**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy, the facility failed to ensure treatments were implemented timely for pressure ulcers. This affected one (#46) of three residents reviewed for pressure ulcers. The facility census was 49. Findings include: Review of the medical record revealed Resident #46 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to thrombosis of left middle cerebral artery, hemiplegia right dominant side, spinal stenosis, major depressive disorder recurrent, pressure ulcer of the right heel, gastrostomy status, acute cystitis without hematuria, hyperlipidemia, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired, dependent for all care, and had a stage three pressure ulcer. Review of the admission nursing assessment dated [DATE] revealed Resident #46 readmitted to the facility after a hospital discharge. Review of the skin integrity documented a new unstageable right heel pressure ulcer that measured 3.1 centimeters (cm) in length by 2 cm in width. Review of nursing progress note dated 07/21/24 revealed Resident #46 had an area to the outer right heel 3.0 cm oval shaped black hard area noted with the area around the area blanchable. Blue boots bilateral were on. Review of nursing progress notes dated 07/23/24 revealed Resident #46's outer right heel was assessed. The area was discolored, soft measures 4 cm by 3 cm. Offloading boots and air mattress present on admission when wound noted. The nurse practitioner was aware, skin prep daily, and continue offloading boots. Review of the wound nurse practitioner consultation dated 07/30/24 revealed a new suspected deep tissue injury on the right lateral heel. Measurements were documented as 3 cm in length by 4 cm in width with new treatment orders. Review of the medical record revealed no previous orders provided treatment to the right heel. Interview on 10/17/24 at 8:24 A.M. with Unit Manager Licensed Practical Nurse (LPN) #204 verified Resident #46 had a suspected deep tissue injury upon readmission from the hospital on [DATE] and no treatment orders were in place until 07/30/24. Review of the undated policy Pressure Ulcer Risk Assessment and Management verified residents with pressure areas will receive treatment and services to promote healing. Treatment orders will be obtained by the floor nurse utilizing the wound care protocols established by the quality assurance committee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, and facility policy, the facility failed to ensure communication with dialysis treatment center and and failed to provide ongoing monitoring/assessment of the dialysis access site. This affected one (#150) of one resident reviewed for dialysis. The census was 49. Findings include: Review of the medical record revealed Resident #150 was admitted on [DATE]. Diagnoses included abscess of liver, acute kidney failure, cognitive communication deficit, chronic kidney disease stage 3, vascular dementia, major depressive disorder, type two diabetes mellitus with hyperglycemia, and hyperlipidemia. Review of physician orders dated 10/07/24 revealed Resident #150 received outpatient dialysis on Monday, Wednesday, and Fridays. Review of the most recent care plan dated 10/16/24 revealed Resident #150 was care planned for dialysis with interventions. None of the interventions included monitoring of the dialysis access site. Interview on 10/16/24 at 11:12 A.M. with Resident #150 revealed no paper work has been provided to bring to dialysis. Interview on 10/16/24 at 12:49 P.M. with Licensed Practical Nurse (LPN) #264 verified no communication is sent to the dialysis center for Resident #150. Interview on 10/16/24 at approximately 3:00 P.M. with the Director of Nursing (DON) verified there was no physician order for monitoring Resident #150's dialysis access site. Review of the undated policy, Dialysis, verified the facility will complete ongoing assessment and oversight of the resident before and after dialysis treatments, including monitoring for complications, implementing appropriate interventions, and using appropriate infection control practices. In addition, the facility will provide ongoing communication and collaboration with the dialysis facility regarding dialysis care and service as outlined in the agreement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, resident interview, and policy review, the facility failed to ensure residents who were dependent on staff for activities of daily living were provided with nail care. This affected three (#4, 19 and #26) of three residents reviewed for assistance with activities of daily living. The facility census was 44. Findings include: 1. Review of Resident #4's medical record revealed an admission date of 03/03/22, with diagnosis including dementia with mood disturbance, cerebral infarction, psychosis, and macular degeneration. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a cognitive deficit and required extensive assistance for personal hygiene. Review of Resident #4's most recent care plan revealed the resident had an activity of daily living (ADL) self-care performance deficit related to decreased strength and endurance, impaired cognition related to dementia. Interventions were to provide limited to extensive assistance with personal hygiene. Review of Resident #4's medical record revealed he was to receive a shower/bath every Wednesday and Saturday. Observation of Resident #4 on 09/18/23 at 10:02 A.M., revealed the resident's fingernails were long and unkept. Observation of Resident #4 was observed eating breakfast on 09/21/23 at 7:55 A.M., and his fingernails remained long and failed to be cut on his shower day. 2. Review of Resident #19's medical record revealed an admission date of 09/02/19, with diagnosis including dementia with psychotic disturbance, hemiplegia and hemiparesis following a cerebral vascular accident, glaucoma, and congestive heart failure. Review of Resident #19's quarterly MDS assessment dated [DATE] revealed had a low cognitive function and required extensive assistance for personal hygiene. Review of Resident #19's more recent care plan revealed he had an ADL self-care deficit related to hemiplegia affecting the left non-dominant side and cognitive deficit. Interventions included providing extensive assistance with personal hygiene. Observation on 09/18/23 at 10:22 A.M., revealed Resident #19 was sitting in his wheelchair in a common area with his blanket over his head. He was not able to be interviewed due to low cognitive function. His fingernails were noted to be long and unkept. Two nails were seen to be jagged. Observation on 09/21/23 at 8:23 A.M., revealed the resident was in the dining room eating breakfast. The resident's fingernails continued to be long and unkept. 3. Review of Resident #26's medical record revealed an admission date of 02/16/23, with diagnosis including dementia, Alzheimer's, ischemic cardiomyopathy, diabetes mellitus, acute renal failure, and congestive heart failure. Review of Resident #26's quarterly MDS assessment dated [DATE] revealed the resident had a low cognitive function. He required personal assistance from two staff for dressing and personal hygiene. Review of Resident #26's shower and bath schedule revealed he was to receive a shower every Monday and Thursday. Review of Resident #26's most recent care plan revealed he had an ADL self-care performance deficit related to hemiplegia following an old cerebral vascular accident., neuropathy, dementia, weakness, arthritis, anxiety, tremor, health/functional decline. Resident #26 was noted to have bilateral lower extremity contracture's and required an extensive need of one to two staff for personal hygiene. Review of Resident #26's medical record revealed he was to have a bath/shower every Monday and Thursday. Observations on 09/18/23 at 1:08 P.M. revealed Resident #26 was lying in bed. His fingernails were noted to be long and unkept. Further observation of Resident #26 on 09/20/23 at 11:01 A.M., revealed the resident's fingernails continued to be long and jagged. Interview with Resident #26 on 09/18/23 at 9:52 A.M., revealed he would like to have his nails trimmed. Interview with Licensed Practical Nurse (LPN) #305, on 09/20/23 at 1:12 P.M., revealed nails were to be trimmed and filed/checked at each shower twice weekly. If a resident refused nail care, it should be reported to the nurse and the nurse would then attempt. If the resident refused care, it would be documented in the medical record. The nurses were also responsible for diabetic resident's nail care. Interview with State Tested Nursing Aide (STNA) #306, on 09/20/23 at 1:12 P.M., revealed all residents nails were to be trimmed/checked after every shower which would be twice weekly. Interview with LPN #305, on 09/21/23 at 7:59 A.M., verified Residents #4, #19, and #26's nails were long and in need of trimming and nail care should have been completed on their shower day. Review of the policy titled Activities of Daily Living dated September 2018 revealed the facility will provide care and services for the following activities of daily living: hygiene which included bathing, dressing, grooming, oral care, and nail care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and review of the facility's Hospice Agreement, the facility failed to ensure coordination of care between the facility and Hospice provider. This affected one (#43) of one resident reviewed for Hospice care. The facility identified one resident in the facility was under Hospice care. The facility census was 44. Findings include: Review of the medical record for Resident #43 revealed an admission date of 01/04/23, with diagnoses of dementia, hemiplegia, and hemiparesis. Review of the modified quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #43 had impaired cognition and required extensive assistance of two people for bed mobility, dressing, was totally dependent on two people for transfers, and required extensive assistance of one person for eating. Review