**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure resident Preadmission Screening and Resident Reviews (PASARRs) were accurate and included resident's mental health diagnoses and mental health services. This affected two (#05 and #14) of the three residents reviewed for PASARRs. The facility census was 71 residents. Findings include: 1) Review of the medical record for Resident #05 revealed an admission date of 02/21/23 with diagnoses including dementia, psychosis, mood disorder. Review of the current diagnoses revealed a new diagnosis of anxiety added on 07/26/24. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #05 had severely impaired cognition. Review of the completed PASARR documents revealed the facility did not complete a new PASARR designation following the addition of the anxiety diagnosis on 07/26/24. 2) Review of the medical record for Resident #14 revealed an admission date of 10/03/23 with diagnoses including acute and chronic respiratory failure, chronic obstructive pulmonary disease, diabetes mellitus type II, congestive heart failure, acute kidney failure, hypertension, hypothyroidism, depression, diverticulosis, anemia, cerebrovascular disease, neuromuscular dysfunction of the bladder, insomnia, anxiety, unspecified psychosis, bipolar disorder, and adult failure to thrive. Review of the current diagnoses revealed a new diagnosis of unspecified psychosis not due to a substance or known physiological condition was added on 03/21/25. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had severely impaired cognition. Review of the completed PASARR documents revealed the facility did not complete a new PASSAR designation following the addition of the unspecified psychosis diagnosis on 03/21/25. Interview with Social Services Director (SSD) #14 on 05/08/25 at 09:47 A.M., verified a new PASARR should have been completed for Resident #05 following a new diagnosis of anxiety on 07/26/24. SSD #14 also verified a new PASARR should have been completed for Resident #14 following a new diagnosis of unspecified psychosis on 03/21/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, observations, and staff interviews, the facility failed to ensure the medication error rate was less than five percent, as evidenced by three medication errors out of 31 opportunities observed, resulting in 9.68 percent (%) medication error rate. This affected two (#17 and #60) of the four residents observed for medication administration. The facility census was 71. Findings include: 1) Record review for Resident #17 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included hypertension, bipolar disorder, and insomnia. Review of the physician order for Resident #17 dated 03/07/25, revealed an order for Amlodipine Besylate 10 milligrams (mg) to be administered one time a day for hypertension and to hold the medication for a systolic blood pressure (SBP) below 120 millimeters of mercury (mm/Hg) or a diastolic blood pressure (DBP) below 80 mm/Hg. Review of the physician order for Resident #17 dated 03/10/25, revealed an order for Hydralazine 25 mg to be administered twice a day for hypertension and administer the medication if the resident's SBP is over 160 mm/Hg and/or DBP over 120 mm/Hg. Observation of the medication administration on 05/06/25 at 8:28 A.M., with Licensed Practical Nurse (LPN) #517 revealed medications including Amlodipine Besylate 10 mg and Hydralazine 25 mg were prepared for administration to Resident #17. LPN #517 entered the room of Resident #17 with the prepared medications and obtained the residents Blood Pressure (BP) with results of SBP 155 mg/Hg and DBP 74 mm/Hg. LPN #517 administered all ordered medications, including the Amlodipine Besylate and Hydralazine, to the resident and exited the room. Interview with LPN #517 at the same time, verified the medications were administered to Resident #17. Interview on 05/07/25 at 10:05 A.M., with the Director of Nursing (DON) verified Resident #17 should not have been administered Amlodipine Besylate or Hydralazine by LPN #517 on 05/06/25 at 8:20 A.M. due to the residents BP reading being outside the parameters for administration. 2) Record review for Resident #60 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included paroxysmal atrial fibrillation, hypertension, and presence of a cardiac pacemaker. Review of the physician order dated 03/06/25 revealed an order for Digoxin 125 micrograms (mcg) to be administered once a day for the Heart. Observation of the medication administration on 05/06/25 at 8:20 A.M., with LPN #517 revealed medications including Digoxin 125 mcg were prepared for administration to Resident #60. LPN #517 entered the room of Resident #60 with the prepared medications and obtained the residents pulse using a pulse oximeter placed on the residents left first finger. The pulse oximeter was in place for less than 30 seconds with a result of 77 heart beats per minute. LPN #517 administered all ordered medications, including the Digoxin, to the resident and exited the room. Interview with LPN #517 at the same time, verified the medication was administered to Resident #17. Interview on 05/07/25 at 10:05 A.M., with the DON verified the facility nurses should obtain a resident's apical pulse (the pulse rate located at the apex of the heart on the left side of the chest) for one full minute prior to the administration of Digoxin. Review of the facility policy titled Administering Medications, revised 04/2019, revealed medications are administered in a safe and timely manner, and as prescribed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, observations, staff interview, and review of