Based on observation, staff interviews, resident interviews, agency staff interview, Community Member interview and review of policy, the facility failed to report an allegation of abuse to the state agency. This affected one (#63) of three residents reviewed for potential abuse. The facility census was 34. Findings include: Observation of the main entrance of the facility revealed the residents who smoke come out to the front of the building and sit outside of the main entrance to smoke. There is a small handicap ramp in the entrance about 4 feet wide extended from the cemented area to the parking lot. Interview on 10/23/23 at 10:00 A.M. to 10:05 A.M., with Community Member #1 revealed she does not work at the facility and received this information from a friend via text form with pictures. Community Member #1 described the picture was of a black woman in a wheelchair smoking, being pushed down the ramp into the parking lot and agency State Tested Nurse Assistant (STNA) laughing with a caption. Community Member #1 revealed she called the facility two times and reported the incident. The first time the facility took the information, the complainant informed the facility it was agency STNA #170 who works for an agency. Community Member #1 stated she called 3 weeks ago and was told by the Director of Nursing (DON); the facility took care of it. Community Member #1 could not identify the resident's name. Interview on 10/23/23 at 10:56 A.M., with the Social Services Designee #105 revealed the DON did receive a call from an anonymous caller about an agency nurse taking pictures of a resident and posting them on social media. Interview on 10/23/23 at 11:00 A.M., with the DON confirmed she received an anonymous call about Agency STNA #170. The anonymous caller accused STNA #170 of taking a picture of a blind black lady while smoking in her wheelchair and posted it on social media. The DON explained, because they do not have a blind black lady in the facility, she did not investigate the allegation. She interviewed the seven smokers and they all denied getting their picture taken. She reported the incident to the contracted staffing agency. The DON stated the Human Resources Manager #120 confirmed the agency also received the same complaint and will address the situation. The DON confirmed she did not report the abuse allegation to the state agency, file a Self-Reported Incident or investigate the allegation of abuse. She has no documentation of any interviews with her residents who smoke. Interview on 10/23/23 from 11:10 A.M. to 11:30 A.M., with Resident #64, who smokes, stated witnessing Resident #63, as the person who was in a wheelchair and a STNA let go and Resident #63 slid down the little ramp into the parking lot, but the STNA stopped her. Resident #64 denied knowing if anyone took a picture of it. Interview on 10/23/23 from 11:10 A.M. to 11:30 A.M., with Resident #61 stated recalled the incident when a female resident was in her wheelchair and the STNA let go of the chair and it wheeled down the ramp into parking lot. She could not recall the resident's name or if anyone took a picture. Interview on 10/23/23 from 11:10 A.M. to 11:30 A.M., with Resident #63, (who matched description provided by Community Member #1) revealed the resident is cognitively impaired and gets people and times confused. Resident #63 stated she does go out to smoke in a wheelchair; however, she could not recall if she was pushed in her wheelchair by an STNA down a ramp while smoking. Interview on 10/23/23 at 12:18 P.M., with the Human Resource Manager #120, from the contracted staffing agency, confirmed she received a call from the facility's DON about STNA #170 taking pictures while working. She confirmed her agency also received a call from an anonymous person who identified STNA #170 as taking pictures of a resident at the facility. Human Resource Manager #120 stated the agency followed up with STNA #170, who wrote a statement on 09/18/23 at 2:45 P.M., explaining she would never take a picture of a resident, make fun of them, or post it on social media. Human Resource Manager #120 stated she believes family members have made falls accusations about STNA #170. STNA #170 was educated over the phone on the agency use of cellphones, taking pictures and social media. Review of the policy titled, Ohio Resident Abuse Policy, dated 08/30/23, revealed it is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown origin. Facility must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/ Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in the policy. For this policy nursing home staff includes employees, consultants, contractors, volunteers, and other care givers who provide care and services to the residents on behalf of the facility. Abuse includes mental abuse, including abuse facilitated or enabled using technology. This deficiency represents noncompliance investigated under Complaint Number OH00147011.