of a physician order dated 05/26/23 revealed Resident #43 was admitted to hospice. Review of the facility's current care plan for Resident #43 revealed she received Hospice services. Interventions included Hospice aide to provide care and Hospice Registered Nurse to provide care. The care plan provided no guidance regarding the tasks to be completed by Hospice and the tasks to be completed by the facility when providing care to Resident #43. Interview on 09/19/23 at 4:47 P.M., with Unit Manger (UM) #309 revealed a Hospice care plan was not in Resident #43's medical record. Further interview confirmed a Hospice care plan should be in the paper chart for each resident under Hospice care. Interview on 09/21/23 at 12:21 P.M., with UM #309 revealed she called Hospice and a care plan for Resident #43 was faxed to the facility on [DATE]. UM #309 confirmed the care plan began 05/26/23. UM #309 further confirmed the facility's Hospice care plan for Resident #43 provided no guidance regarding the coordination of care between the facility and the Hospice staff. Review of the facility's Hospice agreement, initiated 10/20/14, revealed responsibilities of the facility included coordinating with Hospice in developing a plan of care for each Hospice patient.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, Certified Nurse Practitioner interview, and review of the policy, the facility failed to ensure behavior interventions of non pharmacological interventions were implemented prior to increasing antipsychotic medication doses. This affected one (#18) of five residents reviewed for psychotropic medications. The facility census was 44. Findings include: Review of the medical record for Resident #18 revealed an admission date of 05/03/19, with diagnoses of schizoaffective disorder and traumatic brain injury. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition and required supervision with one person assistance for transfers and locomotion. Further review revealed no physical or verbal behaviors towards others or not toward others, no rejection of care. Review of the behavior care plan initiated 05/19/18 revealed Resident #18 had a traumatic brain injury, schizoaffective disorder, impaired decision making, and short term memory loss, and may exhibit episodes of being short tempered, cursing, or giving gestures. Resident #18 had a tendency to overreact to situations and could become agitated and aggressive and not easily redirected by staff. Resident #18 needed supervision with group activity and meals when other residents were around. Interventions included an update 09/12/23 for Resident #18 to avoid group settings. Meals to be provided in room instead of dining room. Resident to not attend group activities with other residents in the facility. Review of a discontinued physician order for Resident #18 revealed an order dated 02/24/22 through 07/25/23 for Risperdal (an antipsychotic medication) 0.5 milligrams (mg) by mouth twice daily. Review of a nursing progress note dated 06/25/23 revealed Resident #18 was in the dining room for the evening meal at a table with another resident (Resident #38) who accidentally spilled his water on the table. The water spilled onto Resident #18 who became upset and threw his own water cup, with water in it, at Resident #38. Resident #18 was sent to the emergency room on [DATE] and returned to the facility the same day with no new orders. The facility initiated a self-reported incident with the State of Ohio on 06/25/23. Review of a nursing progress note dated 07/24/23 revealed Resident #18 was agitated when another resident called him junior. Review of a nursing progress note dated 07/25/23 revealed the behavioral and mental health Nurse Practitioner (NP) (Certified Nurse Practitioner #308) was aware of Resident #18's increased agitation and outbursts. The NP ordered an increase in the Risperdal to 1.0 mg twice daily. Review of the current physician order dated 07/25/23 revealed Resident #18 received Risperdal 1.0 mg by mouth twice daily. Interview on 09/18/23 at 4:36 P.M., with Resident #18 revealed he was not allowed to participate in activities such as bingo and wished he could eat in the dining room. Resident #18 stated he had not recently asked to eat in the dining room or participate in activities. Interview on 09/18/23 at approximately 5:10 P.M., with the Administrator and Director of Nursing (DON) revealed Resident #18 demonstrated behaviors that were disruptive to other residents and therefore was permitted to attend only supervised activities such as bingo. Resident #18 would not be permitted to attend unsupervised activities such as watching a movie. Further interview revealed Resident #18 was offered a choice between eating in his room or eating in the dining room at his own table, and Resident #18 chose to eat in his room. Interview on 09/19/23 at approximately 10:00 A.M., with Unit Manager #309 confirmed behavioral health had not seen Resident #18 since 06/28/23 because the Nurse Practitioner