facility policy, the facility failed to ensure medications were administered per physician's order resulting in significant medication errors. This affected two (#17 and #60) of the four residents observed for medication administration. The facility census was 71. Findings include: 1) Record review for Resident #17 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included hypertension, bipolar disorder, and insomnia. Review of the physician order for Resident #17 dated 03/07/25, revealed an order for Amlodipine Besylate 10 milligrams (mg) to be administered one time a day for hypertension and to hold the medication for a systolic blood pressure (SBP) below 120 millimeters of mercury (mm/Hg) or a diastolic blood pressure (DBP) below 80 mm/Hg. Review of the physician order for Resident #17 dated 03/10/25, revealed an order for Hydralazine 25 mg to be administered twice a day for hypertension and administer the medication if the resident's SBP is over 160 mm/Hg and/or DBP over 120 mm/Hg. Observation of the medication administration on 05/06/25 at 8:28 A.M., with Licensed Practical Nurse (LPN) #517 revealed medications including Amlodipine Besylate 10 mg and Hydralazine 25 mg were prepared for administration to Resident #17. LPN #517 entered the room of Resident #17 with the prepared medications and obtained the residents Blood Pressure (BP) with results of SBP 155 mg/Hg and DBP 74 mm/Hg. LPN #517 administered all ordered medications, including the Amlodipine Besylate and Hydralazine, to the resident and exited the room. Interview with LPN #517 at the same time, verified the medications were administered to Resident #17. Interview on 05/07/25 at 10:05 A.M., with the Director of Nursing (DON) verified Resident #17 should not have been administered Amlodipine Besylate or Hydralazine by LPN #517 on 05/06/25 at 8:20 A.M. due to the residents BP reading being outside the parameters for administration. 2) Record review for Resident #60 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included paroxysmal atrial fibrillation, hypertension, and presence of a cardiac pacemaker. Review of the physician order for Resident #60 dated 03/06/25 revealed an order for Digoxin 125 micrograms (mcg) to be administered once a day for the Heart. Observation of the medication administration on 05/06/25 at 8:20 A.M., with LPN #517 revealed medications including Digoxin 125 mcg were prepared for administration to Resident #60. LPN #517 entered the room of Resident #60 with the prepared medications and obtained the residents pulse using a pulse oximeter placed on the residents left first finger. The pulse oximeter was in place for less than 30 seconds with a result of 77 heart beats per minute. LPN #517 administered all ordered medications, including the Digoxin, to the resident and exited the room. Interview with LPN #517 at the same time, verified the medication was administered to Resident #17. Interview on 05/07/25 at 10:05 A.M., with the DON verified the facility nurses should obtain a resident's apical pulse (the pulse rate located at the apex of the heart on the left side of the chest) for one full minute prior to the administration of Digoxin. Review of the facility policy titled Administering Medications, revised 04/2019, revealed medications are administered in a safe and timely manner, and as prescribed.

Based on observations, staff interview and policy review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This affected all but two (#18 and #70) residents who received food from the kitchen. The census was 78. Findings include: Observation of the kitchen with Dietary Manager #90 on 11/15/23 at 10:50 A.M. revealed a scoop that was stored inside a bulk container of flour. The large can opener had a heavy build-up of substance on the blade and on the metal holder attached to the worktable. Interview with Dietary Manager #90 at the same time, verified the findings. Interview with the Director of Nursing (DON) on 11/15/23 at 3:15 P.M. identified two (#18 and #70) residents who received all their nutritional needs via tube feeding and consumed no food prepared in the kitchen. Review of the facility policy titled Food Storage dated 2017, revealed scoops were provided for bulk foods such as flour. The scoops were not stored in food but were kept covered in a protected area near the container. Under Hazard Analysis Critical Control Point (HACCP) Principles the policy stated to use clean and sanitized equipment. This deficiency represents non-compliance investigated under Master Complaint Number OH00147894 and Complaint Number OH00147633.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide baths/showers to dependent residents as scheduled. This affected two (#61 and #63) of three residents reviewed for bathing/showering. The census was 69. Findings include: 1. Review of the medical record for Resident #61 revealed an admission date of 02/20/12. His diagnoses were cerebral infarction, bipolar disorder, dementia, hemiplegia and hemiparesis, hyperlipidemia, personality disorder, psychosis, type II diabetes, obesity, cerebral atherosclerosis, mild cognitive impairment, peripheral vascular disease, anxiety disorder, insomnia, and atherosclerotic heart disease. Review of Resident #61's minimum data set (MDS) assessment, dated 02/24/23, revealed he had a mild cognitive impairment. Review of Resident #61 MDS Assessment, section G, revealed he needed a total of one-person physical assistance for bathing. Review of Resident #61's bathing schedule revealed prior to 04/11/23, his scheduled shower/bath days were Sunday and Wednesday evenings. On 04/11/23 to present, his shower/bath days were Tuesday and Saturday evenings. Review of Resident #61's bathing logs, dated 03/01/23 to 05/26/23, revealed a total of 14 missed scheduled showers/baths. 