the Director of Nursing (DON) stated LPN #82 became symptomatic and tested positive for COVID-19 prior to the start of her shift on the evening of 09/24/21. The DON stated residents were not tested for COVID-19 until the evening of 09/27/21 and all staff began testing on the morning of 09/28/21 for routine testing. The DON stated resident and staff testing was not initiated immediately because they did not consider the one positive employee test to be an outbreak. DON stated LPN #18 tested positive for COVID-19 on 09/28/21 at approximately 10:00 A.M. DON verified LPN #18 worked for 3.5 hours on 09/28/21 before being tested for COVID-19. Review of the CMS QSO-20-38-NH-revised, dated 09/10/21, revealed, a new COVID-19 infection in any staff triggers an outbreak investigation. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. 2. Observation on 09/27/21 at 12:48 P.M. revealed Resident #22 in her room with two visitors on the B-wing of the facility. Observation on 09/27/21 at 12:35 P.M. revealed Resident #30's wife visiting Resident #30 in his room on the [NAME] wing. During observation of [NAME] wing on 09/27/21 at 12:00 P.M., two visitors entered Resident #2's room. Resident #2 was in quarantine status due to being a new admission and being unvaccinated. The visitor exited Resident #2's room with a lunch tray and placed it at the nursing station. The visitor entered the resident's room again with only a surgical mask in place. Interview with LPN #151 at same time verified Resident #2 had two visitors in his room and also indicated visitors should utilize appropriate PPE when visiting a resident on quarantine. During observation of the [NAME] wing on 09/29/21 at 1:00 P.M., a visitor was in Resident #147's room. Resident #147 was in quarantine status due to being new admission and being unvaccinated. The visitor was wearing only a surgical mask. Interview with Resident #147's visitor at the time of the observation revealed she had visited daily since resident was admitted on [DATE]. During observation on 09/28/21 at 11:47 A.M., a visitor was observed standing next to Resident #95 in the dining room. Concurrent interview with the visitor revealed she was Resident #95, who had recently admitted to the facility and was unaware of any restriction on visitation. During interview on 09/28/21 at 10:51 A.M., the DON stated visitation had not been suspended following LPN #82 testing positive on 09/24/21 and was not suspended at the time of the survey. Review of an email dated 09/29/21 at 9:28 A.M., the DON stated the facility had 91 visitors between 09/24/21 at 6:30 P.M. and 09/29/21 at 10:00 A.M. Review of the CMS QSO-20-39-NH-revised, dated 04/27/21, revealed, when a new case of COVID-19 among residents or staff is identified, a facility should immediately begin outbreak testing and suspend all visitation on the affected unit until at least one round of facility-wide testing was completed and no new cases were discovered. Additionally, the facility should suspend visitation on the affected units until the facility meets the criteria to discontinue outbreak testing which included 14 days of negative testing for HCP and residents. 3. Observation on 09/28/21 at 11:44 A.M. revealed Residents #28 and #95 seated at a table in the dining room. Dining Services Representative (DSR) #29 was observed wearing a surgical mask underneath his chin and delivered food to Resident #95 and briefly conversed with Residents #95 and #28. Interview on 09/28/21 at 11:46 A.M. DSR #29 verified his surgical mask was down below his chin, not covering his nose and mouth, when he delivered food to Resident #95 and conversed with Residents #95 and #28. Review of the facility's staff vaccination log revealed DSR #29 was fully vaccinated. Review of the facility policy titled, COVID-19 Preparedness and Response Plan, last updated 09/21/21 revealed employees are required to wear a mask in all patient and resident-facing areas and employees should never remove their mask in the presence of a resident. Review of the CDC guidelines titled, Infection Control Guidance, updated 09/10/21, (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) revealed fully vaccinated health care personnel should wear source control (mask covering a person's mouth and nose to prevent spread of respiratory secretions when they are breathing or talking) when they are in areas of the healthcare facility where they could encounter patients (including cafeteria and common halls/corridors). 4. During observation of medication administration on 09/29/21 at 812 A.M., LPN #56 applied hand sanitizer and started to prepare medications for Resident #195. LPN #56 used her keys to open the medication cart, touched numerous areas on the cart, touched the computer and computer mouse, touched her face mask, her face shield, and her eyeglasses before she started to prepare medications, LPN #56 prepped three medications by opening the foil/paper packages and pouring them into a medicine cup. LPN #56 opened the top drawer, retrieved a bottle of multivitamins, poured a tablet in the lid, used her left thumb to secure the pill in the lid and then dumped the multivitamin in the medication cup with other medications. LPN #56 opened the drawer, retrieved a Mobic 7.5 milligram (mg) package, and laid it on top of the medication cart. When