Based on observation, staff interviews, resident interviews, agency staff interview, Community Member interview and review of policy, the facility failed to investigate and an allegation of abuse. This affected one (#63) of three residents reviewed for potential abuse. The facility census was 34. Findings include: Observation of the main entrance of the facility revealed the residents who smoke come out to the front of the building and sit outside of the main entrance to smoke. There is a small handicap ramp in the entrance about 4 feet wide extended from the cemented area to the parking lot. Interview on 10/23/23 at 10:00 A.M. to 10:05 A.M., with Community Member #1 revealed she does not work at the facility and received this information from a friend via text form with pictures. Community Member #1 described the picture was of a black woman in a wheelchair smoking, being pushed down the ramp into the parking lot and agency State Tested Nurse Assistant (STNA) laughing with a caption. Community Member #1 revealed she called the facility two times and reported the incident. The first time the facility took the information, the complainant informed the facility it was agency STNA #170 who works for an agency. Community Member #1 stated she called 3 weeks ago and was told by the Director of Nursing (DON); the facility took care of it. Community Member #1 could not identify the resident's name. Interview on 10/23/23 at 10:56 A.M., with the Social Services Designee #105 revealed the DON did receive a call from an anonymous caller about an agency nurse taking pictures of a resident and posting them on social media. Interview on 10/23/23 at 11:00 A.M., with the DON confirmed she received an anonymous call about Agency STNA #170. The anonymous caller accused STNA #170 of taking a picture of a blind black lady while smoking in her wheelchair and posted it on social media. The DON explained, because they do not have a blind black lady in the facility, she did not investigate the allegation. She interviewed the seven smokers and they all denied getting their picture taken. She reported the incident to the contracted staffing agency. The DON stated the Human Resources Manager #120 confirmed the agency also received the same complaint and will address the situation. The DON confirmed she did not report the abuse allegation to the state agency, file a Self-Reported Incident or investigate the allegation of abuse. She has no documentation of any interviews with her residents who smoke. Interview on 10/23/23 from 11:10 A.M. to 11:30 A.M., with Resident #64, who smokes, stated witnessing Resident #63, as the person who was in a wheelchair and a STNA let go and Resident #63 slid down the little ramp into the parking lot, but the STNA stopped her. Resident #64 denied knowing if anyone took a picture of it. Interview on 10/23/23 from 11:10 A.M. to 11:30 A.M., with Resident #61 stated recalled the incident when a female resident was in her wheelchair and the STNA let go of the chair and it wheeled down the ramp into parking lot. She could not recall the resident's name or if anyone took a picture. Interview on 10/23/23 from 11:10 A.M. to 11:30 A.M., with Resident #63, (who matched description provided by Community Member #1) revealed the resident is cognitively impaired and gets people and times confused. Resident #63 stated she does go out to smoke in a wheelchair; however, she could not recall if she was pushed in her wheelchair by an STNA down a ramp while smoking. Interview on 10/23/23 at 12:18 P.M., with the Human Resource Manager #120, from the contracted staffing agency, confirmed she received a call from the facility's DON about STNA #170 taking pictures while working. She confirmed her agency also received a call from an anonymous person who identified STNA #170 as taking pictures of a resident at the facility. Human Resource Manager #120 stated the agency followed up with STNA #170, who wrote a statement on 09/18/23 at 2:45 P.M., explaining she would never take a picture of a resident, make fun of them, or post it on social media. Human Resource Manager #120 stated she believes family members have made falls accusations about STNA #170. STNA #170 was educated over the phone on the agency use of cellphones, taking pictures and social media. Review of the policy titled, Ohio Resident Abuse Policy, dated 08/30/23, revealed it is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect involuntary seclusion, exploitation of residents, misappropriation of resident property and injuries of unknown origin. Facility must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/ Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in the policy. For this policy nursing home staff includes employees, consultants, contractors, volunteers, and other care givers who provide care and services to the residents on behalf of the facility. Abuse includes mental abuse, including abuse facilitated or enabled using technology. This deficiency represents noncompliance investigated under Complaint Number OH00147011.