2. Review of the medical record for Resident #63 revealed an admission date of 07/01/11. Her diagnoses were osteoarthritis, dementia, major depressive disorder, osteoporosis, hypertension, macular degeneration, cardiomegaly, and arthropathy. Review of Resident #61's MDS assessment dated [DATE], revealed she had a significant cognitive impairment. Review of section G revealed she needed physical assistance from one person for bathing. Review of Resident #63's bathing schedule revealed her shower/bath days were Wednesdays and Saturdays. Review of Resident #63's bathing logs, dated 03/01/23 to 05/26/23, revealed a total of 10 missed scheduled showers/baths. Interview with State Tested Nursing Aide (STNA) #104, STNA #105, Registered Nurse (RN) #107, and Licensed Practical Nurse (LPN) #108 on 05/26/23 at 2:30 P.M., 2:46 P.M., 2:55 P.M., and 3:03 P.M., revealed if not applicable is selected as the choice for showers in the electronic medical record, they confirmed it means the resident did not receive a bath/shower that day. They confirmed if the resident refuses a bath/shower, there is an option for that and that would be selected. They are to give each resident a bath/shower on their scheduled days, and when the resident requests them. If there was no documentation to support a bath/shower was taken, they confirmed that it was not offered or completed. Interview with Unit Manager #101 on 05/26/23 at 1:54 P.M., confirmed the shower/bath logs and documentation provided, was all they could find for each of the residents. She confirmed there was no other shower documentation available to support the fact that showers were being completed for both residents as scheduled. This deficiency represents the noncompliance discovered during investigation of Complaint Number OH00142697.

Based on observation and interview, the facility failed to maintain the kitchen walk-in freezer in operational fashion which caused an excessive build up of ice and solid ice crystals on the inside of the freezer. This had the potential to affect all residents in the facility with the exception of one(Resident #76) who did not receive food from the kitchen. The facility census was 81. Findings include: Observation of the kitchen walk in freezer on 12/12/22 at 09:13 A.M. revealed an excessive build up of ice and solid ice crystals on the inside of the door and shelving to the left. Three shelves contained multiple food items from the bottom to the top shelf which were also covered with ice. A solid ice block was also stuck to the closure side of the freezer and the door itself. Dietary [NAME] #1000 verified the buildup of ice on the inside of the freezer, and stated this has been this way for several months. Observation of the kitchen walk in freezer on 12/13/22 at 1:06 P.M. revealed the buildup of ice and ice crystals remain to the inside of the walk in freezer which still covers multiple food items. Interview with the Administrator and Dietary Manager #2000 on 12/13/22 at 1:06 P.M. verified there is an excessive amount of ice and ice crystals on the inside of the walk in freezer. Observation of the kitchen walk in freezer on 12/14/22 at 2:07 P.M. revealed the excessive amount of ice remains and still covers multiple food items. Ice remains on the inside of the door and the left side of the freezer. Interview with the Administrator and the Regional Quality Assurance Consultant #3000 on 12/14/22 at 2:07 P.M. verified the presence of a large amount of ice and ice crystals on the inside of the freezer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to respect the rights of two residents (#47 and #178) of two observed wearing smoking aprons when they were not needed. The facility census was 81. Findings include: 1. Review of Resident #47's medical record revealed an admission date of 7/18/18 with diagnoses including type two diabetes mellitus, congestive heart failure, left above the knee amputation, and major depressive disorder. Review of Resident #47's care plan dated 07/19/19 revealed the resident had a history of smoking and desired to smoke. Interventions included to smoke safely in designated areas, offer smoking cessation options, staff to provide smoking materials and light cigarettes and not to leave resident unattended when smoking. Review of Resident #47's smoking assessment dated [DATE] revealed interventions included allowing the resident to smoke independently in designated areas, and the resident did not require a smoking apron or vest. Review of Resident #47's Minimum Data Set (MDS) dated [DATE] revealed resident was cognitively intact. Observation of residents smoking on 09/23/19 at 10:03 A.M. revealed State Tested Nurse Aide (STNA) #520 placed a smoking apron on Resident #47. Interview with Resident # 47 on 09/24/19 at 8:51 A.M. revealed the facility had never put smoking aprons on the residents in the past and wearing a smoking apron made him feel uncomfortable and embarrassed. 