Based on observation, medical record review and staff interview, the facility failed to ensure residents received meal textures as physician ordered. This affected two (#37 and #38) of three residents reviewed for altered food textures. The facility census was 56. Findings include: 1. Review of the medical record for Resident #37 revealed an admission date of 07/11/24 with a diagnosis of dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/14/25, revealed Resident #37 had impaired cognition and required set-up or clean-up assistance for eating. Review of a physician order, dated 10/31/24, revealed Resident #37 received a regular diet with mechanical soft textures and ground meats, with regular texture liquids. Also noted in the physician's order was Resident #37 should receive gravy or sauce on all foods, and should receive no skins, seeds, or nuts. Observation on 04/02/25 at 12:10 P.M. revealed Resident #37 seated in the dining room during the noon meal. Resident #37 received ground Salisbury steak, mashed potatoes, and whole peas with diced carrots on his plate. Resident #37 ate his meal without assistance. Observation and interview on 04/02/25 at 12:12 P.M. with Certified Nursing Assistant (CNA) #101 confirmed Resident #37 received peas and was eating them. 2. Review of the medical record for Resident #38 revealed an admission date of 9/19/24 with diagnoses of dementia and dysphagia (difficulty swallowing). Review of the quarterly MDS assessment, dated 02/13/25, revealed Resident #38 was rarely/never understood and required set-up or clean-up assistance for eating. Review of a physician order, dated 11/11/24, revealed Resident #38 received a regular diet with mechanical soft textures and ground meats, with regular texture liquids. Also noted in the physician's order was Resident #38 should receive gravy or sauce on all foods, and should receive no skins, seeds, or nuts. Observation on 04/02/25 at 12:18 P.M., in the dining room, revealed Resident #38 was served a plate with ground Salisbury steak, mashed potatoes, and whole peas and carrots. Concurrent interview with Dietary Aide (DA) #301 confirmed Resident #38 received peas on her tray and confirmed Resident #38's diet ticket stated she should not receive skins, seeds, or nuts. DA #301 stated items with skins would include foods such as grapes or other fruit with skins. Interview on 04/02/25 at 12:37 P.M. with Dietary Manager (DM) #300 revealed food items with skins included corn and dried beans. DM #300 further stated she had no defined list of items to be excluded for residents who should not receive skins, seeds, or nuts with their meals. A telephone interview on 04/02/25 at 12:47 P.M. with Speech Therapist (ST) #200 verified peas would be included as a food item with skin. Further, ST #200 confirmed Resident #37 and Resident #38 should not receive peas. This deficiency represents non-compliance investigated under Complaint Number OH00161460.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure resident assessments were accurately completed. This affected two (#15 and #31) of two residents reviewed for accurate resident assessments. The facility census was 43. Findings include: 1. Review of the medical record revealed Resident #15 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, acute and chronic respiratory failure, hemiplegia affecting left nondominant side, essential hypertension, Alzheimer's disease, major depressive disorder, and acute respiratory failure with hypoxia. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #15 was cognitively intact. The assessment documented Resident #15 was taking an anticoagulant. Review of current physician orders revealed an order dated 09/15/22 for aspirin chewable tablet 81 milligram (mg) with directions to give one tablet by mouth one time a day. 2. Review of the medical record revealed Resident #31 was admitted on [DATE]. Diagnoses included poly-osteoarthritis, unspecified dementia, unspecified osteoarthritis, essential hypertension, type two diabetes mellitus without complications, muscle weakness, fibromyalgia, unspecified dementia, hyperlipidemia, anxiety disorder, and depression. Review of the MDS assessment dated [DATE] revealed Resident #31 was severely cognitively impaired. The assessment documented Resident #31 was taking an anticoagulant. Review of physician orders dated 01/26/23 revealed an order for aspirin tablet delayed release 81 milligram (mg) with directions to give one tablet by mouth at bedtime. Review of physician orders from 01/25/23 to 01/18/24 revealed no medications classified as a anticoagulant were prescribed for Resident #31. Interview on 01/18/24 at 8:33 A.M. with MDS Coordinator #150 verified Resident #15 and #31's physician order for aspirin were miscoded as an anticoagulant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure medications stored in the medication room were not expired. This had the potential to affect all residents who resided in