rounded on Monday when Resident #18 was at day-work. Interview on 09/20/23 at 10:09 A.M., with the DON revealed Resident #18 had an outburst in June 2023 and remained angry after that, so the facility began at that time to separate Resident #18 from other residents to keep from triggering his behaviors. The DON stated Resident #18 was disruptive to other residents and used foul language in the facility. The DON stated Resident #18's guardian regularly visited and provided diet Pepsi, but when Resident #18 used foul language and was disruptive, Resident #18's guardian withheld the visits and diet Pepsi. The DON stated Resident #18 would fixate on his desire for diet Pepsi, and when the facility offered an off-brand of soda to Resident #18, he refused because he preferred only diet Pepsi. Further interview revealed staff would occasionally purchase a diet Pepsi with their own money to calm Resident #18 down. However, the DON stated Resident #18 would continue to request more diet Pepsi and was not calmed with only one. The facility did not purchase diet Pepsi for Resident #18. The DON, verified there was no other interventions attempted. Continued interview at that time, with the DON revealed the facility did not speak with Resident #18's guardian to advise her of Resident #18's increased behaviors due to the lack of visits and diet Pepsi. Interview on 09/20/23 at 4:09 P.M., with the Administrator revealed Resident #18 was unable to de-escalate himself once he became upset. The Administrator stated Resident #18 was upset since the interaction in June when Resident #38 accidentally spilled water on Resident #18. Further interview revealed Resident #18's guardian, shortly after that time, began withholding visits, snacks and drinks from Resident #18 which increased his behaviors. The Administrator stated the facility did not consider purchasing Resident #18 diet Pepsi. Telephone interview on 09/21/23 at 12:25 P.M., with Certified Nurse Practitioner (CNP) #308 for the behavioral and mental health company, who provided services to Resident #18 revealed she recalled the conversation from July 2023 regarding the increase in Risperdal for Resident #18. CNP #308 stated she only met Resident #18 once, but as yet had not conducted a face-to-face session with him since she began with the facility in July 2023. CNP #308 stated when she visited in the facility in July and August 2023, Resident #18 was out of the facility at a day-work. CNP #308 recalled the conversation from July 2023 wherein the facility advised her Resident #18 was having behaviors and threw a cup at another resident. Further interview revealed she was aware Resident #18's guardian was not visiting or providing snacks, and was also aware Resident #18 was restricted from activities and the dining room. CNP #308 stated diet Pepsi was not mentioned specifically. CNP #308 restated she was new to the facility in July 2023 and had not had a session with Resident #18 at that time and relied on the facility's perspective at that point. Further interview revealed CNP #308 and the facility staff did not discuss alternative behavioral interventions before doubling the Risperdal dose on 07/25/23. Telephone interview on 09/21/23 at 1:58 P.M., with Resident #18's Case Manager #312 revealed Resident #18 had no negative behaviors or outbursts at workshop. Resident #18 attended workshop three days per week. The facility had given the Resident #18 a 30 day notice to discharge and his guardian was upset as to where Resident #18 would go because she was unable to care for him at home. Case Manager #312 stated Resident #18's guardian, as a result of the 30-day notice, told Resident #18 he had to behave and stopped buying his diet Pepsi. Case Manager #312 stated she arranged for Resident #18 to attend many shows and outings paid for by his guardian. Resident #18 never had any issues with behaviors at these outings. Review of the policy Psychotropic Medications, revised 09/14/23, revealed it is the intent of the policy that a resident's mood, mental status, or behavior may be appropriately managed without antipsychotic drugs through the use of non-drug interventions to manage resident behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the menu spreadsheet, review of recipe, review of resident diet list, the facility failed to ensure pureed protein was prepared following the recipe to ensure adequate protein was provided. This affected one (#19) of one resident identified on a pureed diet. Additionally, the facility failed to ensure appropriate scoop sizes were used to serve protein portions to Resident #19 on a pureed diet, and to 11 (#2, #4, #9, #17, #23, #24, #26, #35, #36, #38, and #40) residents identified on a mechanical soft diet. The facility census was 44. Findings include: 1. Review of Resident #19's medical record revealed an admission date of 09/02/19. Diagnoses included dementia with psychotic disturbance and hemiplegia and hemiparesis following a cerebral vascular accident. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had a low cognitive function. Review of a physician order dated 12/20/21 revealed Resident #19 received a no-added-salt diet with pureed texture and thin liquids. Observation on 09/20/23 at 10:52 A.M., revealed [NAME] #301 preparing the pureed protein using a food processor. Observed inside the food processor was noodles, two veal parmesan patties and marinara sauce. Continued observation revealed [NAME] #301 added an unmeasured amount of hot water at two intervals during the preparation of the puree. Interview on 09/20/23 at approximately 10:54 A.M., with Dietary Manager #307 revealed the food processor contained two veal parmesan patties, one cup of noodles, and eight ounces of marinara sauce. Further interview revealed a double portion was made because the size of the machine made it difficult to make a single portion of puree. Interview on 09/20/23 at approximately 12:40 P.M., with Dietary Manager #307 while reviewing the recipe for pureed veal parmesan, revealed only the veal patty should be pureed and served with a three-ounce scoop. No additional menu items, such as noodles or sauce, should have been included in the protein serving. Further review revealed a nutritive liquid, such as broth or milk, should be used to thin the protein, as needed. Continued interview with Dietary Manager #307 confirmed [NAME] #301 used only water to thin the pureed protein. Review of the recipe for Veal Parmesan, dated 09/25/17, revealed puree instructions: remove desired number of servings and add nutritive liquid, milk, broth, etc. Blend until desired consistency. 2. Review of the menu spreadsheet for the noon meal on 09/20/23 revealed residents on a pureed diet should receive three ounces of pureed veal parmesan. Further review revealed residents on a mechanical soft diet should receive three ounces of ground veal parmesan. Observations beginning on 09/20/23 at 12:00 P.M., revealed [NAME] #301 serving lunch using a green handled scoop to serve the pureed protein and to serve the mechanical soft protein. Interview on 09/20/23 at approximately 12:15 P.M., with Dietary Manager #307 stated the green handled scoop portions provided three-ounce servings. Review of a facility provided diet list revealed one resident (#19) was on a pureed diet, and 11 (#2, #4, #9, #17, #23, #24, #26, #35, #36, #38, and #40) residents identified on a mechanical soft diet. Follow up interview on 09/21/23 at 9:32 A.M., with Dietary Manager #307 confirmed the green handle scoops provided only two and two-third (2 2/3) ounce portions and further confirmed residents who received the puree portion of protein and mechanical soft portion of protein did not receive the required amount of protein for the meal.

Based on observation, staff interview, review of resident diet list, and review of policy, the facility failed to ensure hand hygiene was practiced during the preparation of mechanical soft food. This had the potential to affect 11 residents (#2, #4, #9, #17, #23, #24, #26, #35, #36, #38, and #40) identified on a mechanical soft diet. The facility census was 44. Findings include: Observations on 09/20/23 beginning at 11:03 A.M., revealed [NAME] #301 wearing gloves and handling tongs to pick up patties of veal parmesan to prepare mechanical soft textured food. Interview at that time with [NAME] #301 stated there were 11 residents on a mechanical soft diet, and she prepared the patties of veal parmesan in batches to not overload the food processor. Continued observation revealed [NAME] #301 placing four patties in the food processor, closing the lid, pressing the start button, pressing the stop button, opening the lid, using a spatula lying on the countertop to push the food lower into the food processor, picking up a carafe of hot water and pouring the water into the food processor, replacing the lid of the food processor, and continuing to process the patties. Continued observation revealed [NAME] #301 retrieved a pan for the final product, stopped the food processor, opened the lid, tapped the stirring arm of the food processor with her right index finger to allow the food to drop back into the machine, then picked up the food processor and spatula and scooped the processed patties into the pan. [NAME] #301 repeated this process two more times, each time tapping the stirring arm of the food processor with her right finger, and also wiping food from the blade with her finger, into the processor before removing the blade. Interview on 09/20/23 at 11:11 A.M., with [NAME] #301 confirmed she touched multiple non-food items and also touched ready-to-eat mechanical soft veal parmesan patties. Review of a facility provided diet list revealed 11 (#2, #4, #9, #17, #23, #24, #26, #35, #36, #38, and #40) residents identified on a mechanical soft diet. Review of the undated policy Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices revealed employees must wash their hands during food preparation to prevent cross contamination.