Based on medical record review and staff interview the facility failed to ensure physician orders were followed. This effected one Resident (#180) of seven residents reviewed for laboratory services. The facility census was 35. Findings include: Review of the medical record of Resident #180 revealed a physician order dated 11/17/21 for a basic metabolic panel (BMP) to be monitored every Wednesday for four weeks. Review of the medical record revealed no results of any BMP as ordered. Review of the progress notes revealed no documentation of the physician being notified the labs were not completed. Review of the medical record revealed no laboratory reports for the BMPs. Interview on 12/16/21 at 11:00 A.M. with Director of Nursing (DON) provided verification of the lack of BMP results. DON stated they had not been obtained as ordered. This deficiency substantiates complaint #OH00128116.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review for Resident #36 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease, chronic obstructive pulmonary disease, diabetes type II, sickle cell anemia, hypertension, alcoholic cirrhosis of the liver, iron deficiency and anxiety disorder. Review of a physician order, dated 03/13/19, revealed the resident's advanced directive was a full code status. Review of the social service progress note, dated 04/03/19, stated Resident #36's advanced directives have been reviewed and were located on the chart. He has chosen to have a Full Code status. Review of the plan of care, revised on 04/17/19, revealed Resident #36 has chosen a full code status for his advance directive. The interventions included staff was to document his advance directive in the chart. Interview on 05/01/19 at 2:30 P.M. with Licensed Practical Nurse (LPN) #119 verified there was no code status listed on the electronic record face sheet. She stated if the resident was found unresponsive she would check the resident's code status on the electronic record . Since there was no code status in the electronic record, she would go to the resident's hard copy chart to check his code status. She verified there was no code status listed under advanced directives in the hard copy chart. Interview with Regional Director Clinical Services #104 she verified Resident #36 did not have a advance directive in the electronic record or in the chart. Review of an undated facility policy titled Advance Directive Policy revealed documentation, written or oral, of informed consent to withhold or withdraw treatment must be placed in the resident's medical record together with the attending physician's order regarding the withholding or withdrawal of treatment. The physician's order should also be noted on the resident's plan of care and on the inside and outside of the resident's medical record. Based on record review, staff interview and review of facility policy, the facility failed to have consistent documentation of Advanced Directive status across all medical records for Resident #1 and #29) and failed to have any documented evidence of Advanced Directive status for Resident #36. This affected three (#1, #29 and #36) of four residents were reviewed for Advance Directives. The facility census was 36. Findings include: 1. Medical record review for Resident #1 revealed an admission date of 01/08/19. Diagnoses included mixed hyperlipidemia, essential hypertension, primary generalized osteoarthritis, other idiopathic scoliosis, atrial fibrillation and cerebral palsy. Review of the electronic medical record for Resident #1 on 04/30/19 at 9:25 A.M. reflected the profile page to be silent to any advance directive code status. Review of the physician orders also found no advance directive code status. Review of the hard medical record found a Do Not Resuscitate (DNR) form dated 01/08/19 that had been signed by both physician and resident and marked for Do Not Resuscitate Comfort Care (DNRCC). Interview with Registered Nurse (RN) #115 on 04/30/19 at 10:00 A.M. stated she would go to the electronic resident profile page to ascertain code status if on the floor, or she could check the hard paper chart for code status of a red paper stating DNRCC, or a green paper stating Full Code. Interview with Licensed Practical Nurse (LPN) #103 on 04/30/19 at 3:00 P.M. stated she would look at the electronic resident profile page and physician orders for code status, and the code status should be flagged right inside the hard chart by a red no code or green full code paper right inside the hard chart. Interview with Social Service Designee (SSD) #101 on 05/02/19 at 8:54 A.M. stated SSD #101 stated when a resident was admitted , she determined the advance directive status and enters it on the care plan. She passes along this information to nursing and they were to enter it in the electronic record and flag the hard medical chart so they match. The DNR form was to be in the hard record and should also be in physician orders. The SSD #101 stated she was to review the code status for every resident quarterly. It was also her responsibility to audit medical records for accuracy of code status. She verified the electronic and hard chart for Resident #1 did not match. Interview on 05/02/19 at 2:30 P.M. with Regional Director of Clinical Services (RDCS) #104 verified theses findings. 