facility. The facility census was 43. Findings include: Observation on [DATE] at 11:09 A.M. of medication storage room revealed 17 bottles of Milk of Magnesia with expiration date of 09/2023, and two bottles of polyethylene glycol with expiration date of 06/2023 in a cupboard hanging on the wall. Observation on [DATE] at 11:15 A.M. and 11:38 A.M. of both medication carts revealed no outdated Milk of Magnesia or polyethylene glycol. Medication cart on the C hall had no Milk of Magnesia. Interview on [DATE] at 11:11 A.M. with Licensed Practical Nurse (LPN #167) verified 17 bottles of Milk of Magnesia were expired as of [DATE], and two bottles of polyethylene glycol were expired as of 06/2023. Interview on [DATE] at 11:57 A.M. with Registered Nurse (RN #166) verified if the cart did not have Milk of Magnesia they would get it from the medication storage room if available or call the pharmacy if none available in the medication storage room. Interview on [DATE] at approximately 3:45 P.M. with Director of Nursing (DON) verified that every resident had an order for bowel protocol which included if no bowel movement in three days administer Milk of Magnesia per order. Review of policy titled, Storage of Medications revised [DATE] revealed the facility shall not use outdated, discontinued, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to obtain a resident's blood glucose levels as ordered by a physician. This affected one (#18) of five residents reviewed for unnecessary medications. The facility identified four residents with orders for blood glucose monitoring. The census was 37. Findings include: Review of Resident #18's medical record revealed an admission date 03/17/20. Diagnoses included vascular dementia without behavioral disturbances, anxiety disorder, psychotic disorders, diabetes mellitus type I, cardiac arrhythmia, and essential hypertension. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had severely impaired cognitive skills for daily decision making and received insulin injections seven days during the seven day look back period. Review of a diabetic care plan date 03/17/20 revealed Resident #18 was at risk for hyper/hypoglycemic episodes episodes with and intervention dated 06/29/20 to monitor blood sugars and given insulin per sliding scale as ordered by the physician. Review of a physician order dated 01/10/21 revealed Resident #18 was ordered insulin lispro via sliding scale subcutaneously three times daily scheduled for 8:00 A.M., 12:00 P.M., and 5:00 P.M. Resident #18 sliding scale was ordered for blood glucose levels between zero and 200 milligrams per deciliter (mg/dL) administer four units of insulin; for blood glucose levels between 201 and 300 mg/dL given six units of insulin; and for blood glucose levels 301 and above given eight units of insulin and repeat blood glucose check in two hours and repeat sliding scale if the blood glucose level was above 200 mg/dL. Review of the January 2021 medication administration record (MAR) revealed on 01/16/21 at 12:00 P.M. Resident #18's blood glucose level was 346 mg/dL; on 01/21/21 at 12:00 P.M. Resident #18's blood glucose levels was 308 mg/dL; and on 01/22/21 at 12:00 P.M. Resident #18's blood glucose level was 343 mg/dL. There was no documentation on the MAR of Resident #18's blood glucose level being rechecked two hours after her blood glucose levels were 301 mg/dL or above. Review of the February 2021 MAR revealed on 02/01/21 at 12:00 P.M. Resident #18's blood glucose level was 322 mg/dL; on 02/03/21 at 12:00 P.M. Resident #18's blood glucose level was 339 mg/dL and on 02/13/21 at 12:00 P.M. Resident #18's blood glucose level was 346 mg/dL. There was no documentation on the MAR of Resident #18's blood glucose level being rechecked two hours after her blood glucose levels were 301 mg/dL or above. Review of Resident #18's nursing progress notes and blood glucose levels documented in the electronic health record under vital signs dated between 01/01/21 and 02/28/21 revealed no documentation of Resident #18's blood glucose levels being rechecked as ordered by the physician on 01/16/21, 01/21/21, 01/22/21, on 02/01/21, on 02/03/21, and on 02/13/21 after Resident #18's blood glucose levels were 301 mg/dL or above. Further review of the nursing progress notes revealed Resident #18 did not experience any changes in condition during this time frame and no additional medical interventions were implemented. Observation on 05/04/21 at 10:58 A.M., 1:23 P.M., and 4:17 P.M., and on 05/05/21 at 8:47 A.M., 11:40 A.M., and 2:03 P.M. revealed Resident #18 was free from any distress or discomfort. Resident #18 was not observed experiencing any outward signs or symptoms of hyperglycemia. Interview on 05/05/21 at 2:29 P.M. with Licensed Practical Nurse (LPN) #490 verified Resident #18's insulin lispro sliding scale order contained instructions if Resident #18's blood glucose level was 301 mg/dL or above the nurse was to recheck her blood glucose