**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Resident #36 received his meal at the same time as the other residents. This affected one of three residents (Resident's #28, #36 and #49) reviewed for dining. The facility census was 54. Finding include: Review of the medical record revealed Resident #36 was admitted on [DATE] with diagnoses including Parkinson's disease, scoliosis, obsessive compulsive disorder, anxiety, and type II diabetes. Physician order dated 04/23/21 revealed Resident #36 received a regular diet, mechanical soft texture, thin consistency. Review of the Significant Change Minimum Data Summary (MDS) 3.0 assessment dated [DATE] revealed Resident #36 was moderately cognitively impaired with fluctuating periods of inattention, required supervision and set-up only for eating, had a significant weight loss and an infection to his foot. Review of the care plan dated 04/18/22 revealed a care area for a nutritional problem or potential nutritional problem related to increased calorie/nutrient needs due to system inefficiency related to chronic disease (compromised cardiac function, Parkinson's, type II diabetes), infection healing/repletion needs and a history of artificial weight inflation due to fluid. Interventions included a preference of dining in the south dining room in a specific chair with a tray table or in his room, weight goal of 125 to 135 pounds (lbs.), providing, serving diet as ordered and recording meal intake. Review of the weights for Resident #36 revealed the most recent weight on 05/17/22 of 109.5 lbs., with a body mass index (BMI) of 18.8 and an ideal body weight of 140 to 169 lbs. Observation of lunch on 05/18/22 revealed Resident #36 entered the dining room at 12:04 P.M. All residents, except Resident #36 were served their meal by 12:31 P.M. At 12:33 P.M. servers began placing plates of food covered in foil at the seats where residents had not arrived, including tables near where Resident #36 was sitting. At 12:41 P.M. Dietary Personnel (DP) #344 noticed Resident #36 had not received his meal and provided him a plate of food according to his diet order. Interview on 05/18/22 at 12:45 P.M. with DP #344 revealed she was not aware Resident #36 had not received a meal until she had placed the foil covered meals on tables. She was unable to provide an explanation other than sometimes Resident #36 ate in his room. A tray would be sent to the resident's unit, prior to plates being served in the dining room and returned to the dining room if he was eating in the dining room. Interview on 05/18/22 at 2:13 P.M. with Certified Dietary Manager (CDM) #257 revealed the hall carts were prepared first, as residents came into the dining room. The residents seated closest to the serving area were served first then serving progressed towards the back of the dining room. She verified Resident #36 should have been served prior to the foil covered plates being set out for residents who had not yet arrived in the dining room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review, and policy review the facility failed to ensure Resident #26 had fall interventions implemented according to physician orders and/ or care plan. This affected one resident (Resident #26) of four residents (Resident's #26, #36, #37 and #45) reviewed for falls. This had the potential to affect 23 residents (Resident's #4, #12, #16, #18, #19, #24, #26, #27 #29, #31, #33, #35, #36, #37, #38, #45, #47, #49, #52, #53, #55, #158 and #159) at high risk for falls. The facility census was 54. Findings include: Review of the medical record for Resident #26 revealed an admission date of 07/25/17 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, acute respiratory failure with hypoxia, diabetes, and muscle weakness. Review of the care plan dated 07/30/21 revealed Resident #26 was at risk for falls related to deconditioning, gait and balance problems, limited mobility, poor decision-making, and history of falls. Interventions included anti-roll back brakes to wheelchair, assist with transfers and ambulation as ordered, Dycem (non-slip material) between wheelchair, cushion, and resident, mat on floor next to bed, and non-skid material to grab bar in bathroom. Review of the facility form labeled Fall Risk Evaluation, dated 03/23/22, and completed by Minimum Data Set (MDS)/ Registered Nurse (RN) #304 revealed Resident #26 was at high risk for falls due to Resident #26 was disoriented, history of falls, chair bound, on medication causing high risk for falls, and had diagnoses including at risk for falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 had impaired cognition. She required extensive assist of one staff with bed mobility, transfers, and toileting. She was unable to ambulate. Review of the physician order for May 2022 revealed Resident #26 had an order dated 06/22/21 to have a mat on the floor next to her bed while she was in bed. Observation on 05/17/22 at 12:10 P.M. revealed no floor mat was observed in Resident #26's room. Resident #26 was not in her room at the time. The grab bar in Resident #26's bathroom did not have non-skid material on it. Observation on 05/18/22 at 11:02 A.M. of Resident #26 revealed she was in bed with eyes closed, and there