Based on medical record review, staff interview, and policy review, the facility failed to send notification of a resident transfer and discharge from the facility to the Office of the State Long-Term Care Ombudsman. This affected one (#43) of two residents who were transferred or discharged from the facility. The facility identified five residents who were transferred or discharged from the facility since 01/01/21. The census was 45. Findings include: Review of Resident #43's medical record revealed an admission date of 01/01/21. Diagnoses included Wernicke's encephalopathy, muscle weakness, major depression, schizoaffective disorder, anxiety, and alcohol dependence with alcohol-induced persisting amnestic disorder. Resident #43 was discharged from the facility on 01/21/21. Review of a physician order dated 01/21/21 revealed Resident #43 could be transferred to another facility when arrangements were made. Review of nursing progress notes dated between 01/20/21 and 02/01/21 revealed Resident #43 was discharged to another skilled nursing facility; however, the medical record contained no documentation of the long-term care ombudsman being notified of the discharge. Interview on 04/15/21 at 8:51 A.M. with the Administrator verified the Office of the State Long-Term Care Ombudsman was not notified of Resident #43's discharge from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and resident interview, the facility failed to ensure residents and resident representatives were provided a copy of the bed hold notice upon discharge when the resident was transferred to the hospital. This affected one resident (#40) of one resident reviewed for hospitalization. The facility identified five residents were transferred/discharged to the hospital since 01/02/21. The census was 45. Findings include: Review of the medical record for Resident #40 revealed the resident was admitted to the facility on [DATE]. Diagnoses included heart disease, diabetes mellitus type II, gastro-esophageal reflux disease, hypertension, chronic kidney disease stage IV, wedge compression fracture of the thoracic vertebrae, intellectual disabilities and history of pulmonary embolus. Review of progress notes for Resident #40 dated 03/14/21 at 5:31 A.M. revealed the resident had an emergent transfer to the hospital for evaluation. An attempt was made to notify family and a message was left for the family to return their call. Review of progress notes dated 03/15/21 at 10:57 A.M. revealed the family was notified of the transfer. There was no documentation of any bed hold policy being provided to the family. Interview with Resident #40 on 04/12/21 at 3:00 P.M. revealed the resident did not receive a copy of the bed hold notice at the time of her transfer to the hospital or at anytime after her transfer to the hospital. Interview with Social Worker #130 on 04/14/21 at 3:30 P.M. verified no bed hold notice was provided to the resident or resident representative upon the resident's transfer to the hospital.