LPN #56 completed preparing all medications for Resident #159, LPN #56 placed the packaged Mobic in the medicine cups with other pills. LPN #56 stated she wanted to ask Resident #159 if she wanted the medication prior to opening the pill. Observation at 8:20 A.M. revealed LPN #56 entered Resident #159's room, removed the package of Mobic 7.5 from the medicine cup and handed the medicine cup to Resident #159. Observation at 8:21 A.M. revealed Resident #159 took the medications in the medicine cup. During interview with LPN #56 on 09/29/21 at 8:28 A.M. verified she touched numerous items then touched Resident #159's multivitamin with her fingers. LPN #56 also verified she placed the medication package for Mobic in with the other medications. This deficiency substantiates Complaint Number OH00111057.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the Centers for Medicare and Medicaid Services (CMS) memorandums, the facility failed to initiate immediate outbreak testing when an employee tested positive for COVID-19. This had the potential to affect all 40 residents residing in the facility. Findings include: 1. Review of the COVID-19 employee testing revealed, on 09/24/21, Licensed Practical Nurse (LPN) #82 tested positive for COVID-19 and on 09/28/21 and LPN #18 tested positive for COVID-19. Review of the nursing schedule revealed LPN #18 worked on 09/14/21 on the facility's [NAME] wing, and 09/15/21, 09/16/21, and 09/28/21 on the facility's [NAME] wing and LPN #82 worked on 09/19/21 on the facility's [NAME] wing. Review of the punch detail report for LPN #18 revealed she clocked in on 09/28/21 at 6:32 A.M. and clocked out at 10:00 A.M. During interview on 09/28/21 at 10:51 A.M., the Director of Nursing (DON) stated LPN #82 became symptomatic and tested positive for COVID-19 prior to the start of her shift on the evening of 09/24/21. The DON stated residents were not tested for COVID-19 until the evening of 09/27/21 and all staff began testing on the morning of 09/28/21 for routine testing. The DON stated resident and staff testing was not initiated immediately because they did not consider the one positive employee test to be an outbreak. The DON stated LPN #18 tested positive for COVID-19 on 09/28/21 at approximately 10:00 A.M. She verified LPN #18 worked for 3.5 hours on 09/28/21 before being tested for COVID-19. Review of the CMS QSO-20-38-NH-revised, dated 09/10/21, revealed, a new COVID-19 infection in any staff triggers an outbreak investigation. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. This deficiency substantiates Complaint Number OH00111057.

Based on observation, staff interview and policy review, the facility failed to ensure foods in the coolers and freezer were dated and stored in closed containers. The facility also failed to ensure the kitchen was clean. Additionally, the facility failed to appropriately discard items that were contaminated. This had the potential to affect all 46 residents residing in the facility whose meals were prepared in the kitchen. The facility census was 46. Findings included: 1. The initial tour of the kitchen on 02/18/20 at 10:19 A.M. revealed the following areas of concern: • Floor under deep fryer had a heavy black buildup of unknown material. • The reach in cooler #2 had four hot dogs in plastic bag and a log of sliced cheese which was open and undated. • The reach in freezer #1 had four, three-gallon containers of ice cream and a bag of french fries which was opened and undated. Ice cream containers were not sealed properly with lids exposing contents to air. • Walk in freezer had an opened undated bag of french fries. There was also a plastic mat on the floor with an open weave, in between multiple weaves was a buildup of unidentified multicolored material. • Dry food storage had an opened and undated bag of pinto beans. Interview with Interim General Manager #288 verified all areas of concern on 02/18/20 at 11:30 A.M. During the interview a request for cleaning schedules revealed an blank daily document. Interview with Interim General Manager #288 on 02/19/20 at 12:35 P.M. verified the process for cleaning the kitchen areas was being revamped and not all aspects of the cleaning schedule have been implemented. Further stated the facility was obtaining financial quotes from outside cleaning suppliers for deep cleaning. 2. Observation on 02/19/20 at 12:01 P.M. of Dietary Staff #72 opening reach in refrigerator and removed individual cups of fruit in a closed plastic bag and plastic silverware in a separate closed plastic bag. Dietary Staff #72 dropped the plastic bag with silverware onto the kitchen floor. Dietary Staff #72 then picked up the bag containing the plastic silverware from the floor and placed it back into the refrigerator laying it on top of the cups of individual fruit cups. Interview with Assistant Dining Services Director #289 immediately following the observation verified the silverware should have been discarded. The facility confirmed the dietary concerns had the potential to affect all 46 residents residing in the facility as all residents received their meals from the kitchen. Review of the Food Storage and Handling policy, revealed it was the policy of the dining services department to cover, label, date and store all foods in a safe and appropriate manner.