**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, observation, and mechanical lift policy the facility failed to ensure Resident #30 was safely transferred with a Hoyer (mechanical) lift to prevent a fall. This affected one resident (Resident #30) of four residents reviewed for accidents. The facility census was 55.Findings include:Review of the medical record for Resident #30 revealed an admission date of 08/20/25 with diagnosis that include: urinary tract infection, type 2 diabetes mellitus with diabetic nephropathy, catatonic disorder, dementia without behavioral disturbance, metabolic encephalopathy, dysphagia and altered mental status.Review of Morse Fall Scale dated 08/20/25 revealed Resident #30 was a high risk for falling.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 cognition was moderately impaired and was dependent on staff for transfers from the chair to the bed.Review of Resident #30 medical chart revealed resident had fallen on 08/21/25, 08/30/25, 08/31/25, and 09/03/25.Review of Resident #30's care plan dated 09/02/25 revealed Resident #30 required assistance with activities of daily living impaired mobility, weakness, debility, catatonic and cognition. An intervention dated 08/22/25 with a revised date of 09/02/25 revealed Resident #30 required a mechanical lift for transfers usually a Hoyer lift.Review of the nursing progress note dated 09/03/25 at 1:15 P.M. authored by Licensed Practical Nurse (LPN) #578 revealed she was preparing to assist Certified Nursing Assistant (CNA) #555 on the left side of the bed when CNA #555 moved the hoyer, the front left hook let loose and Resident #30 fell out of the hoyer, hitting her head on the floor. Resident #30 stated her head hurt a little and the resident was able to move all four extremities without limitations. Resident was sent out to the emergency room.Review of Resident #30's computerized tomography (CT Scan) from the hospital dated 09/03/25 at 12:04 P.M revealed no evidence of an acute infarct or other acute parenchymal process. Resident #30's medical record revealed the resident returned to the facility with no noted injuries.Interview on 09/04/25 at 11:31 A.M. with CNA #555 revealed Resident #30 hoyer pad was hooked up to the hoyer lift, she checked to make sure hoyer pad was hooked up to hoyer, and lifted Resident #30 with the hoyer. Resident #30 came out of the sling and went to the floor. CNA #555 revealed Resident #30 does not want to be here and that she thought the resident tried to move the hoyer strap off. CNA #555 does not remember the last time she had training for the hoyer.Interview on 09/04/25 at 12:06 P.M. with LPN #578 revealed she was assisting CNA #555 in Resident #30's room. LPN #578 was on the left side of the bed and Resident #30 and CNA #555 were by the door when the front left hook gave out and Resident #30 did a somersault out of the hoyer lift and bumped her head. LPN #578 did not witness CNA #555 check hooks because she was in the bathroom gathering supplies at the time. LPN #578 checked hoyer pad after the fall and all straps were in working order. LPN #578 revealed she had not been trained on the hoyer during orientation.Review of the facility policy titled, Transfers and Mechanical Lifts Policy dated 01/02/24, revealed bullet 10: two staff members must be utilized when transferring residents with a mechanical lift. Further, bullet 12 revealed: The staff must demonstrate competency in the use of the mechanical lifts prior to use and annually with documentation of that competency placed in their education file.This deficiency represents non-compliance investigated under Complaint Number 1364232.

Based on record review and interview, the facility failed to ensure medications to treat diabetes and to improve glucose control were administered as ordered by the physician. This affected one (Resident #61) of six reviewed for medication administration. The facility census was 55.Findings include:Review of the medical record for Resident #61 revealed an admission date of 12/21/24 with diagnoses including diabetes mellitus, hypertension and heart failure. Review of the physician's orders for Resident #61 revealed an order for Insulin Lispro (medication for hyperglycemia) 55 units in the morning and at night dated 12/22/24 and Humalog (medication for hyperglycemia) sliding scale insulin to be given per the blood sugar to be done in the morning, at lunch, at dinner and at bedtime dated 12/22/24.Review of the Medication Administration Record for December 2024 for Resident #61 revealed his Insulin Lispro was not administered on 12/23/24 in the morning and Humalog sliding scale was not administered on 12/23/24 at lunch.Review of Resident #61's care plan dated 12/23/24 revealed he had diabetes mellitus and staff should administer medications as ordered.Interview on 08/28/25 at 11:11 A.M. with the Director of Nursing Services verified Resident #61's insulin was not administered as ordered on 12/23/24.Review of the facility policy titled, Medication Administration, dated 01/02/24, revealed medications were to be administered as ordered.This deficiency represents non-compliance investigated under Complaint Number 1364233 and Complaint Number 1364234.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being for Resident #2, #20 and #48. This affected three residents (#2, #20 and #48) out of four residents reviewed for mental health services. The facility census was 49. Findings include: 1. Review of the medical record for Resident #48 revealed an admission date of 11/27/22 and diagnoses included major depressive disorder and bipolar disorder. Review of the care plan, dated 11/29/22, revealed Resident #48 used antidepressant medication related to depression diagnosis with an intervention to provide psychiatric/psychological consult as ordered. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/02/23, revealed Resident #48 felt down, depressed or hopeless seven to 11 days. Review of the quarterly MDS 3.0 assessment, dated 06/02/23, revealed Resident #48 was cognitively intact and felt bad about self, had thoughts she would be better off dead, or could hurt self 12 to 14 days which showed an overall decline since the MDS assessment dated [DATE]. Review of the Psych 360 counseling progress note, dated 05/03/23, revealed the purpose of the psychotherapy counseling for Resident #48 was for depression management. Resident #48 had shown some backsliding since baseline and was engaged in counseling for supportive mental health services to sustain mental health. The plan was to proceed with weekly session of individual cognitive behavioral treatments. There were no further counseling progress notes from Psych 360 after 05/03/23. Review of the facility service agreement for psychotherapy services revealed a new consultant service agreement was entered into as of 04/24/23 with Psycho Social Therapies Ltd with the facility and the consultant would provide medically necessary behavioral health services to the facility's residents. Review of the document titled Consent to Treatment, signed by Resident #48 on 05/12/23 revealed Resident #48 voluntarily requested for Psycho Social Therapies Ltd to provide medically necessary psychosocial interventions which included counseling, psychotherapy, and medication management, and it was understood the purpose of the service was to achieve important benefits including a decrease in mental health symptoms, and improved ability to cope with stressors, improved relationships, and overall well-being Review of the 06/05/23 Physician Assistant progress note revealed Resident #48 admitted her mood was sad and had been having issues with her son. Resident #48 attributed her depressed mood and anxiety over wanting to get out of the facility. Resident #48 denied any suicidal intentions. Resident #48 reported her sleep was poor and her energy level was terrible. Nursing reported Resident #48 had a very depressed mood. The plan was to increase Buspar (antianxiety) to 10 milligram (mg) twice a day and increase Amitriptyline (antidepressant) to 50 mg before bedtime for worsened anxiety and depression and to add Vistaril (antianxiety) 25 mg every six hours as needed for breakthrough anxiety. Review of physician orders for Resident #48 revealed on 06/05/23 an order for Amitriptyline HCI 25 mg give 25 mg at bedtime was discontinued , an order for Amitriptyline 25 mg give 50 mg at bedtime was started, buspirone HCI tablet 5 mg give one tablet by mouth two times a day was discontinued, buspirone HCI tablet 5 mg give two tablets by mouth two times a day was started, and an order for hydroxyzine pamoate capsule 25 mg give one capsule every six hours as needed for 14 days was written. Further review of the medical record for Resident #48 revealed there was no evidence supportive mental health counseling services by a licensed clinical counselor or licensed social worker were provided from 05/04/23 to 07/05/23. Interview on 07/06/23 at 8:14 A.M. with Resident #48 revealed she had been seeing a counselor and didn't understand why the counseling sessions had stopped. Resident #48 confirmed she felt better when she had talked with a counselor and wished the sessions had continued. Resident #48 stated she had anxiety issues and have been talking with her friends instead. 2. Review of the medical record for Resident #20 revealed an admission date of 09/14/21 and diagnoses which included quadriplegia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, anxiety disorder, and major depressive disorder. Review of the 04/14/23 quarterly MDS 3.0 assessment revealed during the previous two weeks of the assessment reference period, for seven to 11 days, Resident #20 showed little interest or pleasure in doing things, had trouble falling or staying asleep or slept too much, felt tired or had little energy, and had a poor appetite or was overeating. Review of 05/10/23 Psych 360 counseling progress note revealed Resident #20 had been receiving counseling services to address the problems of depression and low self-esteem. Resident #20 had shown some backsliding in the severity of depression since baseline. The plan was to proceed with weekly sessions of individual cognitive behavioral treatments. There were no further counseling progress notes from Psych 360 after 05/10/23. Review of document titled Consent to Treatment, signed with an X by Resident #20 and witnessed by SSD #343 on 05/12/23 revealed Resident #20 voluntarily requested that Psycho Social Therapies Ltd provide medically necessary psychosocial interventions which included counseling, psychotherapy, and medication management, and it was understood the purpose of the services was to achieve important benefits, including a decrease in mental health symptoms, an improved ability to cope with stressors, improved relationships, and overall well-being. Review of 05/22/23 Physician Assistant progress note from Psycho Social Therapy Ltd revealed Resident #20 reported her mood was iffy and admitted to feeling depressed from missing her kids. Resident #20 admitted to general feelings of anxiety, poor appetite and sleep. The plan was to increase Remeron (an antidepressant) to 30 milligrams before bedtime for improvement of sleep and appetite. Review of Resident #20's physician orders revealed on 05/22/23 Mirtazapine (Remeron) was increased from one 15 milligram tablet to one 30 milligram tablet before bedtime. Further review of medical record for Resident #20 from 05/11/23 to 07/06/23 revealed there was no evidence Resident #20 had received counseling services. Interview on 06/28/23 at 12:08 P.M. with Resident #20 revealed she would like to speak with someone since Resident #20 felt she was depressed. Resident #20 confirmed her counseling sessions had stopped in May 2023. 3. Review of medical record for Resident #2 revealed an admission date of 08/21/21. Diagnoses included Parkinson's disease, depression, and anxiety disorder. Review of 06/29/22 care plan revealed Resident #2 had a mood problem related to the diagnoses of depression and anxiety with interventions which include behavioral health consults as needed. Review of 10/10/22 Patient Health Questionnaire (PHQ) assessment, a multipurpose instrument for screening, diagnosing, monitoring, and measuring the severity of depression, revealed over the previous 14 days, Resident #2 had felt down, depressed, or hopeless never or one day. Review of 03/31/23 annual MDS 3.0 assessment revealed Resident #2 was cognitively intact, felt down, depressed, or hopeless two to six days over the fourteen day look back period for the assessment, and received seven days of antianxiety and antidepressant medications. Review of 04/26/23 Psych 360 counseling note revealed the severity of her nervousness was at baseline and Resident #2 needed the emotional support counseling provided to sustain mental health and weekly sessions would continue. Review of 05/03/23 Psych 360 counseling note revealed Resident #2 was hospitalized so no service was rendered. Review of document titled Consent to Treatment, signed by Resident #20 on 05/12/23 revealed Resident #2 voluntarily requested that Psycho Social Therapies Ltd provide medically necessary psychosocial interventions which included counseling, psychotherapy, and medication management, and it was understood the purpose of the services was to achieve important benefits, including a decrease in mental health symptoms, an improved ability to cope with stressors, improved relationships, and overall well-being. Review of the 06/30/23 Patient Health Questionnaire (PHQ) revealed over the previous 14 days Resident #2 had felt down, depressed, or hopeless and had poor appetite or overate seven to 11 days. Further review of Resident #2's medical record revealed no evidence counseling services were provided from 04/27/23 to 07/05/23. Interview on 07/06/23 at 8:24 A.M. with Resident #2 revealed she felt better when she had been receiving counseling services and had not received counseling services from the new company. Interview on 06/28/23 at 4:39 P.M. with Social Services Designee (SSD) #343 regarding counseling services for Resident #2, #20 and #48 revealed there was a change in which company would be providing psychotherapy and psychiatry services. The facility had been using Psych 360, which provided someone to manage medications and someone to provide psychological counseling services. The SSD #343 verified Psycho Social Therapy Ltd had not sent any counselor or licensed social worker to provide counseling services since Psych 360 stopped providing services in May 2023. Interview on 06/29/23 at 10:10 A.M. with the Administrator confirmed Psycho Social Therapy company had not sent any counselors out but were supposed to provide those services to the residents who needed it. Interview on 07/05/23 at 4:08 P.M. with the Administrator confirmed the new company had not provided counselors, and she had been under the understanding that the person who was managing medications was also counseling. The new company had been trying to obtain a counselor to provide counseling at the facility. Interview on 07/06/23 at 12:19 P.M. with Licensed Independent Social Worker (LISW) #382, who worked for Psycho Social Therapy LTD, revealed the nurse practitioners and physician assistants provided the psychiatry medication management services, and the LISWs provided the counseling services for Psycho Social Therapy LTD . LISW #382 confirmed 07/06/23 was the first day this company had provided counseling services for the facility residents, and LISW #382 planned to provide counseling services bi-weekly. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00144060.