**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 side rails were applied to a resident bed to assist with bed mobility. This affected one (#12) of one residents reviewed for activities of daily living (ADLs). The facility identified 15 residents with orders for side rails used to assist with bed mobility. The census was 45. Findings include: Review of Resident #12's medical record revealed an admission date of 02/02/21. Diagnoses included diabetes mellitus type II, encounter for palliative care, personal history of transient ischemic attack, malignant neoplasm of female breast, and cardiomegaly. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact and was assessed to require extensive two-plus person physical assistance with bed mobility. Review of the Care Area Assessment (CAA) for ADL Functional/Rehabilitation Potential revealed Resident #12 required extensive staff assistance for bed mobility and her goal was to maintain her current level of function with ADLs or have a slow decline. Review of an ADL self care performance deficit care plan, dated 02/15/21, revealed Resident #12 required extensive assistance of one to two staff members for bed mobility and had an intervention for bilateral half side enablers to her bed to improve bed mobility. Review of a physician order dated 02/02/21 revealed Resident #12 was ordered bilateral half side enablers to improve bed mobility. Review of the February, March, and April 2021 treatment administration record (TAR) revealed Resident #12's bilateral half side enablers were documented as in place to her bed every shift during these months. Observation on 04/12/21 at 2:19 P.M., 3:04 P.M., and 3:56 P.M. revealed Resident #12 was laying in bed in her room. Further observation of Resident #12's bed frame revealed no side rails were installed to her bed. Review of Resident #12's census information revealed she was moved to her current room on 04/01/21. Observation on 04/13/21 at 7:27 A.M. revealed Resident #12 laying in bed with no side rails installed on her bed. A subsequent observation was made on 04/13/21 at 10:28 A.M. and revealed Resident #12 was sitting in a chair in her room and her bed continued to have no side rails installed. Interview on 04/13/21 at 10:40 A.M. with Resident #12 stated she was not able to fully turn and reposition herself in bed and required staff assistance with this task. Resident #12 stated she was not aware if she was supposed to have bilateral half side rails on her bed. Interview on 04/13/21 at 2:29 P.M. with Stated Tested Nurse Aide (STNA) #258 stated Resident #12 did assist with some ADLs and stated it was often difficult to turn and reposition Resident #12 in bed due to her inability to fully assist. STNA #258 verified Resident #12 did not have side rails on her bed to assist with bed mobility. Interview on 04/13/21 at 2:50 P.M. with Maintenance Assistant (MA) #460 stated Resident #12 was getting a different bed because the one she was currently in did not have side rails and Resident #12 needed them.

**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 complete pressure wound assessments at least once every seven days. This failed practice affected one (#20) of three residents reviewed for pressure wounds. The facility identified four residents with pressure ulcers. The census was 45. Findings include: Review of the medical record for Resident #20 revealed an admission dated of 02/23/21, discharged [DATE] and re-admission date of 03/19/21. Diagnoses include history of hip fracture, chronic kidney disease, diabetes mellitus, hypertension, congestive heart failure and presence of a Stage 2 pressure ulcer at the sacral region which was present upon admission on [DATE]. ,, Review of the pressure wound assessments revealed assessments were completed on 02/23/21, 03/05/21, 03/12/21, 03/19/21, 03/22/21, 04/02/21, and 04/09/21. The weekly assessment was not completed for 11 days from 02/23/21 to 03/05/21 and not completed for eight days from 03/22/21 to 04/02/21. Interview on 04/13/21 at 3:28 P.M. with the wound nurse, Licensed Practical Nurse (LPN) #109, verified a minimum of every seven wound assessments was not completed for Resident #20. Review of the facility policy titled Pressure Ulcer Risk Assessment and Management, revised 10/25/16, revealed all skin conditions and pressure areas will be treated according to physician's orders, monitored on a regular basis and documented according to facility procedures. A facility nurse will be responsible for measurement and treatment evaluation of pressure areas during weekly rounds. The wound care nurse or designee will measure each pressure area weekly.