2. Medical record review for Resident #29 revealed an admission date of 05/28/14. Diagnoses included hypertension, hyperlipidemia, dementia without behavioral disturbance, acute embolism and thrombosis of unspecified deep veins of right lower extremity, dermatitis, asthma, and osteoarthritis. Review of the electronic profile page for Resident #29 reflected the resident was a Full Code status. However, the hard medical record contained a DNR form, dated 10/05/18, which identified the resident as a DNRCC-A. Review of current physician orders for May 2019 found an entry which stated the resident was a Full Code. Social service progress notes were silent to advance directive status. Review of the plan of care, initiated 02/09/17 with a revision date of 03/18/19, stated the resident has chosen a Full Code status. Interview on 05/01/19 at 2:30 P.M. with RDCS #104 verified the code status for Resident #29 was not consistent across all parts of the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide written notification to a resident's representative of a transfer to the hospital. This affected one (#22) of one resident reviewed for hospitalization. The facility census was 36. Findings include: Record review for Resident #22 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dysphagia, chronic kidney disease, dementia without behaviors, and cognitive communication deficit. Review of the nursing progress notes, dated 03/16/19, revealed the resident had an unwitnessed fall in her room sustaining a laceration to her head. She complained of severe pain in her left hip following the fall. The resident was transferred to the hospital and admitted for surgical repair of a left hip fracture. Review of the medical record revealed there was no evidence the resident's representative was given a written notice for the resident's transfer to the hospital on [DATE]. Interview on 05/02/19 at 3:40 P.M. with the Regional Director of Clinical Services #104 verified there was no written notice given to Resident #22's representative at the time of the resident's transfer to the hospital on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide a bed hold notice to a resident's representative when the resident was transferred to the hospital. This affected one (#22) of one resident reviewed for hospitalization. The facility census was 36. Findings include: Record review for Resident #22 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dysphagia, chronic kidney disease, dementia without behaviors, and cognitive communication deficit. Review of the nursing progress notes, dated 03/16/19, revealed the resident had an unwitnessed fall in her room sustaining a laceration to her head. She complained of severe pain in her left hip following the fall. The resident was transferred to the hospital and admitted for surgical repair of a left hip fracture. Review of the medical record revealed there was no evidence the resident's representative was given a bed hold notice when the resident transferred to the hospital on [DATE]. Interview on 05/02/19 at 3:40 P.M. with the Regional Director of Clinical Services #104 verified there was no bed hold notice given to Resident #22's representative at the time of the resident's transfer to the hospital on [DATE].

Based on record review and staff interview, the facility failed to ensure a comprehensive person centered care plan was written for Resident #25 and the correct code status for Resident #29's care plan. This affected two (#25 and #29) of 17 residents reviewed for care plans. The facility census was 36. Findings include: 1. Medical record review for Resident #25 revealed an admission date of 01/05/19. Diagnoses included anxiety disorder. Review of the current physician orders, dated 03/05/19, revealed the resident had an order to receive an antianxiety medication named Buspar five milligrams (mg.) twice daily. Review of a Minimum Date Set (MDS) assessment, dated 04/09/19, revealed the resident had a diagnosis of anxiety with the use of antianxiety medication. Review of the comprehensive care plan, initiated 01/05/19 and revised 04/09/19, revealed it was silent to the resident's diagnosis of anxiety disorder with no planned interventions to address this need, and did not address the use of the psychoactive antianxiety medication. Interview with MDS Coordinator #102 on 05/01/19 at 1:30 P.M. verified there was no care plan to address the diagnosis of anxiety disorder and there were no planned interventions to address this need. 2. Medical record review for Resident #29 revealed an admission date of 05/28/14. Diagnoses included dementia without behavioral disturbance, acute embolism and thrombosis of unspecified deep veins of right lower extremity and osteoarthritis. Review of the medical record revealed a Do Not Resuscitate (DNR) form, dated 10/05/18, which identified the resident as a Do Not Resuscitate comfort care arrest (DNRCC-A). Review of the comprehensive plan of care, initiated 02/09/17 with a revision date of 03/18/19, the resident has chosen Full Code status, which was not the correct code status. Interview on 05/01/19 at 2:30 P.M. with the Regional Director of Clinical Services (RDCS) #104 verified Resident #29's comprehensive care plans had not been accurately developed to reflect the resident's code status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, and policy review, the facility failed to have care conferences on a quarterly basis and invite a resident to attend a care conference. This affected one (#32) of two residents reviewed for care conference attendance. The