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, policy review, and interview the facility failed to implement wound care orders for former Resident #49. This affected one resident (#49) of three residents reviewed for skin impairments. Findings include: Review of the closed medical record for former Resident #49 revealed an admission date of 08/18/22, discharge date of 06/15/23 with diagnoses of paraplegia, complete lesion at C5 level spinal cord, autonomic dysreflexia, and neurogenic bladder. Review of the skin alteration incident report dated 05/08/23 revealed during resident care, this nurse observed a skin alteration to resident's right heel. Effected area had discoloration and peeling skin. Review of the skin grid non-pressure assessment dated [DATE] revealed Resident #49 had a new non-pressure area to the right heel described as a red area with chapped skin and bruising measuring 3.0 centimeters (cm) by 3.0 cm. The surrounding tissue/wound edges were normal and there was no exudate. Resident #49 had current treatment order to pad and protect. Review of the general note dated 05/09/23, timed 10:06 A.M. revealed the wound physician was at Resident #49's bedside to evaluate and treat. New orders for skin treatment were received. Review of Physician #16's wound assessment and plan dated 05/10/23 revealed Resident #49 had a skin tear to the right posterior heel measuring 0.3 cm by 0.2 cm secondary to right lower extremity spasm and striking wheelchair. Physician #16 ordered medical honey (Medihoney) gel Xeroform, clean wound with normal saline or sterile water, apply to wound bed, cover with dry clean dressing daily and as instructed, offload pressure/float foot on pillow while in bed (may also use Prevalon style boot) and a daily multivitamin. Review of the physician orders from May 2023 revealed Resident #49 had an order to pad and protect right heel with bordered foam and change per the resident's request as needed. There was no evidence Physician #16's orders were transcribed in the physician orders in the electronic medical record (EMR) including the Medihoney daily wound care, floating foot on pillow, or the daily multivitamin. Review of the skin grid non-pressure assessment dated [DATE] revealed Resident #49's right heel skin tear had deteriorated showing a moderate amount of exudate of serosanguineous drainage, and there was maceration of the surrounding tissue/wound edges. Resident #49 was seen by the wound physician during wound rounds. Area caused by right lower extremity spasm and causing area to strike wheelchair. The area had deteriorated. The resident stated to the nurse and physician that he had refused to allow the Medihoney (medical honey) to be applied during dressing changes. Review of Physician #16's wound assessment and plan dated 05/17/23 revealed Resident #49's right heel skin tear had declined and was measuring 1.5 cm by 2.0 cm. Review of the pressure ulcer care plan updated 05/17/23 revealed Resident #49 had potential for pressure ulcer development related to immobility and had a skin tear to his right posterior heel with interventions to administer treatments as ordered. Review of the May 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the pad and protect to the right heel was not implemented/completed on 05/08/23 or 05/09/23. The physician order of medical honey gel Xeroform, clean wound with normal saline or sterile water, apply to wound bed, cover with dry clean dressing daily and as instructed, offload pressure/float foot on pillow while in bed (may also use Prevalon style boot) were not listed in the MAR or TAR from 05/10/23 through 05/16/23 for the resident to refuse the orders. The daily multivitamin was not administered at all during May 2023. Review of the June 2023 MAR revealed the daily multivitamin was not administered at all during June 2023. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #49 was cognitively intact, needed physical extensive assistance of two-person for transfers, bed mobility and dressing and had a skin tear. Interview on 06/21/23 at 11:40 A.M. with Resident #49 revealed he still had a wound on his right heel. Interview on 06/21/23 at 4:00 P.M. with the Director of Nursing (DON) verified Resident #49 did not receive the pad and protect on the right heel on 05/08/23 or 05/09/23 and verified Physician #16's orders were not transcribed into the EMR so Resident #49 did not receive nor was offered the Medihoney daily wound care from 05/10/23 through 05/16/23. A follow-up interview on 06/21/23 at 4:40 P.M. with the DON verified Resident #49 was not administered the daily multivitamin during May 2023 or June 2023. Review of the facility's wound management program policy dated November 2021 revealed any resident with wounds receives treatment and services consistent with the resident's goals of treatment. Orders were verified and obtained as needed. This deficiency represents non-compliance investigated under Complaint Number OH00143397.

Based on interview and record review, the facility did not ensure Residnet #20 and #23's authorization agreement to manage funds were witnessed by a person not affiliated with the facility. This affected two residents (Resident #20 and #23) out of five residents reviewed for resident funds. Findings included: 1. Review of medical record for Resident #20 revealed an admission date of 04/01/19 and her diagnoses included encephalopathy, chronic obstructive pulmonary disease, and cognitive communication deficit. Review of care plan dated 05/05/19 revealed Resident #20 had impaired cognition, dementia, and/ or impaired thought process due to encephalopathy, frontal lobe dementia, and short term memory loss. Interventions included communicate with family regarding capabilities and needs and provide assistance with decision making. Review of facility form labeled Resident Fund Management Service dated 03/10/20 revealed Resident #20 signed the authorization agreement to allow the facility to handle her funds. The authorization agreement was not witnessed. Interview on 03/28/23 at 4:04 P.M. with Medical Records/ Central Supply/Receptionist #505 verified Resident #20 signed the authorization agreement on 03/10/20 to allow the facility to handle Resident #20's funds but that the authorization was not witnessed. 2. Review of medical record for Resident #23 revealed an admission date of 12/06/19 and her diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease, heart disease with heart failure and psychotic disturbances. Review of care plan dated 12/20/19 revealed Resident #23 had impaired cognition. Interventions included communicate with Resident #23's family regarding capabilities and needs. Review of facility form labeled Resident Fund Management Service dated 02/15/20 revealed Resident #23's power of attorney signed the authorization agreement to allow the facility to handle Resident #23's funds. The authorization agreement was not witnessed. Interview on 03/28/23 at 4:04 P.M. with Medical Records/ Central Supply/Receptionist #505 verified Resident #23's power of attorney signed the authorization agreement on 02/15/20 to allow the facility to handle Resident #23's funds but that the authorization was not witnessed. Review of facility policy labeled, Managing Resident Personal Funds dated March 2022 revealed residents were not required to entrust personal funds to the facility. The policy did not include anything in regards to having an authorization agreement between the resident and/ or resident responsible party with the facility to manage the handling of a resident's funds. The policy also did not include any information regarding having the agreement witnessed after being signed by a resident and/ or resident responsible party.

Based on observation, interview, and record review, the facility failed to ensure Resident #12 was free from physical abuse involving manual restraint. This affected one resident (#12) out of three residents reviewed for abuse. Findings include: Review of the medical record for Resident #12 revealed an admission date of 02/10/23. Resident #12's diagnoses included dementia, diabetes mellitus, post-traumatic stress disorder, major depressive disorder, heart failure and anxiety disorder. Review of the plan of care for Resident #12 dated 02/15/23 and a revision date of 02/28/23 revealed Resident #12 had a traumatic event identified as physical abuse by a homecare worker in 2019 with injury. Resident #12's triggers were identified as receiving care. Resident #12 would make false allegations of abuse and refuses medications at times. Interventions include but were not limited to allow resident to express feelings when triggers are identified, develop strategies with resident to avoid or decrease trauma triggers, and staff being aware of triggers or potential triggers and understand strategies to assist resident in avoiding. Review of the plan of care for Resident #12 dated 02/15/23 and a revision date of 03/14/23 revealed Resident #12 was resistive to care related to anxiety and dementia. Resident #12 would refuse to allow staff to assist with personal care, refuse medications and weights. Interventions included but were not limited to allow resident to make decisions about treatment regimen, give clear explanation of all care activities, if resident resisted activities of daily living (ADLs), reassure resident, leave and return five to ten minutes later and try again, provide consistency in care to promote comfort and provide resident with opportunities for choice during care provision. Review of the plan of care for Resident #12 dated 02/15/23 revealed the resident had a history of suspected abuse and/or neglect. The resident's comprehensive assessment revealed a history of suspected abuse and/or neglect or factors that may increase and/or personality that draws him/her susceptibility to abuse/neglect. A history of unhealthy, even abusive, relationships. Behavior that might be characterized as provoking include antagonizing, disrespectful, angry, insensitive, and/or annoying, behavioral symptoms, difficulty in adjustment and generalized mood distress. Symptoms may be manifested by: observable signs of distress, psychosocial distress, disturbed functioning, The resident demonstrated verbal expressions of distress. Interventions include but were not limited to reviewing assessment information; emphasize treatment causal factors and/or interventions designed to moderate/reduce symptoms; establish a counseling schedule with the resident; encourage the resident to verbalize/share thoughts, anxieties, fears, concerns, and general feelings; assure the resident that he/she was in a safe and secure environment with caring professionals; explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (i.e., social worker, nurse, nursing assistant, peer) and by verbalizing thoughts, needs and feelings; observe the resident for signs of fear and insecurity during delivery of care; take steps to calm the resident and help her feel safe; assure the resident that staff members are available to help, and department heads maintain an open door' policy. Review of the plan of care for Resident #12 dated 02/15/23 with a revision date of 02/21/23 revealed Resident #12 was incontinent of bowel and bladder. Interventions included but were not limited to check resident as needed and assist with toileting as needed, provide loose fitting easy to remove clothing and provide peri-care after each incontinent episode. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/17/23, revealed the resident had intact cognition. The resident required extensive assistance of two staff for bed mobility and transfers. Further review of the MDS revealed Resident #12 had verbal and other behaviors that occurred one to three days during the look back period. Review of nurse progress note dated 03/24/23 at 4:45 A.M. revealed the fire department arrived at the facility at approximately 04:30 A.M. and notified staff that a call was received concerning resident care. Resident #12 alleged that she was attacked when provided care. Review of the Self Reported Incident (SRI) #233305, submitted by the facility, dated 03/24/23 and timed 9:56 A.M., revealed on 03/24/23 Resident #12 alleged she had been attacked by three staff members. Administrator notified and an investigation initiated. Staff were suspended pending investigation. Resident was interviewed by Social Service Designee #549 on 03/24/23, Police on 03/24/23 and Supervising Ombudsman on 03/24/23. Resident #12's story had not been consistent throughout the investigation ranging from she was attacked, to she was molested, to she was angry they changed her. SSD #549 asked Resident #12 about being molested and resident #12 stated oh no honey, I told you, I was attacked getting my diaper changed. She stated she doesn't want a male care giver. Resident #12 further stated she likes State Tested Nursing Assistant (STNA) #557 because she gives her time to turn and is gentle. Resident #12 stated she was incontinent of bowel and bladder. Resident #12 wanted staff to wait until she is ready to be changed and for them to be patient with her turning. Police were notified and arrived at approximately 4:00 A.M. Police interviewed Resident #12, who claimed she was assaulted by three staff members. The fire department also arrived and assessed Resident #12 with no injury or abuse noted. On 03/29/23, Administrator spoke with the Ombudsman who interviewed Resident #12 on 03/24/23 in person. Ombudsman stated he has known Resident #12 for a long time and is familiar with her. He stated she presents some unique challenges for the facilities in which she has resided in. Ombudsman stated resident #12 said she was attacked by three staff members at 3:00 A.M. Ombudsman further stated he did not observe any bruising or injury and did not have any evidence that abuse occurred. Resident #12 was asked if she would like to be moved and she stated she just didn't want those staff members to care for her. Review of a SRI witness statement dated 03/24/23 at 1:10 P.M. by Regional Clinical Support (RCS) #601 and Human Resource Director #548 revealed a telephone interview with STNA #563. STNA #563 stated Licensed Practical Nurse (LPN) #511 went to change Resident #12 and then came out of the resident's room and called Registered Nurse (RN) #504 down to the room and both nurses then went down to the resident's room. STNA #563 stated, a short time later, he was called down to the resident's room because they needed help to lay the resident down. STNA #563 stated when he arrived in the resident's room, the resident was sitting up in bed. STNA #563 stated he was on the right side of the resident and RN #504 was on the left side of the resident with a dirty brief in her hand. STNA #563 stated he was informed by LPN #511 and RN #504 that the resident was in pain but refused any pain medications and that the resident had been combative with them prior to his arrival to the resident's room. STNA #563 stated Resident #12 didn't become combative at all while he was present in the room. STNA #563 stated he assisted the resident to lay down by the resident's shoulders and gently laid her down in bed. STNA #563 stated Resident #12 wasn't on the pad and they just needed his help to reposition her on the bed. STNA #563 stated once the nurses put a new brief on the resident, they all left the resident's room. STNA #563 stated that at no time did he secure the resident's hands. STNA #563 stated he just repositioned her in the bed by her shoulders and didn't touch the resident's hands. STNA #563 stated the police and fire department arrived at the facility and spoke to LPN #511. Review of the SRI witness statement dated 03/24/23 at 1:21 P.M. by Regional Clinical Support (RCS) #601 and Human Resource Director # 548 revealed a telephone interview with RN #504. RN #504 stated Resident #12 refused to allow STNA #563 to change because she was incontinent. RN #504 stated Resident #12 was soaked with feces and urine up to her bra. RN #504 stated LPN #511 tried to perform incontinence care, but Resident #12 refused saying, Don't touch me, leave me as I am. RN #504 stated that all three staff members: herself, LPN #511, and STNA #563 went to resident's room to reapproach but stated the resident was still refusing at that time. RN #504 stated the resident became combative by Resident #12 hitting and pushing her. RN #504 stated she initially tried to hold the resident's hands to keep the resident from hitting her, but states STNA #563 took over holding the resident's hands while LPN #511 and her performed incontinence care on the resident. RN #504 stated Resident #12 was stating for them not to touch her and to leave her the way that she was and refusing to have care provided. RN #504 states that as soon as the care was quickly provided, LPN #511, STNA #563 and she left the resident's room. RN #504 stated that one police officer and two or three EMTs arrived at facility around 4:00 A.M. RN #504 stated Resident #12 called someone who then called the police. RN #504 stated the police officer and EMTs went in to speak to Resident #12 and came back out and stated the resident stated she had been molested by three staff members. RN #504 stated the EMTs stated they checked the resident over and didn't see any wounds, or obvious signs of molestation, abuse, or neglect. RN #504 stated that the police officer