Based on observation, staff interview, and medical record review, the facility failed to ensure hand positioning devices for contractures were applied as ordered by a physician. This affected one (#19) of two reviewed for positioning and mobility. The facility identified four residents with orders for positioning devices. The census was 45. Findings include: Review of Resident #19's medical record revealed an admission date of 01/01/18. Diagnoses included dementia with Lewy bodies, hypertension, contracture of the left and right hand, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 02/17/21, revealed Resident #19 had severely impaired cognitive skills for daily decision making. Review of a physician order dated 02/02/21 revealed Resident #19 was ordered bilateral hand rolls on when up for the day and off at night with instructions for the wide end of the roll to go toward the thumb. Review of an activities of daily living (ADL) self care performance deficit care plan, dated 01/04/21, revealed Resident #19 required extensive assistance from staff for dressing, using between one and two staff members. An intervention was added on 02/03/21 which revealed Resident #19 had bilateral hand rolls to be applied in the morning and taken off at night. Review of a splint and brace program care plan, dated 02/24/21, revealed Resident #19 was dependent with splint and brace application and removal and had contractures to bilateral hands. An intervention as part of the care plan revealed Resident #19's bilateral hand rolls should be on when he was up for the day and off at night with the wide end of the roll applied toward the thumb. Observation on 04/12/21 at 2:23 P.M. and 3:16 P.M. revealed Resident #19 laying in bed with no hand rolls in place. The resident's fingers on bilateral hands were observed to be flexed over his palms in a fixed position, with the pads of his fingers lying against the palm of his hands. One blue padded hand roll was observed on top of the dresser in Resident #19's bedroom. Observation on 04/13/21 at 7:31 A.M., 8:07 A.M., 9:07 A.M., and 10:25 A.M. revealed Resident #19 was laying in bed with no hand roll placed in either hand. A blue padded hand roll was observed on the over-bed table in Resident #19's bedroom. Observation on 04/13/21 at 11:23 A.M. revealed Resident #19 was sitting in his reclining chair with no hand rolls in place. At 2:32 P.M. Resident #19 was laying back in bed with no hands rolls placed in his hands. The blue padded hand roll remained on the over-bed table. Review of Resident #19's April 2021 treatment administration record (TAR) on 04/13/21 at 2:35 P.M. revealed documentation to indicate Resident #19's hand roll was applied on the day shift on 04/13/21. Interview on 04/13/21 at 2:48 P.M., Registered Nurse (RN) #124 stated Resident #19 was dependent on staff for dressing and verified Resident #19's hand rolls were to be placed on during the day and taken of at night. RN #124 stated none of the nurse aides informed her Resident #19 refused to wear his hand rolls on 04/13/21. Observation on 04/13/21 at 2:54 P.M. of Resident #19 in his bedroom, with RN #124, revealed Resident #19 was laying in bed with no hand rolls in place, which RN #124 verified. RN #124 located the blue hand roll laying on his over-bed table, but after searching in Resident #19's dresser, closet, bathroom, chair, and bed, a second hand roll was not located. Interview on 04/13/21 at 3:07 P.M. with State Tested Nurse Aide (STNA) #136 and at 3:15 P.M. with STNA #137 both stated they were not told by the off-going nurse aides that Resident #19 refused any of his care on their shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and facility policy review, the facility staff failed to follow their policy to complete hand sanitizing to prevent the spread of infection. This failed practice had the potential to affect 45 of 45 residents residing in the facility. The census was 45. Findings include: Review of the medical record for Resident #147 revealed she was admitted to the facility on [DATE] with diagnoses of dementia, anemia, depression and urinary tract infection. Review of the physician orders dated 03/29/21 revealed Resident #147 was under contact precautions for Proteus Mirabilis/Morganella Morganii (an infection causing bacteria) in the urine. Observation on 04/12/21 at 12:02 P.M. revealed State Tested Nurse Aid (STNA) #112 was passing lunch trays on the 200-Hall. STNA #112 left one resident room and without sanitizer her hands. She went to the tray cart, obtained a meal tray and entered the isolation room of Resident #147. STNA #112 could be heard asking Resident #147 if she wanted tarter sauce. STNA #112 then exited the isolation room without hand sanitizing, walked down the hall toward the kitchen and returned to the isolation room with tarter sauce. STNA #112 did not sanitizer her hands prior to reentering the room. Interview with STNA #112 on 04/12/21 at 12:06 P.M. she stated she was not aware Resident #147 was in isolation. STNA #112 verified there was a Contact Precautions isolation sign on the wall beside the door and there was a supply of personal protective equipment on the door. STNA #112 verified she did not apply hand sanitizer prior to entering the room, after exiting the room, or upon re-entering the room. Observation of the signage beside the room door revealed Contact Precautions with instructions to clean hands when entering and exiting the room. Interview on 04/12/21 at 12:11 P.M. with Registered Nurse (RN) #124 verified Resident #147 was on contact precautions for bacteria in her urine. Review of the undated facility policy titled Procedure for Handwashing revealed when to wash hands included before and after resident contact.