facility census was 36. Findings include: Record review for Resident #32 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hypertension, gastro-esophageal reflux disease, chronic obstructive pulmonary disease, and dementia with behavioral disturbances. Review of the annual comprehensive Minimum Data Set (MDS) assessment, dated 04/05/19, revealed the resident has no cognitive impairments. He was assessed to have no delusion, hallucinations, or any behavioral symptoms. Review of the social service progress note, dated 01/23/19, stated Social Service Designee #101 approached the resident concerning a care conference and the resident refused stating no, he didn't want to go. He stated to just find him a place to live and get him out of the facility. Review of the progress notes, from 01/22/19 through the present date 04/30/19, revealed no documentation that a care conference was held to discuss the resident's care. During an interview with Resident #32 on 04/29/19 at 10:06 A.M., he stated he has not been invited to a care conference to discuss his plan care. On 04/30/19 at at 3:00 P.M., during an interview with Social Service Designee #101, she verified there was no care conference held following the annual comprehensive assessment on 04/04/19. She verified Resident #32 had not been invited to a care conference following the MDS assessment on 04/04/19. She verified the interdisciplinary team did not have a care conference following the 04/04/19 MDS assessment. Review of the facility's policy on Care Conference, dated 01/27/11, stated under the procedure, each resident shall be invited to participate in their care conference. The policy also stated a care conference should be held quarterly and annually.

2. Review of the medical record for Resident #5 revealed an admission date of 10/23/14 with diagnoses including multiple sclerosis, paraplegia, developmental disorder, cerebral palsy, depression, and aphasia. Further review of the medical record revealed Resident #5 was admitted to hospice services on 11/02/18 with Hospice Entity #120. Review of the hospice binder revealed no documentation of services provided by Hospice Entity #120's staff in March 2019 and April 2019. Interview with Licensed Practical Nurse (LPN) #103 on 04/30/19 at 2:39 P.M. revealed hospice staff does not leave progress notes detailing the care they provided prior to leaving the facility. Interview with Registered Nurse (RN) #104 on 05/01/19 at 12:30 P.M. revealed Hospice Entity #120's staff were supposed to leave progress notes in the hospice binder at the nurse's station. RN #104 verified the facility did not have documentation of services provided by Hospice Entity #120's staff in March 2019 or April 2019. Review of the facilities Hospice Agreement with Hospice Entity #120 revealed hospice shall promote open and frequent communication with the facility and shall provide the facility with sufficient information to ensure that the provision of services under this agreement is in accordance with the hospice plan of care, assessments, treatment planning and care coordination. Hospice will promptly inform the facility of any change in a hospice patient's condition which requires a modification to the hospice plan of care. Based on record review, staff interview, and review of hospice contracts, the facility failed to ensure collaboration and communication between the facility and hospice entities for two (#5 and #31) of two residents reviewed for hospice services. The facility identified four residents currently receiving hospice services. The facility census was 36. Findings include: 1. Medical record review for Resident #31 revealed an admission date of 03/05/19. Diagnoses included dementia with behaviors. Review of the current physician orders for May 2019 reflected an order to admit to Hospice services for end stage dementia. The medical record contained a Hospice contract signed by the resident's responsible party, dated 04/12/19. On 05/01/19 at 10:50 A.M. a Hospice nurse from Hospice Entity #105 was observed at the nurse's station writing orders and talking with staff Registered Nurse (RN) #106. After the hospice nurse left the nurse's station, an interview with RN #106 found that the hospice nurse speaks with facility staff during her visits, but leaves no progress notes in the medical record regarding her observations and interactions with the resident, or care rendered. There were also no care notes provided by hospice nurse aide assistants after their visits twice weekly. On 05/01/19 at 12:00 P.M., an interview with Regional Nurse #104 was conducted. She stated it was the facility expectation that Hospice should be leave progress notes of all visits with the facility as part of the medical record. She verified that the hospice entity had not provided their progress notes to the facility for continuity of care. Review of the contract titled Nursing Facility Agreement, dated 02/03/17, stated the agreement was between Hospice Entity #105 and the nursing facility. The document, under section 4.8 Medical Chart, reflected Facility and Hospice will prepare and maintain complete medical records for Hospice Patients receiving Facility services in accordance with this Agreement and will include all treatments, progress notes, authorizations, physician orders and other pertinent information. Documentation of care and services provided by Hospice will be filed and maintained in the Facility chart.