asked for a diagnosis list, and one was provided. RN #504 stated EMTs offered to take the resident to the hospital for safety and the resident refused to go. RN #504 stated she was aware of resident rights and was aware of the right to refuse care. RN #504 stated she felt if she would've left the resident covered in feces and urine it would've been neglect and felt she had to do something. Review of the SRI witness statement dated 03/24/23 at 1:05 P.M. by Regional Clinical Support (RCS) #601 and Human Resource Director # 548 revealed a telephone interview with LPN #511. LPN #511 stated STNA #563 asked her at 12:00 A.M. to be the STNA for Resident #12 due to resident #12 wouldn't allow STNA #563 to perform care. Observation and interview made on 03/27/23 at 10:14 A.M. revealed Resident #12 was sitting up in bed. Resident #12 stated she was assaulted by a white man many years ago and showed this surveyor her scars on her legs and arms, and no bruises of any color were located on her body. Resident #12 stated recently, she could not remember the date, one male and two female aides came into her room and beat her up. Resident #12 stated because her one eye was dead and the other was not wonderful she couldn't tell who was were, and she did not recognize faces or characteristics. Resident #12 stated she does not care about people. She stated that she was not sure if they work here but they were wearing blue smocks at 3:00 A.M. Resident # 12 could not give a date. Resident # 12 stated that she cannot walk or stand. Interview on 03/30/23 at 3:29 P.M. with Administrator and Director of Nursing (DON) revealed Resident #12's orders and care plan were updated after the incident on 03/24/23 to not have male care givers. Administrator stated STNA #563 had asked LPN #511 to assist in taking care of Resident #12 because she would not allow him. DON stated Resident #12 will not allow male aides to check and change her or perform incontinence care. Administrator stated LPN #511 called STNA #563 and RN #504 for assistance. STNA #563 did not perform care, he was just in the room. Administrator stated that she was the Abuse Coordinator for the facility and was notified between 8:00 A.M. and 8:30 A.M. of the Resident #12's allegation of abuse via phone because she was off on 03/24/23. The Administrator revealed the Assistant Director of Nursing (ADON) was notified via text message by a nurse of the incident. The Administrator stated the Assistant Director of Nursing (ADON) must have missed the text because she was a nurse on duty that night. Director of Nursing (DON) stated he was notified by the ADON when he walked through the door of the facility between 8:00 A.M. and 8:30 A.M. and then DON notified the Administrator. Neither LPN #511, STNA #563 or RN #504 documented in Resident #12's electronic record about refusing care on 03/24/23 or about the incident. The Administrator stated staff should know how to go up the chain of command if they could not get a hold of whoever they called, especially for abuse. The Administrator also stated nursing probably forgot to document anything because of what was going on throughout their shift. DON stated he didn't have time to document in the electronic chart until 7:11 P.M. on 03/24/23, assessed the resident at 10:00 A.M. with the charge nurse, but did not have evidence Resident #12 was assessed after the incident until 2:45 P.M. The Administrator stated the EMT's assessed her and found no evidence of abuse or neglect. Phone interview on 03/30/23 at 4:43 P.M. with LPN #511 revealed she called DON and ADON by phone to report the incident involving Resident #12 on 03/24/23. DON did not answer but ADON stated that she was coming in and the events all happened so fast. LPN #511 revealed Resident #12 was flailing her arms, STNA #563 was on the left side closer to the headboard and STNA #563 had its arms around the resident's arms, but she could move her arms freely. Phone interview on 03/30/23 at 4:50 P.M. with STNA #563 revealed he assisted in repositioning Resident #12 by putting his arms around her arms. He stated that he was standing on the left side of the bed and had to move the resident to the middle of the bed so that care could be provided. Resident #12 was complaining of pain while she was elevated to provide care. STNA #563 stated he left the room after she was repositioned and didn't hold her wrists and there were no signs of abuse. Phone interview on 03/30/23 at 5:45 P.M. with RN #504 revealed Resident #12 was resisting care and had urine and feces all over her. Resident #12 refused STNA #563 from providing care. Resident #12 started swinging, so STNA #563 held her hand inside his hand. She and LPN #511 provided the care, and incontinence care took less than two minutes. RN #504 revealed DON was called at 4:00 A.M. but it went to voicemail and the ADON then was called and she said she was coming in. Review of facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/2022, revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint that is not required to treat the resident's medical symptoms. The meaning of physical abuse is any manual method, or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement. Freedom of movement means any change in place or position of the body or any part of the body that the resident is physically able to control. The facility will educate its staff upon hire and annually thereafter regarding the facility's policy concerning Abuse, Neglect, Exploitation, Misappropriation of resident's property, and how to handle resident-to-resident Abuse and Injuries of Unknown Source. These training sessions will include, but not necessarily be limited to, the following topics: how to identify what constitutes Abuse, Neglect, Exploitation or Misappropriation of resident property and how to recognize signs of Abuse, Neglect, Exploitation or Misappropriation of resident property; how staff should report their knowledge related to allegations without fear of reprisal; how to recognize signs of burnout, frustration and stress; understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond; appropriate interventions to deal with aggressive and/or catastrophic reactions of resident; and dementia management and abuse prevention (Catastrophic reactions mean extraordinary reactions of residents to ordinary stimuli, such as the attempt to provide care). This deficiency represents non-compliance investigation under Complaint Number OH00141557 and OH00141432.

Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse towards Resident #12 was reported immediately and failed to ensure the resident was protected from further abuse after the allegation was made. This affected one resident (#12) out of three residents reviewed for abuse. Findings include: Review of the medical record for Resident #12 revealed an admission date of 02/10/23. Resident #12's diagnoses included dementia, diabetes mellitus, post-traumatic stress disorder, major depressive disorder, heart failure and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/17/23, revealed the resident had intact cognition. The resident required extensive assistance of two staff for bed mobility and transfers. Further review of the MDS revealed Resident #12 had verbal and other behaviors that occurred one to three days during the look back period. Review of the plan of care for Resident #12 dated 02/15/23 and a revision date of 02/28/23 revealed Resident #12 had a traumatic event identified as physical abuse by a homecare worker in 2019 with injury. Resident #12's triggers were identified as receiving care. Resident #12 would make false allegations of abuse and refuses medications at times. Interventions include but were not limited to allow resident to express feelings when triggers are identified, develop strategies with resident to avoid or decrease trauma triggers, and staff being aware of triggers or potential triggers and understand strategies to assist resident in avoiding. Review of the plan of care for Resident #12 dated 02/15/23 and a revision date of 03/14/23 revealed Resident #12 was resistive to care related to anxiety and dementia. Resident #12 would refuse to allow staff to assist with personal care, refuse medications and weights. Interventions included but were not limited to allow resident to make decisions about treatment regimen, give clear explanation of all care activities, if resident resisted activities of daily living (ADLs), reassure resident, leave and return five to ten minutes later and try again, provide consistency in care to promote comfort and provide resident with opportunities for choice during care provision. Review of the plan of care for Resident #12 dated 02/15/23 revealed the resident had a history of suspected abuse and/or neglect. The resident's comprehensive assessment revealed a history of suspected abuse and/or neglect or factors that may increase and/or personality that draws him/her susceptibility to abuse/neglect. A history of unhealthy, even abusive, relationships. Behavior that might be characterized as provoking include antagonizing, disrespectful, angry, insensitive, and/or annoying, behavioral symptoms, difficulty in adjustment and generalized mood distress. Symptoms may be manifested by: observable signs of distress, psychosocial distress, disturbed functioning, The resident demonstrated verbal expressions of distress. Interventions include but were not limited to reviewing assessment information; emphasize treatment causal factors and/or interventions designed to moderate/reduce symptoms; establish a counseling schedule with the resident; encourage the resident to verbalize/share thoughts, anxieties, fears, concerns, and general feelings; assure the resident that he/she was in a safe and secure environment with caring professionals; explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (i.e., social worker, nurse, nursing assistant, peer) and by verbalizing thoughts, needs and feelings; observe the resident for signs of fear and insecurity during delivery of care; take steps to calm the resident and help her feel safe; assure the resident that staff members are available to help, and department heads maintain an open door' policy. Review of the plan of care for Resident #12 dated 02/15/23 with a revision date of 02/21/23 revealed Resident #12 was incontinent of bowel and bladder. Interventions included but were not limited to check resident as needed and assist with toileting as needed, provide loose fitting easy to remove clothing and provide peri-care after each incontinent episode. Review of nurse progress note dated 03/24/23 at 4:45 A.M. revealed the fire department arrived at the facility at approximately 04:30 A.M. and notified staff that a call was received concerning resident care. Resident #12 alleged that she was attacked when provided care. Review of the Self Reported Incident (SRI) #233305, submitted by the facility, dated 03/24/23 and timed 9:56 A.M., revealed on 03/24/23 Resident #12 alleged she had been attacked by three staff members. Administrator notified and an investigation initiated. Staff were suspended pending investigation. Resident was interviewed by Social Service Designee #549 on 03/24/23, Police on 03/24/23 and Supervising Ombudsman on 03/24/23. Resident #12's story had not been consistent throughout the investigation from she was attacked, to she was molested, to she was angry they changed her. SSD #549 asked Resident #12 about being molested and resident #12 stated oh no honey, I told you, I was attacked getting my diaper changed. She stated she doesn't want a male care giver. Resident #12 further stated she likes State Tested Nursing Assistant (STNA) #557 because she gives her time to turn and is gentle. Resident #12 states she is incontinent of bowel and bladder. Resident #12 wants staff to wait until she is ready to be changed and for them to be patient with her turning. Police were notified and arrived at approximately 4:00 A.M. Police interviewed Resident #12, who claimed she was assaulted by three staff members. The fire department also arrived and assessed Resident #12 with no injury or abuse noted. On 03/29/23, Administrator spoke with the Ombudsman who interviewed Resident #12 on 03/24/23 in person. Ombudsman stated he has known Resident #12 for a long time and is familiar with her. He stated she presents some unique challenges for the facilities in which she has resided in. Ombudsman stated resident #12 said she was attacked by three staff members at 3:00 A.M. Ombudsman further stated he did not observe any bruising or injury and did not have any evidence that abuse occurred. Resident #12 was asked if she would like to be moved and she stated she just didn't want those staff members to care for her. Review of a SRI witness statement dated 03/24/23 at 1:10 P.M. by Regional Clinical Support (RCS) #601 and Human Resource Director #548 revealed a telephone interview with STNA #563. STNA #563 stated Licensed Practical Nurse (LPN) #511 went to change Resident #12 and then came out of the resident's room and called Registered Nurse (RN) #504 down to the room and both nurses then went down to the resident's room. STNA #563 stated, a short time later, he was called down to the resident's room because they needed help to lay the resident down. STNA #563 stated when he arrived in the resident's room, the resident was sitting up in bed. STNA #563 stated he was on the right side of the resident and RN #504 was on the left side of the resident with a dirty brief in her hand. STNA #563 stated he was informed by LPN #511 and RN #504 that the resident was in pain but refused any pain medications and that the resident had been combative with them prior to his arrival to the resident's room. STNA #563 stated Resident #12 didn't become combative at all while he was present in the room. STNA #563 stated he assisted the resident to lay down by the resident's shoulders and gently laid her down in bed. STNA #563 stated Resident #12 wasn't on the pad and they just needed his help to reposition her on the bed. STNA #563 stated once the nurses put a new brief on the resident, they all left the resident's room. STNA #563 stated that at no time did he secure the resident's hands. STNA #563 stated he just repositioned her in the bed by her shoulders and didn't touch the resident's hands. STNA #563 stated the police and fire department arrived at the facility and spoke to LPN #511. Review of the SRI witness statement dated 03/24/23 at 1:21 P.M. by Regional Clinical Support (RCS) #601 and Human Resource Director # 548 revealed a telephone interview with RN #504. RN #504 stated Resident #12 refused to allow STNA #563 to change because she was incontinent. RN #504 stated Resident #12 was soaked with feces and urine up to her bra. RN #504 stated LPN #511 tried to perform incontinence care, but Resident #12 refused saying, Don't touch me, leave me as I am. RN #504 stated that all three staff members: herself, LPN #511, and STNA #563 went to resident's room to reapproach but stated the resident was still refusing at that time. RN #504 stated the resident became combative by Resident #12 hitting and pushing her. RN #504 stated she initially tried to hold the resident's hands to keep the resident from hitting her, but states STNA #563 took over holding the resident's hands while LPN #511 and her performed incontinence care on the resident. RN #504 stated Resident #12 was stating for them not to touch her and to leave her the way that she was and refusing to have care provided. RN #504 states that as soon as the care was quickly provided, LPN #511, STNA #563 and she left the resident's room. RN #504 stated that one police officer and two or three EMTs arrived at facility around 4:00 A.M. RN #504 stated Resident #12 called someone who then called the police. RN #504 stated the police officer and EMTs went in to speak to Resident #12 and came back out and stated the resident stated she had been molested by three staff members. RN #504 stated the EMTs stated they checked the resident over and didn't see any wounds, or obvious signs of molestation, abuse, or neglect. RN #504 stated that the police officer asked for a diagnosis list, and one was provided. RN #504 stated EMTs offered to take the resident to the hospital for safety and the resident refused to go. RN #504 stated she was aware of resident rights and was aware of the right to refuse care. RN #504 stated she felt if she would've left the resident covered in feces and urine it would've been neglect