was no mat on the floor next to her bed. Resident #26's bathroom continued to be without non-skid material to the bathroom grab bar. Interview on 05/18/22 at 11:07 A.M. with State Tested Nursing Assistant (STNA) #323 revealed she was the STNA for Resident #26. STNA #323 verified Resident #26 was in her bed with no floor mat next to her bed. STNA #323 revealed she had never seen Resident #26 with a floor mat and revealed she was not aware this was one of Resident #26's fall interventions. Interview on 05/18/22 at 11:30 A.M. with Licensed Practical Nurse (LPN) #332 revealed she was the nurse for Resident #26 and verified she had assisted Resident #26 to her bed. She verified she had not placed a mat by the side of her bed as she revealed she was not aware this was one of Resident #26's fall interventions and had never seen her with a mat by her bed. LPN #332 verified Resident #26 had a physician order to have a mat to the side of her bed as well as it was a care plan intervention. Interview and observation on 05/18/22 at 4:41 P.M. with the Director of Nursing (DON) verified Resident #26 was care planned to have non-skid material on her grab bar in her bathroom. Observation on 05/18/22 at 4:41 P.M. with the DON verified Resident #26 did not have non-skid material on her grab bar in her bathroom. The DON revealed Resident #26 usually used the bathroom by the nursing station on her unit. Upon observation of the bathroom by the nursing station with the DON also revealed the grab bar did not have non-skid material on the bar. Interview on 05/18/22 at 4:43 P.M. with STNA #340 verified she had never seen non-skid material on Resident #26's bathroom grab bar or on the grab bar in the bathroom by the nursing station. STNA #340 also revealed she had not seen Resident #26 have a mat by her bed and was not aware these were Resident #26's fall interventions per her plan of care and/ or physician order. Review of undated facility policy labeled Fall/ Incident Report Policy revealed the purpose of the policy was to investigate, intervene, prevent, and review falls. The policy revealed the facility would implement an intervention to prevent further incidents. The policy revealed any interventions initiated prior, the falls committee reviewed for effectiveness and either maintained or updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review the facility failed to maintain the indwelling urinary catheter bag in a manner to prevent urinary tract infection. This affected one (Resident #37) of one resident reviewed for an indwelling urinary catheter. The facility census was 54. Findings include: Review of the medical record for Resident #37 revealed an admission date of 02/25/10 with diagnoses including dementia without behavioral disturbances, hypertensive heart disease, and obstructive and reflux uropathy. Review of the physician's orders for Resident #37 dated 12/16/21 revealed to change the catheter and drainage bags based on clinical indications such as infection, obstruction, or when the closed system was compromised. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had minimal cognitive impairment. Resident #37 required extensive one-staff physical assistance for bed mobility, dressing, and personal hygiene; supervision set-up help only for eating; and extensive two-staff assistance for toilet use. Resident #37 had an indwelling catheter for urine and was occasionally incontinent of bowel. Review of the care plan for Resident #37 dated 04/18/22 revealed she had an indwelling urinary catheter related to obstructive uropathy. Interventions included to position the drainage bag below bladder level and do not let the bag touch the floor and to use special care during transfers and turning to maintain correct bag level and avoid pulling on the tubing. Observation on 05/16/22 at 4:10 P.M. of Resident #37 ambulating herself in her wheelchair down the hallway by the dining room with her urinary catheter drainage bag underneath her chair dragging on the ground. The bag was placed in a blue dignity bag. Observation on 05/17/22 at 10:25 A.M. revealed Resident #37 in her room sleeping in her wheelchair with her urinary catheter drainage bag under chair on the ground. Observation on 05/17/22 at 10:54 A.M. of Resident #37 revealed her ambulating herself in her wheelchair from the activities room with Therapy #371. Her urinary catheter drainage bag was underneath her chair dragging on the ground. Interview on 05/17/22 at 10:54 A.M. with Therapy #371 confirmed Resident #37's urinary catheter drainage bag was dragging on the ground, and she then readjusted her urinary catheter bag to hang off the ground. Interview on 05/19/22 at 7:35 A.M. with State Tested Nursing Assistant (STNA) #306 confirmed Resident #37's urinary catheter drainage bag was often touching the ground while she was in her wheelchair due to the wheelchair being so low to the ground. Review of the facility policy titled urinary catheter care, dated 11/14/16, revealed no statement regarding catheter drainage bags being kept off the floor. Review of the facility policy titled indwelling catheter drainage bag dignity bags, undated, revealed no statement regarding catheter drainage bags being kept off the floor.