Based on record review, observation, and staff interview, the facility failed to ensure Resident #5 received tube feeding as ordered by the physician. This affected one (Resident #5) of one resident reviewed for tube feeding. This facility identified one resident who received tube feeding. Findings include: Review of the medical record for Resident #5 revealed an admission date of 10/23/14 with diagnoses including multiple sclerosis, paraplegia, developmental disorder, aphasia, and cerebral palsy. Review of the resident's physician orders, dated 08/28/17, revealed a diet order for nothing by mouth (NPO). Further review of the physician orders, dated 01/15/19, revealed Fibersource, a tube feeding formula, was to run at 65 milliliters per hour for a total of 22 hours each day and water was to run at 30 milliliters per hour while the tube feeding was running via gastrostomy tube (a tube used to provide nutrients and fluid into the stomach). Review of the Medication Administration Record (MAR) for Resident #5 revealed a new tube feeding bag was to be hung at 6:00 P.M. Observation on 04/29/19 at 10:38 A.M. revealed Resident #5's tube feeding was turned off. Observation on 04/30/19 at 11:00 A.M., 1:35 P.M., and 2:22 P.M. revealed Resident #5's tube feeding was turned off. Interview with Licensed Practical Nurse (LPN) #103 on 04/30/19 at 2:39 P.M. revealed Resident #5's tube feeding was to run for 22 hours each day from 6:00 P.M. to 4:00 P.M. and the tube feeding was supposed to be turned off for two hours from 4:00 P.M. to 6:00 P.M. Interview with LPN #103 on 04/30/19 at 2:39 P.M. verified Resident #5's tube feeding was turned off. LPN #103 was unable to provide an explanation as to why the tube feeding was turned off.

Based on record review and staff interview, the facility failed to act upon a physician's response to the pharmacist recommendation for a resident. This affected one (#33) of five residents reviewed for unnecessary medication. The facility census was 36. Findings include: Medical record review for Resident #33 revealed an admission date of 03/30/15. Diagnoses included Alzheimer's disease, major depressive disorder, insomnia, psychosis, schizophrenia, and bipolar disorder current episode depressed severe with psychotic features. Review of current physician orders, dated May 2019, revealed the resident had orders for the following psychoactive medications: antidepressants Trazadone 25 milligrams (mg.) daily, mirtazapine 15 mg. at bedtime, and citalopram 20 mg. daily. Review of a pharmacy medication regimen consultation report, dated 04/02/19, revealed the pharmacist noted Resident #33 was receiving three antidepressants concomitantly, and recommended the physician to consider discontinuing Trazodone while continuing mirtazapine at bedtime and while monitoring for re-emergence of depression/insomnia and/or symptoms. Review of the physician's response, dated 04/09/19, revealed the physician agreed with the pharmacist recommendation with the following modifications: Decrease mirtazapine to 7.5 mg. at bedtime and was signed and dated 04/09/19 by the physician. Below the physician signature and date, the previous Director of Nursing (DON) (Registered Nurse (RN) #116) had signed and dated the form, 04/12/19, and written verbal order to leave at 15 mg. Further review of physician orders found no physician signature to verify what the previous DON had written. Review of the medication administration record (MAR) for April 2019 and May 2019 revealed the physician recommendations for mirtazapine 7.5 mg. was never implemented. The resident continued to receive mirtazapine at 15 mg. nightly, as of 05/01/19. On 05/02/19 at 12:32 P.M., an interview with Regional Director of Clinical Services (RDCS) #104 verified the medication dosage was never reduced as ordered, and the physician had never signed and authorized the verbal order written by RN #116.