and felt she had to do something. Review of the SRI witness statement dated 03/24/23 at 1:05 P.M. by Regional Clinical Support (RCS) #601 and Human Resource Director # 548 revealed a telephone interview with LPN #511. LPN #511 stated STNA #563 asked her at 12:00 A.M. to be the STNA for Resident #12 due to resident #12 wouldn't allow STNA #563 to perform care. Review of the time punch card dated 03/24/23 revealed the LPN #511 punched out at 7:22 A.M. at the end of her shift revealing the LPN continued to work after the allegation of abuse was made on 03/24/23 at 4:00 A.M Review of the time punch card dated 03/24/23 revealed RN #504 punched out at 7:21 A.M. at the end of her shift and revealing the RN continued to work after the allegation of abuse was made on 03/24/23 at 4:00 A.M. Review of the time punch card dated 03/24/23 revealed STNA #563 punched out at 6:06 A.M. at the end of his shift revealing the STNA continued to work after the allegation of abuse was made on 03/24/23 at 4:00 A.M. Observation and interview made on 03/27/23 at 10:14 A.M. revealed Resident #12 was sitting up in bed. Resident #12 stated she was assaulted by a white man many years ago and showed this surveyor her scars on her legs and arms, and no bruises of any color were located on her body. Resident #12 stated recently, she could not remember the date, one male and two female aides came into her room and beat her up. Resident #12 stated because her one eye was dead and the other was not wonderful she couldn't tell who was were, and she did not recognize faces or characteristics. Resident #12 stated she does not care about people. She stated that she was not sure if they work here but they were wearing blue smocks at 3:00 A.M. Resident # 12 could not give a date. Resident # 12 stated that she cannot walk or stand. Interview on 03/29/23 at 1:52 P.M. with Assistant Director of Nursing (ADON) revealed she was notified of Resident #12's allegation of abuse when she came into work. The nurses (LPN #511 and RN #504) told ADON as they were walking out that resident #12 still had fecal matter on her and she was resisting care last night. ADON stated she told the nurses to write a statement, but they didn't. Interview on 03/30/23 at 3:29 P.M. with Administrator and Director of Nursing (DON) revealed Resident #12's orders and care plan were updated after the incident on 03/24/23 to not have male care givers. Administrator stated STNA #563 had asked LPN #511 to assist in taking care of Resident #12 because she would not allow him. DON stated Resident #12 will not allow male aides to check and change her or perform incontinence care. Administrator stated LPN #511 called STNA #563 and RN #504 for assistance. STNA #563 did not perform care, he was just in the room. Administrator stated that she was the Abuse Coordinator for the facility and was notified between 8:00 A.M. and 8:30 A.M. of the Resident #12's allegation of abuse via phone because she was off on 03/24/23. The Administrator revealed the Assistant Director of Nursing (ADON) was notified via text message by a nurse of the incident. The Administrator stated the Assistant Director of Nursing (ADON) must have missed the text because she was a nurse on duty that night. Director of Nursing (DON) stated he was notified by the ADON when he walked through the door of the facility between 8:00 A.M. and 8:30 A.M. and then DON notified the Administrator. Neither LPN #511, STNA #563 or RN #504 documented in Resident #12's electronic record about refusing care on 03/24/23 or about the incident. The Administrator stated staff should know how to go up the chain of command if they could not get a hold of whoever they called, especially for abuse. The Administrator also stated nursing probably forgot to document anything because of what was going on throughout their shift. DON stated he didn't have time to document in the electronic chart until 7:11 P.M. on 03/24/23, assessed the resident at 10:00 A.M. with the charge nurse, but did not have evidence Resident #12 was assessed after the incident until 2:45 P.M. The Administrator stated the EMT's assessed her and found no evidence of abuse or neglect. Interview on 03/30/23 at 4:00 P.M. with Administrator and DON verified LPN #511, STNA #563 or RN #504 finished their shifts on 03/24/23 and were not removed at 4:00 A.M. when the abuse was reported by the police. Phone interview on 03/30/23 at 4:43 P.M. with LPN #511 revealed she called DON and ADON by phone to report the incident involving Resident #12 on 03/24/23. DON did not answer but ADON stated that she was coming in and the events all happened so fast. LPN #511 revealed Resident #12 was flailing her arms, STNA #563 was on the left side closer to the headboard and STNA #563 had its arms around the resident's arms, but she could move her arms freely. Phone interview on 03/30/23 at 4:50 P.M. with STNA #563 revealed he assisted in repositioning Resident #12 by putting his arms around her arms. He stated that he was standing on the left side of the bed and had to move the resident to the middle of the bed so that care could be provided. Resident #12 was complaining of pain while she was elevated to provide care. STNA #563 stated he left the room after she was repositioned and didn't hold her wrists and there were no signs of abuse. Phone interview on 03/30/23 at 5:45 P.M. with RN #504 revealed Resident #12 was resisting care and had urine and feces all over her. Resident #12 refused STNA #563 from providing care. Resident #12 started swinging, so STNA #563 held her hand inside his hand. She and LPN #511 provided the care, and incontinence care took less than two minutes. RN #504 revealed DON was called at 4:00 A.M. but it went to voicemail and the ADON then was called and she said she was coming in. Review the personnel records for LPN #511, RN #504 and STNA #563 revealed they were disciplined for violation of resident rights in relation to the alleged abuse incident. Review of facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/2022, revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint that is not required to treat the resident's medical symptoms. The meaning of physical abuse is any manual method, or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement. Freedom of movement means any change in place or position of the body or any part of the body that the resident is physically able to control. The facility will educate its staff upon hire and annually thereafter regarding the facility's policy concerning Abuse, Neglect, Exploitation, Misappropriation of resident's property, and how to handle resident-to-resident Abuse and Injuries of Unknown Source. These training sessions will include, but not necessarily be limited to, the following topics: how to identify what constitutes Abuse, Neglect, Exploitation or Misappropriation of resident property and how to recognize signs of Abuse, Neglect, Exploitation or Misappropriation of resident property; how staff should report their knowledge related to allegations without fear of reprisal; how to recognize signs of burnout, frustration and stress; understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond; appropriate interventions to deal with aggressive and/or catastrophic reactions of resident; and dementia management and abuse prevention. (Catastrophic reactions mean extraordinary reactions of residents to ordinary stimuli, such as the attempt to provide care.) Documentation in the nurses' notes should include the results of the resident's assessment, notification of the physician and the Resident Representative, and any treatment provided. Appropriate quality assurance documentation should be completed as well. All incidents and allegations of Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of resident property and all Injuries of Unknown Source must be reported immediately to the Administrator or designee. The Administrator/designee should be notified by informing him/her in person, calling via telephone, or sending an email or text message. If any form of abuse is alleged (e.g., physical, verbal, etc.) or Serious Bodily Injury is identified related to any other reportable incident (e.g., Injury of Unknown Source or allegation of Neglect involving serious bodily injury), the Administrator or his/her designee will notify ODH Immediately, but not later than 2 hours after the allegation is made or the serious bodily injury identified. This deficiency represents non-compliance investigated under Complaint Number OH00141432 and Complaint Number OH00141557.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure proper incontinence care was provided to Resident #16. This affected one resident (Resident #16) out of two residents who were reviewed incontinence care. Findings included: Resident #16 was admitted to the facility on [DATE]. Her admitting diagnoses included anemia, hypertension, type II diabetes, Alzheimer's Disease, a central venous attack (CVA), and dementia. Review of Resident #16's Minimum Data assessment dated [DATE] revealed this resident had moderate cognitive impairment. Functionally, she needed extensive assistance of one staff member for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of her bowel and bladder assessment of this MDS revealed the resident was always incontinent of bladder and frequently incontinent of bowel. Observation of Resident #16 on 03/28/23 at 3:00 P.M. revealed two State Tested Nursing Assistants (STNA) provided incontinence care to this resident. The resident was positioned flat on her back. State Tested Nursing Assistant #509 assisted the resident to separate her legs. STNA #547 then proceeded to wash the resident peri area. She washed this female resident from back to front once down the middle and then switched to a different side of her washcloth and washed on her left/right side from back to front. Interview with Corporate Regional Support #581, who was also observing the care with this surveyor, verified the STNA did clean the resident's perineal area from back to front. Review of the facility policy titled, Incontinence Care, dated 03/15 revealed the facility failed to follow their policy regarding washing of the resident's perineal area with downward strokes. This deficiency represents non-compliance investigated under Complaint Number OH00141557.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure Resident #38 received his nutritional supplement as ordered. This affected one resident (Resident #38) out of two residents reviewed for nutritional needs. Findings included: Review of medical record for Resident #38 revealed an admission date of 02/20/23 and his diagnoses included catatonic schizophrenia, dementia, dysphagia, and depression. Review of weight record for Resident #38 revealed on 02/20/23 his admission weight was 163 pounds. The weight record revealed Resident #38 had weight loss as his weight on 03/20/23 was 155.2 pounds which was a three percent change over the last 30 days. His weight remained on 03/28/23 at 155 pounds. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was rarely and/ or never understood. He required extensive assistance of one person with eating. His weight was recorded as 165 pounds with no weight loss. He was on a mechanically altered diet. Review of care plan dated 02/24/23 revealed Resident #38 had a nutritional problem related to catatonic schizophrenia, and dysphagia. He received a mechanically altered diet as well as received enteral nutrition through a peg tube. Interventions included monitor for signs of dysphagia included pocketing and choking, provide and serve diet as ordered, and dietitian to evaluate and make diet changes as needed. There was nothing per his care plan regarding receiving oral nutritional supplements. Review of March 2023 physician orders revealed Resident #38 had an order dated 03/08/23 to receive a Boost supplement twice a day. He also had an order dated 03/14/23 to receive a house supplement with meals due to weight loss. Review of written telephone order dated 03/14/23 and completed by Nurse Practitioner (NP) #585 revealed Resident #38 was to receive a house supplement three times a day. The order also noted to have the dietician evaluate due to weight loss and look at possibly restarting his tube feedings. Review of Nutritional progress note dated 03/17/23 at 12:14 P.M. and completed by Dietitian #586 revealed she recommended Resident #38 receive Isosource 1.5 250 milliliter bolus tube feedings three times a day as the tube feeding would provide 1125 calories. The note revealed tube feedings and oral intakes would meet Resident #38's nutritional needs. There was nothing in the progress note regarding his supplements including if Resident #38 was to continue to receive his already ordered boost supplement twice a day and house supplement three times a day. Observation on 03/29/23 at 8:00 A.M. revealed Resident #38 received his breakfast tray of a regular pureed diet from State Tested Nursing Assistant (STNA) #540. There was no supplement on the tray. She set Resident #38's tray up and he began to eat independently. Observation of Resident #38's tray ticket on 03/29/23 at 8:08 A.M. with STNA #540 revealed he was to receive a puree diet. The ticket revealed nothing in regards to Resident #38 to receive a supplement at mealtime. Interview on 03/29/23 at 8:08 A.M. with STNA #540 revealed the dietary department sent down the supplements if a resident was to receive at mealtime. She revealed she also went by what was on the meal tray ticket as to if a resident was supposed to receive a supplement. She verified Resident #38 did not receive a supplement and that on his meal ticket there was no supplement listed that he was to receive one at meals. She revealed she worked on the secured unit on a routine basis and she had never seen Resident #38 receive a supplement on his tray. Interview on 03/29/23 at 8:17 A.M. with Licensed Practical Nurse (LPN) #520 verified on review of his physician orders revealed Resident #38 had two oral supplements ordered: one dated 03/08/23 to receive a Boost supplement twice a day and then another order dated 03/14/23 to receive a house supplement with meals due to weight loss. Phone interview on 03/29/23 at 8:49 A.M. with Dietician #586 revealed she had last reviewed Resident #38 due to weight loss. She revealed she re- initiated his peg tube feeding that included Isosource 1.5 one carton three times a day per peg tube. She revealed on review of his current orders he still had two additional supplement orders: one dated 03/08/23 to receive a Boost supplement twice a day and then another order dated 03/14/23 to receive a house supplement with meals due to weight loss. She revealed she felt she most likely should have discontinued his boost supplement twice a day but had overlooked it but that he should have been still receiving the house supplement with meals. Observation on 03/29/23 at 11:55 A.M. revealed STNA #540 had passed Resident #38 his lunch tray and there was no supplement on his tray. Interview on 03/29/23 at 11:55 A.M. with STNA #540 revealed Resident #38's tray ticket continued to not list that he was to receive a supplement. Interview on 03/29/23 at 12:39 P.M. with Regional Culinary #587 that was working as the Dietary Manager in the facility on 03/29/23. She revealed the nutritional supplements that were ordered to be given at meals were to come from the kitchen on the resident's tray. She revealed the residents tray ticket was to indicate if a resident was to receive a nutritional supplement with their meal. She revealed she had not received any call from the Dietitian #596 regarding Resident #38 that he was to receive a house supplement with meals. She verified the kitchen did not have this listed on his meal ticket to receive a house supplement with his meals and verified she was unsure where the miscommunication occurred regarding Resident #38 as she verified he had a physician order for a house supplement three time a day with his meals as they should have received a dietary communication slip of the new order and the kitchen would have placed the new order on his meal ticket. Review of policy labeled, Weight Policy dated April 2001 revealed weights would be obtained in a timely and accurate manner, documented, and responded to in an appropriate manner. The dietician or physician may order specific nutritional interventions, supplements, or other interventions if indicated. The supplements would be provided on the resident's tray or disbursed by the nursing staff.