2. Review of Resident #178's medical record revealed an admission date of 09/21/19 with diagnoses including cerebral infarction (stroke) and anxiety disorder. Review of Resident #178's care plan dated 9/22/19 revealed the resident had a history of smoking and desired to smoke with interventions to smoke safely in designated areas, offer smoking cessation options, staff to provide smoking materials, light cigarettes and not to leave resident unattended when smoking. Review of Resident #178 smoking assessment dated [DATE] revealed revealed interventions included allowing resident to smoke independently in designated areas and the resident was not required to wear a smoking apron or vest. Observation on 09/23/19 at 10:03 A.M. revealed STNA #520 placed a smoking apron on Resident #178. Interview with STNA #520 on 09/23/19 at 3:16 P.M. revealed only one resident was deemed as needing a smoking apron on the smoking assessment, however she just puts them on the residents to be sure. STNA #520 confirmed Resident #47 and Resident #178 had a smoking apron on at the 10:03 A.M. smoke break. Interview with Resident #178 on 09/26/19 at 10:27 A.M. revealed he did not like wearing a smoking apron when he smoked and did not understand why he had to wear one. Review of the facility policy untitled dated 08/11/06 revealed the interdisciplinary team (IDT) will evaluate and make a decision if a resident is independent or an at risk smoker and if a patient is deemed at risk, the resident will be required to wear a smoking vest or apron.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, staff interview, and facilities policy review, the facility failed to ensure two staff members were present with the use of a mechanical lift during transfers for safety. This affected one resident (#8) of six reveiwed for accidents. The facility census was 81 . Findings include: Review of the medical record for Resident #8 revealed an admission date of 03/07/19 with diagnoses including morbid obesity, diabetes mellitus, depression, and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had no cognitive deficits and required a total assistance of two people for transfers. Review of the care plan revealed Resident #8 required assistance with transferring as evidence by weakness related to spinal stenosis and diabetes mellitus with neuropathy. Intervention included to utilize mechanical lift with large sling for transfers. Observation and interview on 09/24/19 at 10:00 A.M. revealed State Tested Nursing Assistant (STNA) #611 was getting Resident #8 up for the day and she was the only staff member in the room. STNA #611 confirmed she did lift the resident with mechanical lift by herself. She revealed the resident was a a total assist for transfers with mechanical lift and one person could lift him with the lift. Interview on 09/25/19 at 1:36 P.M. with the Director of Nursing (DON) revealed it was her expectation staff always used two staff members when using a mechanical lift for safety. Review of facilities Mechanical Lift Policy dated April 2019 revealed the purpose was to move immobile or obese residents for whom manual transfer poses potential for staff or resident injury. Use of a mechanical lift requires a second caregiver.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #63's medical record revealed an admission date of 02/29/16 with diagnoses including chronic kidney disease stage three, dementia, unspecified psychosis, and altered mental status. Review of Resident #63's physician order dated 03/13/19 revealed an order for Sertraline (anti-depressant) 50 mg for the treatment of dementia with behavior disturbance. Review of Resident #63's Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively impaired. Interview with the Director of Nursing (DON) and the Social Services Director on 09/26/19 at 11:04 A.M. confirmed Resident #62 was on Sertraline for behavioral disturbances due to dementia. The DON further revealed the resident had not had any behaviors for the last 18 months. Based on medical record review and staff interview, the facility failed to initiate a gradual dose reduction (GDR) attempt on residents taking psychotropic medications and also failed to provide proper diagnoses for residents taking antidepressant medications. This affected three residents (#43, #6 and #63) of five reviewed for unnecessary medications. The facility census was 81. Findings include: 1. Review of Resident #43's medical record revealed an admission date of 02/09/19 with diagnoses including type two diabetes mellitus, anxiety, congestive heart failure (CHF), and depression. Review of Resident #43's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43's cognition was intact. Review of Resident #43's current medications revealed Buspirone (anti-depressant) 10 milligrams (mg), one tablet by mouth two times per day related to depression and Duloxetine Capsule 30 mg, take one capsule by mouth one time in the afternoon related to depression, and Trazodone tablet 50 mg take one tablet by mouth at bedtime for insomnia. Review of Resident #43's monthly pharmacy reviews revealed no irregularities were noted from February 2019 through September 2019. There was no evidence an attempts for a GDR was made with any of the resident's psychotropic medications. Interview on 09/26/19 at 2:32 P.M. with the Director of Nursing (DON) verified the facility had not attempted a GDR for Resident #43. 2. Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses, congestive heart failure, chronic kidney disease, diabetes mellitus type II, depression, and anxiety. Review of the most recent MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of Resident #6's current medications revealed Duloxetine 60 mg, one capsule daily for depression and Aripiprazole 2 mg, one tablet for depression Review of Resident #6's monthly pharmacy review with the last date of 09/18/19 revealed the resident had been taking the Duloxetine and Aripiprazole for a diagnosis of depression since the resident's admission date of August 2018. There was no evidence a GDR had been attempted. On 09/25/19 at 1:51 P.M., interview with the Director of Nursing (DON) verified a GDR had not been recommended by the pharmacy, and none have been attempted.