Based on observation, resident and staff interview, the facility failed maintain three resident's wheelchairs in safe operating condition. This affected three (#18, #23 and #37) of 17 residents reviewed for safe operating equipment. The facility identified 20 residents dependent on wheelchairs for locomotion. The facility census was 36. Findings include: On 05/01/19 at 1:00 P.M., an observation of Resident #23 revealed the resident was propelling in his wheelchair in the hallway. On the medial side of the left arm rest, the covering was torn with jagged rough edges. The resident was wearing a short sleeve shirt. The resident stated the arm of his wheelchair was torn and needed repair. On 05/01/19 at 1:10 P.M., an observation of Resident #37 revealed the resident was in a wheelchair in the dining room. The covering of the right arm of his wheelchair was torn in multiple areas causing the covering to have rough edges. On 05/01/19 at 1:12 P.M., an observation of Resident #18 revealed the resident was in a wheelchair in the dining room. The covering of the left arm of his wheelchair was torn in multiple areas causing the covering to have rough edges. On 05/01/19 at 1:20 P.M., interview with the Regional Director of Clinical Services #104 verified the arms on Resident #23, #37, and #18's wheelchairs were in disrepair with tears in the covering of the arms causing rough edges, which could result in skin tears to the resident's arms.

Based observation, staff interview, and review of facility policy, the facility failed to ensure medications were stored in a safe and secure manner for one (#90) resident residing in the facility. This had the potential to affect 15 (#3, #5, #6, #9, #11, #12, #14, #17, #18, #21, #22, #24, #25, #28 and #37) cognitively impaired mobile residents in the facility. The facility census was 36. Finding include: On 05/02/19 at 2:35 P.M., an open box was observed beside the telephone at the nurse's station. The box was labeled with the name of Resident #90 and contained five individual blister dose packs of an anticoagulant medication (Eliquis 2.5 milligrams (mg.)) and one blister pack of an antianginal medication (Isordil 30 mg. half tablet). The nursing station had two entry points without doors or other type of barrier, and there was no barrier to prevent residents or the public from reaching over the top of the desk. There was no staff present at the nursing station at the time of the observation. When questioned, Registered Nurse (RN) #102 and #106 stated Resident #90 was being discharged and needed the medications called into the pharmacy. The box had been placed by the phone and not returned to the medication storage room. Observations from 04/29/19 through 05/02/19, during each day of the survey, cognitively impaired mobile Residents #3 and #32 had been observed standing or sitting in a wheelchair respectively at the nurse's station at various times daily. Interview with the Director of Nursing (DON) on 05/02/19 at 2:40 P.M. verified the box with Resident #90 was left at the nurse's unsecured without any staff present. The DON verified there were 15 cognitively impaired mobile residents (#3, #5, #6, #9, #11, #12, #14, #17, #18, #21, #22, #24, #25, #28 and #37) in the facility. Review of the facility policy titled Storage and Expiration, Dating of Medications, Biologicals, Syringes and Needles, dated October 2016, revealed under the heading General Storage Procedures, the policy stated the facility should ensure that all medications and biologicals, including treatment items, were securely stored in a locked cabinet/cart or locked medication room that was inaccessible by residents and visitors.