Based on observation, interview and record review, the facility failed to ensure oxygen orders were in place for Residents #14 and #18. This affected two residents (Resident #14 and Resident #18) of two residents reviewed for respiratory care. The facility census was 53. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 12/04/20 with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and chronic respiratory failure with hypoxia. Review of the physician's orders for March 2023 revealed there were no orders for Resident #14 to have oxygen. Observation on 03/27/23 at 9:56 A.M. of Resident #14 revealed she had oxygen on via a nasal cannula and the oxygen concentrator was set at three liters. Interview with Resident #14 revealed she always had oxygen on. Interview on 03/27/23 at 10:28 A.M. with Registered Nurse (RN) #576 verified Resident #14 had oxygen on at 3 liters and she did not have a physician's order. Review of the facility policy titled, Oxygen Handling, revised January 2021, revealed a physician's order was required for routine and as needed use of oxygen. 2. Review of the medical record for Resident #18 revealed an admission date of 07/16/22 with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and asthma. Review of the physician's orders for March 2023 revealed there were no orders for Resident #18 to have oxygen. Observation and interview on 03/27/23 at 10:22 A.M. of Resident #18 revealed he had oxygen concentrator turned off sitting in the corner of his room by his bed. He stated he used oxygen a couple of times during the day and always at night. Interview on 03/27/23 at 10:28 A.M. with Registered Nurse (RN) #576 verified Resident #18 did not have a physician's order for oxygen. Review of the facility policy titled, Oxygen Handling, revised January 2021, revealed a physician's order was required for routine and as needed use of oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure dialysis residents were monitored before and after dialysis treatments. This affected one (Resident #2) of one resident receiving dialysis. The facility census was 53. Findings include: Review of the medical record revealed Resident #2 was admitted on [DATE] with diagnoses including chronic kidney disease and dependence on renal dialysis. Review of the physician's order dated 11/29/22 for Resident #2 revealed he had dialysis on Mondays, Wednesday and Fridays. Staff were to obtain vital signs before and after dialysis. Review of Resident #2's assessments for March 2023 revealed dialysis assessments were not completed prior to dialysis. Dialysis assessments for Resident #2 were only completed after dialysis on 03/01/23, 03/13/23, 03/15/23 and 03/20/23. Interview on 03/29/23 at 9:09 A.M. with the Director of Nursing (DON) verified Resident #2's dialysis assessments were not completed as stated above. He stated it was the facility's policy that nursing staff were to complete dialysis assessments prior to and after dialysis. The DON stated the reason why the assessments were not completed were due to having agency nursing staff. Review of the facility policy titled, Communication: Dialysis Centers, revised December 2021, revealed facility staff were to complete the electronic assessment's first portion prior to the resident leaving for the dialysis appointment. The dialysis staff were to complete the second section. The third section was to be completed by the facility nurse upon return from dialysis.

Based on record review, interview, and facility policy review, the facility failed to ensure care planned interventions were implemented to provide Resident #12 comfort and opportunities for choice during care and to maintain the highest practicable mental and psycho-social well being. This affected one resident (Resident #12) out of one resident reviewed for behavioral health services. Findings include: Review of the medical record for the Resident #12 revealed an admission date of 02/10/23. Diagnoses included dementia, diabetes mellitus, post-traumatic stress disorder, major depressive disorder, heart failure and anxiety disorder. Review of the physician orders dated 02/10/23 revealed an order for psychology consult as needed. Review of the physician orders dated 02/14/23 revealed Resident #12 required a room on the secured unit to promote psychosocial well-being and interactions with peers. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/17/23, revealed the resident had intact cognition. The resident required extensive assistance of two staff for bed mobility and transfers. Further review of the MDS revealed that Resident #12 had psychiatric/mood disorder of PTSD and had verbal and other behaviors that occurred one to three days during the assessment look back period. Review of the plan of care for Resident #12 dated 02/15/23 and a revision date of 02/28/23 revealed Resident #12 had a traumatic event identified as physical abuse by a homecare worker in 2019 with injury. Resident #12 ' s triggers were identified as receiving care. Resident #12 would make false allegations of abuse and refuses medications at times. Interventions include but were not limited to allow resident to express feelings when triggers are identified, develop strategies with resident to avoid or decrease trauma triggers, and staff being aware of triggers or potential triggers and understand strategies to assist resident in avoiding. Review of the plan of care for Resident #12 dated 02/15/23 and a revision date of 03/14/23 revealed Resident #12 was resistive to care related to anxiety and dementia. Resident #12 would refuse to allow staff to assist with personal care, refuse medications and weights. Interventions included but were not limited to allow resident to make decisions about treatment regimen, give clear explanation of all care activities, if resident resisted activities of daily living (ADLs), reassure resident, leave and return five to ten minutes later and try again, provide consistency in care to promote comfort and provide resident with opportunities for choice during care provision. Review of the plan of care for Resident #12 dated 02/15/23 revealed the resident had a history of suspected abuse and/or neglect. The resident's comprehensive assessment revealed a history of suspected abuse and/or neglect or factors that may increase and/or personality that draws him/her susceptibility to abuse/neglect. A history of unhealthy, even abusive, relationships. Behavior that might be characterized as provoking include antagonizing, disrespectful, angry, insensitive, and/or annoying, behavioral symptoms, difficulty in adjustment and generalized mood distress. Symptoms may be manifested by: observable signs of distress, psychosocial distress, disturbed functioning, The resident demonstrated verbal expressions of distress. Interventions include but were not limited to reviewing assessment information; emphasize treatment causal factors and/or interventions designed to moderate/reduce symptoms; establish a counseling schedule with the resident; encourage the resident to verbalize/share thoughts, anxieties, fears, concerns, and general feelings; assure the resident that he/she was in a safe and secure environment with caring professionals; explain that psychosocial adjustment is often facilitated by developing a trusting relationship with another person (i.e., social worker, nurse, nursing assistant, peer) and by verbalizing thoughts, needs and feelings; observe the resident for signs of fear and insecurity during delivery of care; take steps to calm the resident and help her feel safe; assure the resident that staff members are available to help, and department heads maintain an open door' policy. Review of the plan of care for Resident #12 dated 02/15/23 with a revision date of 02/21/23 revealed Resident #12 was incontinent of bowel and bladder. Interventions included but were not limited to check resident as needed and assist with toileting as needed, provide loose fitting easy to remove clothing and provide peri-care after each incontinent episode. Review of the physician orders dated 02/28/23 revealed a verbal order for psych consult and treat. The medical record contained no evidence the resident had a psych consult to treat. Review of nurse progress note dated 03/24/23 at 4:45 A.M. revealed the fire department arrived at the facility at approximately 04:30 A.M. and notified staff that a call was received concerning resident care. Resident #12 alleged that she was attacked when provided care. Review of the Self Reported Incident (SRI) #233305, submitted by the facility, dated 03/24/23 and timed 9:56 A.M., revealed on 03/24/23 Resident #12 alleged she had been attacked by three staff members. Administrator notified and an investigation initiated. Staff were suspended pending investigation. Resident was interviewed by Social Service Designee #549 on 03/24/23, Police on 03/24/23 and Supervising Ombudsman on 03/24/23. Resident #12's story had not been consistent throughout the investigation from she was attacked, to she was molested, to she was angry they changed her. SSD #549 asked Resident #12 about being molested and resident #12 stated oh no honey, I told you, I was attacked getting my diaper changed. She stated she doesn't want a male care giver. Resident #12 further stated she likes State Tested Nursing Assistant (STNA) #557 because she gives her time to turn and is gentle. Resident #12 states she is incontinent of bowel and bladder. Resident #12 wants staff to wait until she is ready to be changed and for them to be patient with her turning. Police were notified and arrived at approximately 4:00 A.M. Police interviewed Resident #12, who claimed she was assaulted by three staff members. The fire department also arrived and assessed Resident #12 with no injury or abuse noted. On 03/29/23, Administrator spoke with the Ombudsman who interviewed Resident #12 on 03/24/23 in person. Ombudsman stated he has known Resident #12 for a long time and is familiar with her. He stated she presents some unique challenges for the facilities in which she has resided in. Ombudsman stated resident #12 said she was attacked by three staff members at 3:00 A.M. Ombudsman further stated he did not observe any bruising or injury and did not have any evidence that abuse occurred. Resident #12 was asked if she would like to be moved and she stated she just didn't want those staff members to care for her. Review of a SRI witness statement dated 03/24/23 at 1:10 P.M. by Regional Clinical Support (RCS) #601 and Human Resource Director #548 revealed a telephone interview with STNA #563. STNA #563 stated Licensed Practical Nurse (LPN) #511 went to change Resident #12 and then came out of the resident's room and called Registered Nurse (RN) #504 down to the room and both nurses then went down to the resident's room. STNA #563 stated, a short time later, he was called down to the resident's room because they needed help to lay the resident down. STNA #563 stated when he arrived in the resident's room, the resident was sitting up in bed. STNA #563 stated he was on the right side of the resident and RN #504 was on the left side of the resident with a dirty brief in her hand. STNA #563 stated he was informed by LPN #511 and RN #504 that the resident was in pain but refused any pain medications and that the resident had been combative with them prior to his arrival to the resident's room. STNA #563 stated Resident #12 didn't become combative at all while he was present in the room. STNA #563 stated he assisted the resident to lay down by the resident's shoulders and gently laid her down in bed. STNA #563 stated Resident #12 wasn't on the pad and they just needed his help to reposition her on the bed. STNA #563 stated once the nurses put a new brief on the resident, they all left the resident's room. STNA #563 stated that at no time did he secure the resident's hands. STNA #563 stated he just repositioned her in the bed by her shoulders and didn't touch the resident's hands. STNA #563 stated the police and fire department arrived at the facility and spoke to LPN #511. Review of the SRI witness statement dated 03/24/23 at 1:21 P.M. by Regional Clinical Support (RCS) #601 and Human Resource Director # 548 revealed a telephone interview with RN #504. RN #504 stated Resident #12 refused to allow STNA #563 to change because she was incontinent. RN #504 stated Resident #12 was soaked with feces and urine up to her bra. RN #504 stated LPN #511 tried to perform incontinence care, but Resident #12 refused saying, Don't touch me, leave me as I am. RN #504 stated that all three staff members: herself, LPN #511, and STNA #563 went to resident's room to reapproach but stated the resident was still refusing at that time. RN #504 stated the resident became combative by Resident #12 hitting and pushing her. RN #504 stated she initially tried to hold the resident's hands to keep the resident from hitting her, but states STNA #563 took over holding the resident's hands while LPN #511 and her performed incontinence care on the resident. RN #504 stated Resident #12 was stating for them not to touch her and to leave her the way that she was and refusing to have care provided. RN #504 states that as soon as the care was quickly provided, LPN #511, STNA #563 and she left the resident's room. RN #504 stated that one police officer and two or three EMTs arrived at facility around 4:00 A.M. RN #504 stated Resident #12 called someone who then called the police. RN #504 stated the police officer and EMTs went in to speak to Resident #12 and came back out and stated the resident stated she had been molested by three staff members. RN #504 stated the EMTs stated they checked the resident over and didn't see any wounds, or obvious signs of molestation, abuse, or neglect. RN #504 stated that the police officer asked for a diagnosis list, and one was provided. RN #504 stated EMTs offered to take the resident to the hospital for safety and the resident refused to go. RN #504 stated she was aware of resident rights and was aware of the right to refuse care. RN #504 stated she felt if she would've left the resident covered in feces and urine it would've been neglect and felt she had to do something. Review of the SRI witness statement dated 03/24/23 at 1:05 P.M. by Regional Clinical Support (RCS) #601 and Human Resource Director # 548 revealed a telephone interview with LPN #511. LPN #511 stated STNA #563 asked her at 12:00 A.M. to be the STNA for Resident #12 due to resident #12 wouldn't allow STNA #563 to perform care. Observation and interview made on 03/27/23 at 10:14 A.M. revealed Resident #12 was sitting up in bed. Resident #12 stated she was assaulted by a white man many years ago and showed this surveyor her scars on her legs and arms, and no bruises of any color were located on her body. Resident #12 stated recently, she could not remember the date, one male and two female aides came into her room and beat her up. Resident #12 stated because her one eye was dead and the other was not wonderful she couldn ' t tell who was were, and she did not recognize faces or characteristics. Resident #12 stated she does not care about people. She stated that she was not sure if they work here but they were wearing blue smocks at 3:00 A.M. Resident # 12 could not give a date. Resident # 12 stated that she cannot walk or stand. Interview on 03/30/23 at 3:29 P.M. with Administrator and Director of Nursing (DON) revealed Resident #12 ' s orders and care plan were updated after the incident on 03/24/23 to not have male care givers. Administrator stated STNA #563 had asked LPN #511 to assist in taking care of Resident #12 because she would not allow him. DON stated Resident #12 will not allow male aides to check and change her or perform incontinence care. Neither LPN #511, STNA #563 or RN #504 documented in Resident #12's electronic record about refusing care on 03/24/23 or about the incident. The Administrator stated staff should know how to go up the chain of command if they could not get a hold of whoever they called, especially for abuse. The Administrator also stated nursing probably forgot to document anything because of what was going on throughout their shift. Interview on 03/30/23 at 3:50 P.M. with Social Services Designee (SSD) # 549 revealed verbal consent from Resident #12 on 02/15/23 for psych services. SSD #549 stated she sent over the referral on 02/28/23 with a face sheet to get her on the list. SSD #549 stated Resident #12 has not had a psych visit as of this time. The counselor stated he did not get the referral yet when he was at the facility on 03/29/23. The counselor comes every Wednesday. SSD #549 revealed she did not catch that Resident #12 had not been seen by a psychologist. Phone interview on 03/30/23 at 4:43 P.M. with LPN #511 revealed she called DON and ADON by phone to report the incident involving Resident #12 on 03/24/23. DON did not answer but ADON stated that she was coming in and the events all happened so fast. LPN #511 revealed Resident #12 was flailing her arms, STNA #563 was on the left side closer to the headboard and STNA #563 had its arms around the resident ' s arms, but she could move her arms freely. Phone interview on 03/30/23 at 4:50 P.M. with STNA #563 revealed he assisted in repositioning Resident #12 by putting his arms around her arms. He stated that he was standing on the left side of the bed and had to move the resident to the middle of the bed so that care could be provided. Resident #12 was complaining of pain while she was elevated to provide care. STNA #563 stated he left the room after she was repositioned and didn ' t hold her wrists and there were no signs of abuse. Phone interview on 03/30/23 at 5:45 P.M. with RN #504 revealed Resident #12 was resisting care and had urine and feces all over her. Resident #12 refused STNA #563 from providing care. Resident #12 started swinging, so STNA #563 held her hand inside his hand. She and LPN #511 provided the care, and incontinence care took less than two minutes. RN #504 revealed DON was called at 4:00 A.M. but it went to voicemail and the ADON then was called and she said she was coming in. Review of the facility policy dated 10/22 titled, Trauma Informed Care, revealed the facility strived to ensure that residents who are trauma survivors receive trauma-informed care services in accordance with professional standards of practice and accounting for residents' experiences and preference to eliminate or mitigate triggers that may cause re-traumatization of the resident. The facility will deliver care and services using approaches which are culturally competent and account for experiences and preferences that address the needs of trauma survivors. This includes principles including safety, trustworthiness, and transparency, peer support, and mutual self-help, collaboration, empowerment, voice, and choice. This deficiency represents non-compliance investigated under Complaint Number OH00141432.