Based on observation, interview, and review of the Ohio Department of Health, Department of Agriculture 2019 food code revealed the facility failed to serve food to residents in a sanitary manner to prevent infection. This had the potential to affect 52 residents who receive food from the kitchen. The facility identified two (Resident's #9 and #159) who did not receive food by mouth. The facility census was 54. Findings include: Observation on 05/16/22 at 12:08 P.M. revealed Dietary #325 plating food with no gloves on. Her nails appeared painted. She then stopped serving food and reached on top of her head grabbed her safety goggles and placed them back on her face. No hand hygiene was performed. Dietary #325 then began immediately began plating food again. Interview on 05/16/22 at 12:12 P.M. with Dietary #325 confirmed she was not wearing gloves. She also confirmed her nails were painted. Dietary #325 also confirmed she did touch the top of her head to grab her safety googles and put them on her face and did not wash her hands before serving food again. Interview on 05/16/22 at 12:15 P.M. with Dietary Manager #354 revealed she has instructed her staff not to wear gloves when serving food, just to handle the utensils. Review of Ohio Department of Health, Department of Agriculture 2019 food code - chapter 3717-1-02 reference guide for management and personnel, undated, revealed the facility dietary staff must maintain fingernails (nail polish/artificial nails permitted with intact gloves). The report also stated food employees must properly wash hands after coughing, sneezing, eating, drinking, tissue use, or touching body.

Based on observation and interview, the facility failed to prepare pureed food to ensure the proper consistency and nutrient density of a serving. This affected nine Residents (#14, #222, #3, #17, #29, #13, #33, #26 and #11) who were prescribed a pureed diet of 67 residents who consumed foods by mouth. The facility census was 68. Findings include: Observation on 09/03/19 at 10:35 A.M. revealed [NAME] #402 prepared pureed beef teriyaki for lunch on 09/03/19. The cook put the meat, gravy and food thickener into a large food processor and started blending. Then she took out the blades and went to get a spoon for the surveyor to taste, indicating the puree process was complete. The mixture did not appear to be smooth. The mixture was not the proper texture. The concern was verified by Dietary Manager (DM) #401 who told [NAME] #402 to puree the mixture to the proper texture. Cook #402 poured part of the teriyaki mixture into a smaller food processor/blender and started to process. The mixture was thick, so the cook poured an unmeasured amount of water in and blended. The teriyaki mixture was now of a smooth consistency but was too thin. [NAME] #402 was going to put more thickener in. DM #401 stopped her. The puree was to be redone. Review of the diet list revealed Residents (#14, #222, #3, #17, #29, #13, #33, #26 and #11) received pureed diets. Interview on 09/03/19 at 10:53 A.M. DM #401 verified the puree was not initially processed to the proper consistency and then was diluted which diluted the flavor and the nutrient density per serving.