Based on review of the facility's Antibiotic Use Tracking Sheet, staff interview and policy review, the facility failed to ensure eight residents (#2, #4, #8, #10, #14, #20, #21 and #29) of 28 residents reviewed for antibiotic stewardship had active signs and symptoms of infection prior to prescribing antibiotics. The facility census was 36. Findings include: Review of the facility's January 2019 Antibiotic Use Tracking Sheet revealed Resident #29 had a dry scaly scalp with no date of onset. The physician prescribed Bactrim DS (antibiotic ) for 14 days. Four residents (#2, #10, #14 and #20) displayed symptoms of a cough without any other signs and symptoms. There was no diagnostic testing completed for these four residents. Three of the residents (#2, # 10 and #20) were placed on a Z- Pack ( Zithromycin antibiotic) for four days. Resident #14 was placed on Augmentin 875-125 milligrams (mg.) for seven days. The tracking sheet stated Resident #21 had a possible urinary tract infection. The signs and symptoms were listed as increased urination , increased confusion, and increased episodes of incontinence. There was no urinalysis or urine culture. The resident was placed on Rocephin one gram (antibiotic) to be given intramuscularly (IM) for three days. The tracking sheet stated Resident #8 had a urinary tract infection. There was no signs or symptoms listed, no urinalysis, and no urine culture completed . The resident was given Keflex 500 mg. (antibiotic) for seven days. Review of the facility's February 2019 Antibiotic Use Tracking Sheet revealed Resident #20 had an upper respiratory infection with signs and symptoms of a cough. There were no diagnostic test performed. The resident received Doxycycline 100 mg. (antibiotic) for seven days. Three additional residents (#14, #4 and #20) were listed as having urinary tract infections. The tracking sheet stated three residents (#14, #4 and #20) had urinary tract infections with with the signs and symptoms being discolored urine and increased confusion. There was no urinalysis or urine culture was completed on these three residents. Resident #14 and #20 were given Cipro 250 mg. (antibiotic) for seven days. Resident # 4 was given Invanz one gram (antibiotic) for five days. Resident #3 was treated with an antibiotic Azithromycin 250 mg. for five days for abnormal lung sound with no diagnostic tests. Review of the facility's March 2019 Antibiotic Use Tracking Sheet revealed Resident #8 was placed on Keflex 500 mg. (antibiotic) for 10 days. A urinalysis was completed without a culture to identify an organism. Interview with Regional Director of Clinical Services #104 on 05/02/19 at 10:30 A.M. verified there was no Infection Prevention Control Committee. She stated infections were discussed in a weekly meeting with the Interdisciplinary team. She verified Resident #2, #4, #8, #10, #14, #20, #21 and #29 appeared on the Antibiotic Use Tracking Sheet in January, February, and March of 2019 and did not have the indications needed to prescribe antibiotics. Review of the facility's policy on Antibiotic Stewardship Program, dated 04/16/18, revealed the Infection Prevention and Control Committee is to meet monthly to oversee the tracking of antibiotic of prescribing.

Based on personnel file record review, staff interview and review of the facility's tuberculosis risk assessment, the facility failed to complete tuberculosis (TB) skin testing or questionnaire was completed upon hire and/or annual. This affected eight of eight employees reviewed for TB testing. This had to the potential to affect all 36 residents residing in the facility. Findings include: Review of the personnel file for State Tested Nurse Aide (STNA) #108 revealed a hire date of 04/16/19. There was no documentation that a tuberculosis skin test or questionnaire was completed. Review of the personnel file for STNA #109 revealed a hire date of 02/01/19. There was no documentation that a tuberculosis skin test or questionnaire was completed. Review of the personnel file for STNA #110 revealed a hire date of 12/01/16. There was no documentation that a annual tuberculosis skin test or questionnaire was completed. Review of the personnel file for STNA #111 revealed a hire date of 12/01/16. There was no documentation that a annual tuberculosis skin test or questionnaire was completed. Review of the personnel file for STNA #112 revealed a hire date of 06/12/18. There was no documentation that a tuberculosis skin test or questionnaire was completed. Review of the personnel file for Director of Nursing (DON) #113 revealed a hire date of 04/22/19. There was no documentation that a tuberculosis skin test or questionnaire was completed. Review of the personnel file for Assistant Director of Nursing (ADON) #102 revealed a hire date of 02/11/19. There was no documentation that a tuberculosis skin test or questionnaire was completed. Review of the personnel file for Maintenance Supervisor #114 revealed a hire date of 04/10/19. There was no documentation that a tuberculosis skin test or questionnaire was completed. Interview with the Administrator on 05/02/19 at 11:35 A.M. verified there was no documentation of tuberculosis skin tests or questionnaires being completed for STNA #108, STNA #109, STNA #110, STNA #111, STNA #112, DON #113, ADON #102, and Maintenance Supervisor #114. Review of facility TB Risk Assessment Worksheet completed 04/23/19 revealed the facility was considered to be at a low risk for tuberculosis.