Based on observation, interview and record review, the facility failed to honor food preferences. This affected two residents (#12 and #47) out of two residents for food preferences. The facility census was 53. Findings include: 1. Review of the medical record for the Resident #12 revealed an admission date of 02/10/23. Diagnoses included dementia, diabetes mellitus, post-traumatic stress disorder, major depressive disorder, heart failure and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/17/23, revealed the resident had intact cognition. The resident required extensive assistance of two staff for bed mobility and transfers. The resident required supervision with eating and received a therapeutic diet. Review of physician's orders for March 2023 revealed Resident #12 received a consistent carbohydrate diet (CCD), regular texture with thin consistency liquids. Review of the Resident #12's diet tray ticket revealed Resident #12 received a renal CCD diet with no dislikes or preferences mentioned. It indicated a house nutritional shake to be given. Review of Resident #12's preference sheet provided by Regional Culinary Director #602 revealed Resident #12 did not like gravy and did not like many vegetables. Observation and interview on 03/29/23 at 12:16 P.M. with Resident # 12 revealed she did not like the lunch tray. The lunch tray had a pork chop, collard greens and rice as an entrée. Resident #12 stated she did not have a selective menu to choose from today. She stated that she does not like spicy foods, broccoli, salt, salty foods and pepper. She received a house shake but doesn't like them. She stated she has been a diabetic for years and would like a snack at night but only gets cheese and peanut butter crackers but they are too salty. She does not like chocolate. Resident #12 stated that she asked several times to talk to a dietitian, but the dietitian had not come to see her. Interview with Regional Culinary Director #602 on 03/29/23 at 1:20 P.M. verified Resident #12's food preference sheet and diet ticket did not match. 2. Review of the medical record for Resident #47 revealed an admission date of 02/26/22. Diagnoses included but were not limited to dementia and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment for Resident #47, dated 12/31/22, revealed the resident's cognition for decision making was not assessed. The resident required extensive assistance of one staff for bed mobility, supervision with one staff for transfer and locomotion. Review of physician's orders for March 2023 revealed Resident #47 received a no restrictions diet with regular texture and thin consistency liquids. Review of the Resident #47's diet tray ticket revealed Resident #47 received a regular diet with no dislikes and the only preference mentioned was white bread and soup was permitted. Review of Resident #47's food preference sheet provided by Regional Culinary Director #602 revealed the resident did not like stroganoffs, preferred white bread, and soup was permitted. On 03/27/23 at 10:55 A.M. family member for Resident # 47 stated he requested that Resident #47 receive finger foods due to his father eating finger foods better because he likes to make sandwiches out of items but the kitchen cannot seem to deliver them. Observation on 03/29/23 at 12:01 P.M. revealed Resident # 47 was sitting on the side of bed with his lunch tray in front of him. His family was sitting in the room. When the surveyor said hello, Resident #47 shook his head and said no several times. The family member stated that he had one piece of bread and put his ham in between it and had a sandwich. Interview with Regional Culinary Director #602 on 03/29/23 at 1:20 P.M. verified Resident #47's food preference sheet and diet ticket did not match, and there was no mention of his preferred finger foods. Phone interview on 03/29/23 at 8:52 A.M. with Registered Dietitian (RD) #586 revealed she comes into the facility every Friday. RD #586 stated it was the responsibility of the dietary manager to visit residents for food preferences. Interview on 03/29/23 at 2:30 P.M. with Administrator revealed Resident #47's family had a care conference a little over a month ago and it was mentioned about finger foods, and bread was served as the finger food. Review of the spreadsheets/production sheets revealed there was no diet extension for finger foods until 03/30/23. Review of undated facility policy titled Resident Food Preferences, revealed dietary professionals will visit residents periodically to determine if revisions are needed regarding food preferences. The nursing staff will inform the kitchen about resident requests. This deficiency represents non-compliance investigated under Complaint Number OH00141432 and Complaint Number OH00141557.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff followed enhanced barrier precautions during wound care, and failed to ensure staff followed infection control standards to prevent cross contamination in regards to use of a glucometer. This affected one (Resident #22) of one resident reviewed for wound care and two (Residents #2 and #20) of two residents reviewed for blood sugar checks with a glucometer. Findings include: 1. Review of the medical record revealed Resident #22 was admitted on [DATE] with diagnoses including dementia and a pressure ulcer to the sacral region. Review of the physician's orders for Resident #22 revealed an order for enhanced barrier precautions related to catheter and wound care dated 01/09/23. Observation on 03/28/23 at 1:00 P.M. of wound care with Licensed Practical Nurse (LPN) #561 to Resident #22 revealed she was on Enhanced Barrier Precautions. There was signage on the door stating Enhanced barrier precautions, everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: Dressing, bathing/shower, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use including central line, urinary catheter, feeding tube, tracheostomy, and wound care: any skin opening requiring a dressing. There was a cart outside of the room beside the door which had an adequate supply of personal protective equipment including gowns and gloves. LPN #561 gathered her supplies and went into Resident #22's room. LPN #561 performed wound care without applying an isolation gown. Interview on 03/28/23 at 1:30 P.M. with LPN #561 verified she did not follow enhanced barrier precautions for Resident #22 during wound care as she did not put on an isolation gown. Review of the facility policy titled, Enhanced Barrier Precautions (EBP), dated July 2022, stated EBP is indicated for nursing home residents with wounds regardless of them having a multi-drug resistant organism. The policy also stated performing wound care would require EBP. 2. Review of the medical record revealed Resident #20 was admitted on [DATE] with diagnoses including diabetes mellitus. Review of the physician order dated 07/23/21 for Resident #20 had an order to check her blood sugar before meals and at bedtime. Observation on 03/28/23 at 4:10 P.M. of the blood sugar check of Resident #2 revealed Registered Nurse (RN) #578 gather her supplies and then go into Resident #2's room. She placed the glucometer on Resident #2's tray table without placing a barrier on the table. After checking Resident #2's blood sugar, she went out to the medication cart and placed the glucometer on the top of the cart. RN #578 sanitized her hands and without cleaning the glucometer she placed it into a half full alcohol prep pad box and then went to Resident #20's room. She then placed the alcohol pad box on Resident #20's tray table and took the glucometer out of the box and placed it on the resident's tray table without placing a barrier. After checking Resident #20's blood sugar, she placed the glucometer back in the alcohol pad box and went back to the medication cart and placed it on top of the cart. RN #578 then sanitized her hands and was then going to proceed to another resident's room to check their blood sugar when this surveyor stopped her and notified her that she did not clean the glucometer between residents. RN #578 verified she did not cleanse the glucometer between Resident #2 and Resident #20. She then took an alcohol pad out of the box and proceeded to wipe the glucometer. She was unable to state what the facility policy stated on cleansing the glucometer and what disinfectant wipe she should use. Review of the facility policy titled, Glucometer Decontamination, revised July 2016, revealed the glucometer should be decontaminated with the facility approved wipes following use on each resident. Cleaning and disinfecting the glucometer, after performing the glucometer testing, the nurse shall perform hand hygiene, don gloves, and use the disinfectant wipe to clean all external parts of the glucometer. The specific amount of time for wet contact will be according to the wipes' manufacturer recommendations. The specific amount of time for drying will be according to the wipes manufacturer's recommendations. The clean glucometer will be placed on another paper towel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of medical record for Resident #14 revealed an admission date of 12/04/20 with diagnoses including congestive heart failure, diabetes mellitus and depression. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #14 revealed Section C which included Brief Interview for Mental Status (BIMS) score, assessment of short-term memory, assessment of long term assessed memory, assessment of memory/ recall ability assessed, assessment of cognitive skills for daily decision making, and assessment of sign and symptoms of delirium were not assessed. The MDS also revealed Section Q which included resident, family and guardian participation in the assessment, resident's overall expectation, and his discharge plan was not assessed and/or completed. Interview on 03/29/23 at 9:31 A.M. with Regional Mobile Support MDS/ Registered Nurse (RN) #580 verified Section C and Q were not completed for Resident #14 on 02/25/23. He revealed the Social Service Designee (SSD) #549 was responsible for filling these sections out at the facility. Interview on 03/29/23 at 1:51 P.M. with SSD #549 revealed she was hired 12/05/22 and was responsible for completing sections C and Q of the MDS. She verified she had not assessed or completed these sections for Resident #14 on the quarterly MDS dated [DATE]. 4. Review of medical record for Resident #18 revealed an admission date of 07/16/22 with diagnoses including congestive heart failure, anxiety and depression. Review of admission Minimum Data Set (MDS) dated [DATE] for Resident #18 revealed Section C which included Brief Interview for Mental Status (BIMS) score, assessment of short-term memory, assessment of long term assessed memory, assessment of memory/ recall ability assessed, assessment of cognitive skills for daily decision making, and assessment of sign and symptoms of delirium were not assessed. The MDS also revealed Section D, which assesses the resident's mood, Section F for activities and Section P which assesses the resident's pain, were not assessed and/or completed. Section Q which included resident, family and guardian participation in the assessment, resident's overall expectation, and his discharge plan was completed by Resident #18 and it stated he participated in the assessment. Interview on 03/29/23 at 9:31 A.M. with Regional Mobile Support MDS/ Registered Nurse (RN) #580 verified Section C, D, F, P and Q were not completed for Resident #18 on 07/23/22. He revealed the Social Service Designee (SSD) was responsible for filling these sections out at the facility. Interview on 03/29/23 at 11:16 A.M. with State Tested Nurse Aide (STNA) #535, who had previously been the Social Services Designee, stated she was responsible for performing certain sections of the MDS including Section C and Q. STNA #535 verified the MDS for Resident #18 was not completed for the sections listed above on the admission assessment on 07/23/22. Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments for Resident #9, #14, #18, and #51 were complete and accurate. This affected four residents (Resident #9, #14, #18, and #51) of four residents reviewed for the accuracy and completion of their MDS. The facility census was 53. Findings included: 1. Review of medical record for Resident #9 revealed an admission date of 12/01/22 and her diagnoses included cerebral infarction, chronic kidney disease with heart failure, diabetes, and dysphagia. Review of Medicare Five-Day Minimum Data Set (MDS) dated [DATE] for Resident #9 revealed Section C which included Brief Interview for Mental Status (BIMS) score, assessment of short-term memory, assessment of long term assessed memory, assessment of memory/ recall ability assessed, assessment of cognitive skills for daily decision making, and assessment of sign and symptoms of delirium was not assessed. The MDS also revealed Section Q which included resident, family and guardian participation in the assessment, resident's overall expectation, and her discharge plan was not assessed and/ or completed. Interview on 03/29/23 at 9:31 A.M. with Regional Mobile Support MDS/ Registered Nurse (RN) #580 verified Section C and Q was not completed for Resident #9 on 03/01/23. He revealed the Social Service Designee (SSD) #549 was responsible for filling these sections out at the facility. Interview on 03/29/23 at 11:27 A.M. with SSD #549 revealed she was hired 12/05/22 and was responsible for completing sections C and Q of the MDS. She verified she had not assessed or completed these sections for Resident #9 on her Medicare five-day MDS dated [DATE]. 