level two hours later and if the recheck blood glucose level was 200 mg/dL or above to restart the sliding scale. LPN #490 stated nurse usually documented the blood glucose levels on the MAR's but could also document them in a progress note or in the vital signs tab in the electronic health record. LPN #490 verified there was no documentation on the January or February 2021 MAR's or in nursing progress of Resident #18's blood glucose level being rechecked as ordered on 01/16/21, 01/21/21, 01/22/21, on 02/01/21, on 02/03/21, and on 02/13/21 after Resident #18's blood glucose levels were 301 mg/dL or above. Interview on 05/06/21 at 8:14 A.M. with Director of Nursing (DON) #1 verified there was no place for nurses to document on Resident #18's January and February 2021 MAR's when the blood glucose levels were to be rechecked if the level was 301 mg/dl or above. DON #1 verified there was no documentation for blood glucose level rechecks as ordered for Resident #1 on 01/16/21, 01/21/21, 01/22/21, on 02/01/21, on 02/03/21, and on 02/13/21. Review of an undated facility policy titled, Insulin Administration, revealed staff should check blood glucose per physician order or facility policy and document the resident's blood glucose result as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure fall interventions were in place as care planned and as ordered by a physician. This affected one (#234) of three residents reviewed for accidents. The facility identified four residents with orders for personal alarms. The census was 37. Findings include: Review of Resident #234's medical record revealed an admission date of 04/20/21. Diagnoses included unspecified severe protein malnutrition, chronic atrial fibrillation, chronic kidney disease, anxiety, and major depression. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #234 was cognitively impaired and required an extensive two-plus persons physical assistance for bed mobility and transfers. Review of an admission nursing assessment dated [DATE] revealed Resident #234 had an unsteady gait and poor balance and required staff assistance with bed mobility and transfers. Review of an admission fall risk assessment revealed Resident #234 was assessed at high risk for falls. Review of a fall risk care plan dated 04/30/21 revealed Resident #234 had a potential for falls related to a history of falling and a balance deficit. There was an intervention implemented on 05/04/21 for Resident #234 to have a clip alarm on when up in a chair. Review of a physician order dated 05/04/21 revealed Resident #234 was ordered a clip alarm when in a chair to alert staff of unassisted attempts to transfer. Observation on 05/04/21 at 2:43 P.M. revealed Resident #234 sitting in a wheelchair in the common area near the dining room on the Memory Lane hall. There was no clip alarm noted to Resident #234's body, clothing, or wheelchair. Further observation revealed two staff members sitting at a table in the common area within ten feet of Resident #234. Observation on 05/04/21 at approximately 2:55 P.M. revealed both staff members sitting at the table got up from the area and walked down the Memory Lane hall leaving Resident #234 unattended with no clip alarm on. There were no other staff members in the immediate area and Resident #234 was not visible to other staff members working further down the Memory Lane hall or on other halls of the facility. Observation on 05/04/21 at approximately 3:00 P.M. revealed a stated tested nurses aide (STNA) passing ice and water to residents on the Memory Lane further down the hallway away from Resident #234's location. From where the STNA was located in the hallway Resident #234 could not be seen. Interview on 05/04/21 at 3:02 P.M. with STNA #378 verified Resident #234 should have an alarm on when she was up in her wheelchair, and after walking down the hallway toward Resident #234's location, STNA #378 verified Resident #234 did not have an alarm on her body, clothing, or wheelchair. Review of an undated policy titled, Managing Falls and Fall Risk, revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The staff with input of the attending physician will identify appropriate interventions to reduce the risk of falls. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to administer insulin as ordered by a physician. This affected one (#18) of five residents reviewed for unnecessary medications. The facility identified four residents with orders for insulin. The census was 37. Findings include: Review of Resident #18's medical record revealed an admission date 03/17/20. Diagnoses included vascular dementia without behavioral disturbances, anxiety disorder, psychotic disorders, diabetes mellitus type I, cardiac arrhythmia, and essential hypertension. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had severely impaired cognitive skills for daily decision making and received insulin injections seven days during the seven day look back period. Review of a diabetic care plan date 03/17/20 revealed Resident #18 was at risk for hyper/hypoglycemic episodes episodes with and intervention dated 06/29/20 to monitor blood sugars and given insulin per sliding scale as ordered by the physician. Review of a physician order dated 01/10/21 revealed Resident #18 was ordered insulin lispro via sliding scale subcutaneously three times daily scheduled for 8:00 A.M., 12:00 P.M., and 5:00 P.M. Resident #18 sliding scale was ordered for blood glucose levels between zero and 200 milligrams per deciliter (mg/dL) administer four units of insulin; for blood glucose levels between 201 and 300 mg/dL given six units of insulin; and for blood glucose levels 301 and above given eight units of insulin and repeat blood glucose check in two hours and repeat sliding scale if the blood glucose level was above 200 mg/dL. Review of the January 2021 medication administration record (MAR) revealed on 01/11/21 at 12:00 P.M. Resident #18's blood glucose level was 395 mg/dL. Review of Resident #18's vital signs in the electronic health record (EHR) revealed Resident #18's blood glucose level was rechecked on 01/11/21 at 2:09 P.M. and was 315 mg/dL. There was no documentation on the MAR of Resident #18 receiving any additional insulin with a rechecked blood glucose level above 200 mg/dL per the physician order. Review of the February 2021 MAR revealed on 02/13/21 at 8:00 A.M. Resident #18's blood glucose level was 307 mg/dL. Review of Resident #18's vital signs in the EHR revealed Resident #18's blood glucose level was rechecked at 10:00 A.M. and was 316 mg/dL. There was no documentation of additional units of insulin given to Resident #18 at this time. Further review of the February 2021 MAR revealed Resident #18's blood glucose level on 02/14/21 at 12:00 P.M. was 357 mg/dL. Review of Resident #18's vital signs in the EHR revealed Resident #18's blood glucose level was recheck at 1:30 P.M. and was 237 mg/dL. There was no documentation of Resident #18 receiving any additional units of insulin at this time as ordered. Review of the March 2021 MAR revealed on 03/04/21 at 12:00 P.M. Resident #18's blood glucose level was 331 mg/dL. Review of Resident #18's vital signs in the EHR revealed Resident #18's blood glucose level was rechecked at 1:45 P.M. and was 239 mg/dL. There was no documentation of additional units of insulin given to Resident #18 at this time. Review of the nursing progress notes dated between 01/01/21 and 03/31/21 revealed no documentation of Resident #18 receiving any additional units of insulin on 01/11/21, 02/13/21, 02/14/21, or 03/04/21 after Resident #18's initial blood glucose levels were 301 mg/dL or above, and after it was rechecked as ordered, Resident #18's blood glucose level was above 200 mg/dL. Resident #18 experienced no acute changes in condition and required no additional medical interventions during this time frame. Observation on 05/04/21 at 10:58 A.M., 1:23 P.M., and 4:17 P.M., and on 05/05/21 at 8:47 A.M., 11:40 A.M., and 2:03 P.M. revealed Resident #18 was free from any distress or discomfort. Resident #18 was not observed experiencing any outward signs or symptoms of hyperglycemia. Interview on 05/05/21 at 2:29 P.M. with Licensed Practical Nurse (LPN) #490 verified Resident #18's insulin lispro sliding scale order contained instructions if Resident #18's blood glucose level was 301 mg/dL or above the nurse was to recheck her blood glucose level two hours later and if the recheck blood glucose level was 200 mg/dL or above to restart the sliding scale. LPN #490 stated nurse usually documented the blood glucose levels on the MAR's but could also document them in a progress note or in the vital signs tab in the electronic health record. LPN #490 verified there was no documentation on the January, February, or March 2021 MAR's or in nursing progress of Resident #18 receiving any additional insulin as ordered on 01/11/21, 02/13/21, 02/14/21, and 03/04/21 when her initial blood glucose levels were at or above 301 mg/dL and recheck blood glucose levels were above 200 mg/dL. Interview on 05/06/21 at 8:14 A.M. with Director of Nursing (DON) #1 verified there was no place for nurses to document on Resident #18's January, February, or March 2021 MAR's when the blood glucose levels were rechecked, and if the level was above 200 mg/dL, there was no place to document additional insulin doses given. DON #1 verified there was no documentation of additional insulin doses given per the physician ordered sliding scale when Resident #18's rechecked blood glucose levels were above 200 mg/dL on 01/11/21, 02/13/21, 02/14/21, and 03/04/21. Review of an undated facility policy titled, Insulin Administration, revealed the type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's orders. Staff should check blood glucose per physician order or facility policy and document the resident's blood glucose result as ordered and also document the dose of the insulin injection.