2. Review of medical record for Resident #51 revealed an admission dated 12/27/22 and her diagnosis included osteoarthritis of knee, diabetes, morbid obesity, adult failure to thrive, anxiety disorder, hypertension, and chronic obstructive disorder. Review of admission Medicare five-day Minimum Data Set (MDS) dated [DATE] for Resident #51 revealed Section C which included Brief Interview for Mental Status (BIMS) score, assessment of short-term memory, assessment of long term assessed memory, assessment of memory/ recall ability assessed, assessment of cognitive skills for daily decision making, and assessment of sign and symptoms of delirium was not assessed. The MDS also revealed Section Q which included resident, family and guardian participation in assessment, resident's overall expectation, and her discharge plan was not assessed and/ or completed. Interview on 03/29/23 at 9:31 A.M. with Regional Mobile Support MDS/ Registered Nurse (RN) #580 verified Section C and Q was not completed for Resident #51 on 01/03/23. He revealed the Social Service Designee (SSD) #549 was responsible for filling these sections out at the facility. Interview on 03/29/23 at 11:27 A.M. with SSD #549 revealed she was hired 12/05/22 and was responsible for completing sections C and Q of the MDS. She verified she had not assessed or completed these sections for Resident #51 on her admission MDS dated [DATE]. Interview on 03/30/23 at 10:35 A.M. with the Administrator revealed the facility did not have a policy for the accuracy and completion of a MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications were stored in a secure manner and disposed of when they had expired. This affected four residents (Residents #2, #14, #18 and #48) with the potential to affect all residents residing in the facility. The facility census was 53. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of [DATE] with diagnoses including diabetes mellitus, chronic kidney disease and dependence on renal dialysis. Review of Resident #2's physician's orders for [DATE] revealed he had an order for Insulin Glargine (Lantus) (medication used for high blood sugar) 100 units per milliliter (mL) dated [DATE]. The nursing staff were to inject 30 units subcutaneously at bedtime. Review of the Medication Administration Record for [DATE] revealed Resident #2 received his Insulin Glargine as ordered. Observation on [DATE] at 3:05 P.M. with Registered Nurse (RN) #576 of the medication cart on the 200 hall revealed Resident #2 had two bottles of Lantus (Insulin Glargine) 100 units/mL in one Lantus box. One bottle was dated [DATE] when it was opened and the other bottle was dated [DATE] on the date it was opened. RN #576 verified the medications were expired and should not be used greater than 28 days from the date it was opened. Review of the facility policy titled, Administration and Documentation of Medications, revised [DATE], revealed once insulin is opened the vial must be dated and discarded after 28 days or as otherwise directed by the manufacturer. 2. Review of the medical record for Resident #14 revealed an admission date of [DATE] with diagnoses including diabetes mellitus. Review of Resident #14's physician's orders for [DATE] revealed she had an order for Levemir Solution (long acting insulin) 100 units per milliliter (mL) dated [DATE]. The nursing staff were to inject 22 units at bedtime for diabetes. Review of the Medication Administration Record for [DATE] revealed Resident #14 received her Levemir as ordered. Observation on [DATE] at 3:05 P.M. with Registered Nurse (RN) #576 of the medication cart on the 200 hall revealed Resident #14 had one bottle of Levemir dated [DATE] when it was opened. RN #576 verified the medication was expired and should not be used greater than 28 days from the date it was opened. Review of the facility policy titled, Administration and Documentation of Medications, revised [DATE], revealed once insulin is opened the vial must be dated and discarded after 28 days or as otherwise directed by the manufacturer. 3. Review of the medical record for Resident #18 revealed an admission date of [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), anxiety, depression and asthma. Review of Resident #14's physician's orders for [DATE] revealed he had orders including Albuterol Sulfate HFA Solution, two puffs inhale orally every six hours as needed for shortness of breath dated [DATE] and Nasal Moisturizing Spray Nasal Solution, spray one spray in both nostrils every two hours as needed for dryness dated [DATE]. Observation and interview on [DATE] at 10:22 A.M. of Resident #18 revealed a bottle of nasal spray on his tray table and Albuterol Sulfate inhaler in his top dresser drawer. Resident #18 stated nursing had given these medications to him and he kept these medications in his room and used them as needed. He also showed this surveyor an unopened box of Equate Nighttime Flu and Severe Cold and Cough with the expiration date of [DATE] in his top dresser drawer. He stated he brought this medication with him when he was admitted to the facility and kept them in his drawer in case he needed to use them. Interview on [DATE] at 10:23 A.M. with Registered Nurse (RN) #576 verified Resident #18 had the nasal spray, Albuterol inhaler and expired cold medication in his room and these were not stored in a secure manner. RN #576 verified Resident #18 did not have an order for the Equate Nighttime Flu and Severe Cold and Cough medication and that it was expired. Review of the facility policy titled, Storage of Medications, revised [DATE], revealed the facility should store drugs and biologicals in a safe and secure manner. The facility should also not use discontinued or outdated drugs or biologicals. 4. Review of the medical record for Resident #48 revealed an admission date of [DATE] with diagnoses including hypertensive heart disease with heart failure and congestive heart failure (CHF). Review of Resident #48's physician's orders for [DATE] revealed an order for Aspirin 325 milligrams (mg) one time a day for pain dated [DATE]. Review of the Medication Administration Record (MAR) for February 2023 and [DATE], revealed Resident #48 received Aspirin 325 mg as ordered. Observation and interview on [DATE] at 2:55 P.M. of the medication cart on the 100 hall with Licensed Practical Nurse (LPN) #577 revealed a bottle of Aspirin 325 mg to have the expiration date of [DATE]. There were no other bottles of Aspirin 325 mg in the medication cart. LPN #577 verified the Aspirin was expired. Observation and interview on [DATE] at 3:15 P.M. with Registered Nurse (RN) #576 of the medication storage room revealed one of three bottles of Aspirin 325 mg to be expired and have the expiration date of [DATE]. RN #576 verified the Aspirin was expired. Review of the facility policy titled, Storage of Medications, revised [DATE], revealed the facility should not use discontinued or outdated drugs or biologicals. Review of the facility policy titled, Administration and Documentation of Medications, revised [DATE], revealed expiration dates of all medications must be checked prior to dispensing and administering.

Based on observation, interview, and record review, the facility failed to ensure education was provided to State Tested Nursing Assistants regarding residents placed on enhanced barrier precautions. This affected six residents (Resident #1, #2, #17, #22, #42, #45) with the potential to affect all 53 residents in the facility. Findings included: Interview with five Stated Tested Nursing Assistants (STNA #547, STNA #565, STNA #567, STNA #574 and STNA #575) on 03/28/23 from 2:06 P.M. to 3:02 P.M. revealed these STNA's when asked, did not know what enhanced barrier precautions meant. These STNAs also did not know what type of Personal Protective Equipment they were required to wear when entering a resident's room who was on enhanced barrier precautions. Review of residents on enhanced barrier infection control precautions revealed Resident #1, #2, #17, #22, #42, #45 were on precautions. Review of the facility policy titled, Enhanced Barrier Precautions, dated 07/22 revealed enhanced barrier precautions were precautions intended for a resident with infections, wounds, and/or with indwelling devices like a urinary catheter. These precautions included gowning and gloving when providing any wound care, urinary incontinence care and personal hygiene to name a few.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #39, who required staff assistance with toileting received timely and adequate care related to the use of a bedside commode. This affected one resident (#39) of one resident reviewed for activities of daily living (ADLs). Findings include: Record review revealed Resident #39 was admitted to the facility on [DATE] with a diagnosis including closed fractures of the lower end femur and left tibia. The admission Minimum Data Set (MDS) 3.0 assessment, dated 07/12/19 revealed Resident #39 had intact cognition and required extensive assistance of two staff for transfers and toilet use. Interview on 08/12/19 at 11:06 A.M. with Resident #39 revealed she used the bedside commode and often it took staff a long time to empty it. Resident #39 stated she needed assistance on and off the bedside commode, so staff were aware it needed to be emptied. Resident #39 stated one day six hours went by before it was emptied. Observation on 08/14/19 at 9:44 A.M. while talking with Resident #39's roommate revealed Resident #39's bedside commode with urine in it. Resident #39 was not present in her room at the time of the observation. Interview on 08/14/19 at 10:57 A.M. with State Tested Nursing Assistant (STNA) #504 revealed Resident #39 required assistance to the bedside commode and supervision off the commode to her wheelchair. STNA #504 stated the bedside commode was to be emptied when the resident was finished using it. Observation at this time with STNA #504 verified the bedside commode had not been emptied timely following the resident use. Review of the facility policy titled Bedside Commode, Offering/Removing, dated February 2018 revealed after allowing the resident to wash his or her hands, take the bedpan into the bathroom. After checking the output empty and clean the bedpan.

Based on record review and interview the facility failed to ensure resident medical record documentation was accurate and complete related to antibiotic use. This affected three residents (#48, #62 and #63) of three residents reviewed for antibiotic use. Findings include: A review of Resident #48's physician's orders revealed an order for Azithromycin Tablet 500 milligrams (mg), one tablet by mouth at bedtime for upper respiratory infection (URI), to start 08/05/19 for seven days. A review of Resident #48's progress notes revealed only one entry regarding a reaction to the antibiotic. A review of Resident #62's physician's orders revealed an order for Cephalexin 500 mg, one tablet by mouth twice daily for urinary tract infection (UTI), to start on 08/07/19 for seven days. A review of Resident #62's progress notes revealed no entries regarding the start of treatment nor follow up of antibiotic treatment to show progress, resident condition, or any adverse reactions. A review of Resident #63's physician's orders revealed an order for Cephalexin 500 mg, two tablets by mouth once daily for cellulitis, to start on 07/19/19 for three days. A review of Resident #63's progress notes revealed no entries regarding the start of treatment nor follow up of antibiotic treatment to show progress, resident condition, or any adverse reactions. An interview on 08/14/19 at 1:12 P.M. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) both confirmed the lack of documentation for Resident #48, #62 and #63 related to the use of antibiotic medications as noted above.

Based on observation, record review and interview the facility failed to maintain sanitary conditions in the kitchen to prevent contamination and/or food borne illness. This had the potential to affect 71 of 71 residents residing in the facility who received meal trays. The facility identified two residents, Resident #9 and #64 who received nothing by mouth. The facility census was 73. Findings include: A tour of the kitchen on 08/12/19 from 8:30 A.M. to 8:50 A.M. with Dietary Manager (DM) #503, revealed the following observations: On the bottom shelf of the prep sink there were various dried food crumbs scattered throughout. Stored on this shelf were two blenders and attachments, and a silver rack that held cutting boards. The top of the dish machine had a moderate amount of a tannish, wet residue. The prep table next to the steam table, the outer surface appeared worn and rusted. The side of this prep table that faced the steam table had a moderate layer of blackish grease and various dried food splatters. The bottom shelve of the steam table had various dried food crumbs and splatter. Stored on this shelf were multiple large pans. The stove located across from the steam table had a heavy amount of brunt grease build-up, a moderate amount of various dried and burnt food crumbs throughout. There was a two shelved rolling rack next to the stove, the bottom shelf that house miscellaneous items - one being a box of hot cereal, had a moderate amount of various food crumbs and food splatters. Interview on 08/12/19 from 8:30 A.M. to 8:50 A.M. with DM #503 verified the above findings. DM #503 stated she had been in that position for one month and was aware of the concerns. Review of the facility policy titled Cleaning Standards, dated August 2015 revealed equipment, food contact surfaces and utensils shall be clean to sight and touch, non-food contact surfaces of equipment shall be free of accumulation of dust, dirt, food residue, and other debris.