**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 monitor a residents laboratory levels per the physician orders. This affected one (#20) of five residents reviewed for unnecessary medications. The facility census was 37. Findings include: Review of the medical record for Resident #20 revealed she was admitted to the facility on [DATE] with diagnoses of psychosis, vascular dementia, hypothyroidism and osteoporosis. Review of Resident #20's current physician orders revealed Levothyroxine Sodium Tablet 100 micrograms (mcg) every morning for hypothyroidism ordered 02/09/21. Additionally, there was a physician order for laboratory testing for thyroid stimulating hormone (TSH) levels annually in April ordered 04/25/21. Further review of the medical record revealed the annual TSH levels ordered to be completed in April every year was not completed by the facility. Interview on 05/05/21 at 10:48 A.M. the Director of Nursing (DON) verified there was no TSH level completed as per the physician order for April, 2021. Review of the undated facility policy titled Medication Monitoring and Management revealed in order to optimize the therapeutic benefit of medication therapy and minimize or prevent adverse consequences the facility and the physician will perform ongoing monitoring for appropriate, effective and safe medication use.

Based on review of the facility trust account statement, review of the facility surety bond and staff interview and record review, the facility failed to have a surety bond sufficient in coverage to protect resident trust account balances. This had the potential to affect all residents, except Residents #1, #12, #25, #27, #134 and #236. The facility census was 37. Findings include: Review of the resident trust account balance statement, dated 04/30/21, revealed the total amount held in trust accounts by the facility totaled $58,744.61. Review of the facility's surety bond, effective 04/01/21, revealed the value of the bond to be $50,000.00. Interview on 05/05/21 at 3:30 P.M. of the Business Office Manager (BOM) #100 verified the facility's surety bond did not provide sufficient coverage for the total in resident trust accounts. She further stated residents received stimulus checks in April 2021, resulting in resident accounts exceeding the surety bond. BOM #100 confirmed 31 out of the 37 residents residing in the facility had personal funds accounts and that Residents #1, #12, #25, #27, #134 and #236 did not have a personal funds account with the facility.

Based on review of the Quality Assessment and Assurance meeting sign-in sheets and staff interview, the facility failed to ensure the medical director attended the Quality Assessment and Assurance meeting on a quarterly basis. This had the potential to effect all 44 residents residing in the facility. Findings include: Review of the Quality Assessment and Assurance meeting sign-in sheets for July, August, September, November, and December 2019 revealed no medical director signature. The October 2019 meeting was not held due to Administrator illness. Interview on 09/05/19 at 11:00 A.M., the Administrator verified the Medical Director had not attended the required quarterly meetings.

Based on review of a facility policy and staff interview, the facility failed to implement a risk assessment and water management program for the prevention and spread of Legionella. This had the potential to affect all residents. The facility census was 44. Findings include: Review of the facility policy titled Water Management Program, dated 11/17, revealed the facility water management program will include, at a minimum, an initial evaluation of the building water system, and based on that analysis, will complete a water system infection control risk assessment. The program may include disinfectant level controls and specify testing protocols and acceptable ranges for control measures. The facility failed to provide evidence of a risk assessment or water management program. Interview on 09/05/19 at 11:00 A.M. with the Administrator revealed the facility did not have a water management program in place to monitor for Legionella. He further verified the facility did not have a risk assessment completed. He verified the facility did not have a flow sheet to identify potential areas of concern and the facility and was not completing any water testing protocols.