3. Record review revealed Resident #219 was admitted to the facility on on 07/18/19 with a readmission date of 08/01/19. The resident had diagnoses including perforation of intestine (non-traumatic) ileostomy status and alcohol dependence. The admission Minimum Data Set (MDS) 3.0 assessment, dated 07/25/19 revealed Resident #219 had impaired cognition. Review of the August 2019 physician's orders revealed a discontinued order for Vancomycin 125 milligrams (mg) every 6 hours, orally for Clostridium difficile (C-Diff) for 28 administrations, take for seven days from 08/02/19 to 08/09/19. Interview on 08/12/19 at 2:31 P.M. with Registered Nurse (RN) #509 revealed Resident #219 was in contact precautions for C-Diff but the resident's stool was contained as the resident had an ileostomy. RN #509 stated nursing staff provided the ileostomy care. Interview on 08/12/19 at 2:55 P.M. with Resident #219 revealed he was on contact precautions because he had C-Diff. Resident #219 stated he was aware of the procedures for the contact precautions. During an interview on 08/12/19 at 1:46 A.M. Housekeeper (HSK) #506 revealed the procedures used to clean Resident #219's room. HSK #506 stated she used bleach wipes to wipe everything down but used another solution to mop the floor. HSK #506 stated she was unsure what the solution was and that Housekeeping Director (HD) #505 would know. Interview on 08/13/19 from 2:44 P.M. to 2:48 P.M. with HD #503 revealed solution for mopping the floors were used for mopping all rooms including the isolation rooms. HD #503 stated the solution was 3M disinfectant used in hospital and provided a container. Observation at this of the container read 3M Neutral Quat Disinfectant Cleaner Concentrate and listed the pathogens it killed except it was silent for killing C-Diff. HD #503 verified this finding. Review of the facility policy titled Clostridium Difficile- Prevention and Management, dated 2015 revealed quaternary ammonium compounds (Quat) was not effective against C-Diff spores and should not be used. Based on observation, record review and interview the facility failed to maintain adequate infection control practices during meal delivery, blood glucose monitoring and during housekeeping services to prevent the spread of infection. This affected two residents (#4 and #19) observed receiving meal trays, two residents (#16 and #8) observed during blood glucose monitoring, one resident (#219) observed in contact precautions and had the potential to affect all 73 residents residing in the facility. Findings include: 1. Observation on 08/12/19 at 12:15 P.M. revealed State Tested Nurse Assistant (STNA) #500 was observed passing a meal tray to Resident #19. STNA #500 entered the resident's room, placed the tray down and moved the bed tray closer to the resident who was laying in bed. The STNA then exited the room, obtained a meal tray for Resident #4 without first washing hands or using hand sanitizer and proceeded to obtain a meal tray for Resident #4. STNA #500 opened the door to Resident #4's room using the left hand and placed the tray down on the resident's bed tray. STNA #500 lifted the top cover off the plate, grabbed a hotdog in a bun using his/her left hand and gave it to Resident #4 without first washing hands, using any type of hand sanitizer or wearing gloves. Interview on 08/12/19 at 12:30 P.M. with STNA #500 revealed staff were to wash hands after delivering two meal trays. STNA #500 verified she did not wash hands between handling trays and/or after touching door handles and other equipment during the delivery of meal trays for Resident #19 and Resident #4. Review of handwashing/hand hygiene policy, dated 2001 revealed staff were to wash hands after contact with objects (e.g., medical equipment) in the near vicinity of the residents, before and after handling food, and after assisting residents with meals. 2. On 08/13/19 at 11:56 A.M. Registered Nurse (RN) #501 was observed using the glucometer (a device that measures the concentration of glucose (sugar) in the blood) for residents who have diabetes. RN #501 finished checking the blood sugar of Resident #8 and placed the glucometer on top of the medication cart. On 08/13/19 at 12:10 P.M. RN #501 obtained the same glucometer used for Resident #8 and without first cleaning or disinfecting the unit entered Resident #16's room. RN #501 proceeded to check the resident's blood sugar. RN #501 left the room, returned to the medication cart and placed the glucometer in the top drawer of cart without first cleaning or disinfecting it. Interview on 08/13/19 at 12:20 P.M., with RN #501 revealed the facility policy was to clean the glucometer after each resident. RN #501 verified the glucometer was not sanitized after each use. Review of undated blood glucose point of care testing policy revealed an unclean glucometer should not be placed on top of medication cart without a clean barrier under the device. The policy did not state when staff were to sanitize (clean/disinfect) the glucometer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to ensure a weight loss of 15.7 pounds within five days was reassessed and appropriate interventions were put into place for Resident #47, and failed to ensure a re-weigh was completed to ensure weight accuracy for Resident #49. This affected two (Residents #47 and #49) of three residents reviewed for dietary concerns. Findings included: 1. Record review revealed Resident #47 was admitted to the facility on [DATE] with the diagnosis of encounter for other orthopedic after care for multiple fractures following a motor vehicle accident. Review of the resident's weights revealed the following: -06/18/18 - 163 pounds -06/24/18 - 162.5 pounds -06/25/18 - 162.5 pounds -07/01/18 - 146.8 pounds -07/02/18 - 146.8 pounds -07/08/18 - 146.9 pounds There was no documented evidence the facility addressed the five day weight loss identified on 07/01/18 of 15.8 pounds. 07/16/18 at 12:05 P.M. Resident #47 was observed dressed and groomed seated in her wheelchair with the left leg extended, resident had a waxy appearance. Resident #47 spoke with a State Tested Nurse Aide (STNA) telling her she did not want her lunch tray because her father had brought in food. Interview on 07/18/18 at 4:25 P.M. with the Dietician #402 revealed the resident didn't seem to have any problem with the food, it was just that she had a lot of snacks in her room that the family brought her. Dietician #402 stated she thought the weight loss on 07/01/18 may have been due to edema. Dietician #402 verified there was no evidence the resident received any diuretic medication. 2. Record review revealed Resident#49 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, heart failure, hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease. The resident received outpatient renal dialysis on Monday Wednesday and Friday. The MDS 3.0 dated 06/29/18 indicated the resident was independent with eating. The Dietary Assessment completed on 06/26/18 indicated the resident was independent with eating and received hemodialysis on Monday/Wednesday/Friday. She was ordered a carbohydrate controlled renal diet. The resident stated she eats whatever she wants. The recommendations were to continue the diet as ordered, add additional protein (Promod), monitor meal intake, and monitor weight, labs and skin. Review of the resident's weight revealed she had sustained a seven pound weight loss in one day, (07/11/18 - 237.8 lbs. 07/12/18 - 230 lbs), and gained 9.3 lbs in two days (07/16/18 - 240 lbs. 07/18/18 - 249.3 lbs.). Review of the Weight Loss Guidelines dated 2018 stated there was to be a re-weigh when there was a five pound weight loss or gain from the previous weight. Interview on 07/18/18 at 4:25 P.M. with the Dietician #402, she stated that a five (+) pound weight gain or loss was to prompt a re-weigh. She verified this had not been done for the weights on 07/12/18 and 07/18/18.

Based on policy review, observation, and interviews the facility failed to ensure insulin vials were dated when opened. This affected three (Residents #32, #38, and #54) of 13 residents who received insulin. Findings Include: Observations of medication storage on 07/17/18 between 8:30 A.M. and 8:55 A.M revealed the medication cart for the 100 hall had three insulin vials in it, one of the three insulins was not labeled with an opened date. At the time of the observation, interview with Licensed Practical Nurse (LPN) #50 verified the vial of insulin for Resident #32 was not dated when opened. LPN#50 stated that all insulin must be dated when opened. Observations of the medication cart for the 200 hall revealed three of four insulin vials were not dated when opened. These included insulin for Resident #38, and two vials for Resident #54. At the time of the observation, interview with LPN #51 verified the three insulin vials were not dated when opened. Review of facility policy, dated 2016, revealed all insulin must be dated when opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Record review revealed Resident #35 was admitted on [DATE] with diagnoses that included cognitive deficit, heart failure, tracheostomy, and chronic respiratory failure. Review of quarterly Minimum Data Set (MDS) 3.0 dated 06/07/18 for Resident #35 revealed the Brief Interview for Mental Status (BIMS) scored a 99 as Resident #35 was unable to complete the interview as Resident #35 was rarely/ never understood. Interview and observation on 07/16/18 at 8:50 A.M. with Resident #35 revealed that she used a communication board to answer questions appropriately when interviewed. Interview on 07/18/18 at 10:25 A.M. with Licensed Practical Nurse (LPN) #200 revealed that Resident #35 can make her needs known by utilizing her communication board. LPN #200 stated that she can spell out words using the letters on the communication board. Record review of nursing note dated 07/18/18 at 6:23 P.M. authored by LPN #202 revealed Resident #35 was upset pulling at her peg tube feeding. LPN #202 was able to have Resident #35 communicate with her communication board and spell out want to eat. On 07/19/18 at 9:00 A.M. interview with Social Service Designee (SSD) #201 revealed that on Resident #35's admission she attempted the BIMS assessment and Resident #35 was unable to complete the assessment. SSD #201 revealed for the last quarterly assessment on 06/07/18 she did not attempt to assess Resident #35's BIMS score as she did not think Resident #35's cognitive status had changed. SSD #201 verified that she has not attempted to re-assess Resident #35's cognitive ability since MDS 3.0 admission assessment dated [DATE]. Based on record review, observation, resident and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for six residents (Residents #14 ,#25, #35, #44, #50 and #56) of 17 residents reviewed. Findings Include: 1. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, schizoaffective disorder and bipolar disorder. Review of the pre admission screen and resident review (PASRR) results dated 10/06/15 revealed Resident #14 had a level two mental illness. Review of section A of the MDS 3.0 assessment dated [DATE] revealed the facility answered no to the question of Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition? 2. Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses that included schizophrenia,major depressive disorder and anxiety disorder. Review of the pre admission screen and resident review (PASRR) form dated 07/11/16 revealed Resident #44 had a level two mental illness. Review of section A of the MDS 3.0 assessment dated [DATE] revealed the facility answered no to the question of Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition? 3. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, anxiety disorder and major depressive disorder. Review of the pre admission screen and resident review (PASRR) form dated 10/27/16 (from previous facility) revealed Resident #50 had a level two mental illness. Review of section A of the MDS 3.0 assessment dated [DATE] revealed the facility answered no to the question of Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition? Social Service Designee #201 verified all of the above findings in an interview on 07/18/18 at 1:35 P.M. 6. Record review revealed Resident #56 was admitted to the facility on [DATE] from an acute care hospital for skilled services. admission diagnoses included perforation of intestine and aftercare following surgery on the digestive system. Resident #56 previously lived in the community. Review of facility nursing documentation dated 04/20/18 at 1:29 P.M. revealed Resident #56 was discharged to home with all belongings, home going instructions and medications. Review of the facility discharge Minimum Data Set(MDS) 3.0 assessment dated [DATE] revealed the resident was discharged with return not anticipated and documented the resident was discharged to an acute hospital. An interview was conducted with facility Social Service Designee(SSD) # 201 on 07/19/18 at 12:35 P.M. SSD #201 stated Resident #56 was discharged from the facility to her own home and never went to the hospital during her month long stay. A follow up interview was conducted with the facility Director of Nursing (DON) on 07/19/18 at 12:46 P.M. During the interview the resident's discharge MDS data was reviewed and the DON confirmed the MDS was coded inaccurately to reflect a discharge to the hospital for Resident #56. 4. Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses that included persistent vegetative state, anxiety, traumatic brain injury and contractures of the right shoulder, right elbow, left and right hand, right and left hip, left wrist, right and left knee and left ankle. Review of the Minimum Data Set 3.0, a comprehensive assessment, dated 02/02/18 indicated the resident required total assistance with care. Review of the Restorative assessment dated [DATE] indicated all joints were poor and the recommendation was to have the resident perform passive range of motion (ROM). The assessment identified the resident was a candidate for ROM and passive (ROM) was recommended. Record review revealed there was no documented evidence of ROM being completed. Interview on 07/17/18 at 5:00 P.M. with the Director of Nursing (DON) revealed the facility does not have a restorative program and that if the resident was receiving ROM then it would be under the task tab. Interview on 07/17/18 at 5:21 P.M. with LPN #400 revealed the resident didn't receive ROM because when he originally had therapy, the movement of his limbs was very excruciating for him. She stated for the staff to even turn the resident in bed was painful. If the staff were completing ROM with him then they were doing it minimally while dressing him. She stated they no longer got him up into his chair because of the non-verbal demonstration of pain, i.e. stiffening, and grimacing. The surveyor showed LPN #400 the Restorative assessment dated [DATE] that stated the resident was a candidate for ROM. She stated she didn't know where Registered Nurse (RN) #402 got that information. Interview on 07/18/18 at 1:46 P.M. with RN #402 revealed the assessment was done around the time the change in companies and was an inaccurate assessment.

Based on observation and staff interview the facility failed to ensure stored food was labeled and dated properly. This had the potential to affect 59 of 61 residents residing in the facility. The facility identified Residents #25 and #35 as receiving no food by mouth. Findings Include: During the initial kitchen tour conducted on 07/16/18 between 7:20 A.M. and 7:45 A.M. with Dietary Manager #500 the following was noted: - Three containers of peanut butter were open with no open date. -One open package of ground mustard spice contained no open date. - A container of pancake syrup with no open date and sticker stating received on 08/29/17. - A large bowl containing a significant portion of macaroni salad contained no date. - A large container of cheesecake filling contained no date. -A medium container of green beans contained no date. - One container of open Worcestershire sauce with no date. All of the above was verified at the time of observation with Dietary Manager #500. Review of the Food Storage: Cold policy dated May 2014 revealed The food service Director/Cook(s) ensures that all food items are stored properly in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.