**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy, the facility failed to ensure a resident's dignity was maintained. This affected one resident (#47) of one resident reviewed for dignity. The facility census was 66. Findings include: Review of the medical record for Resident #47 revealed she was admitted on [DATE] with diagnoses of hypertension and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #47 revealed she was cognitively intact and required supervision assistance for showering and personal hygiene. Review of the care plan revised 04/25 for Resident #47 revealed she was care planned for self-care deficit related to decreased activities of daily living (ADL), activity intolerance, and arthritis with interventions of one to two assist for care, ADLs, and monitor the five P's (pain, potty, position, proximity of items, and personal needs) during rounding Observation on 04/21/25 at 11:48 A.M. of Resident #47 revealed chin hair at least one quarter of an inch long, and along her chin (greater than 10 hairs.) Concurrent interview with Resident #47 stated the staff assist with removing her chin hair and Resident #47 then stated I don't want to look masculine, I want to look feminine. Observation on 04/22/25 08:47 A.M. of Resident #47 revealed she was sitting at the dining room table eating breakfast and the hair on her chin remained. Interview on 04/22/25 08:49 A.M. with Licensed Practical Nurse (LPN) #124 verified the presence of chin hairs on Resident #47. Review of the facility policy titled, Promoting/Maintaining Resident Dignity, dated 12/24 revealed it is the practice of the facility to protect and promote residents' rights and treat each resident with respect and dignity. Residents should be assisted to be groomed and dressed according to their preference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff and resident interview, and facility policy the facility failed to follow physician orders for wound care. This affected one resident (#8) of three reviewed for wounds. The facility census was 66. Findings include: Review of medical record for Resident #8 revealed admission date of 07/04/23 with diagnoses including diabetes mellitus, dehydration, depression, non-pressure chronic ulcer of lower leg, and chronic osteomyelitis of her right ankle and foot. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she had intact cognition and required extensive one person assistance for bed mobility, transfers, limited assistance with toileting and supervision for eating. Review of the physician orders revealed an order for left forearm to keep steri-strips (skin closure) in place until healed. Cover the wound with dressing (Island) once daily and discontinue when healed with a start date of 04/13/25. Observation on 04/22/25 at 12:54 P.M. with Licensed Practical Nurse (LPN) #124 of dressing change revealed the dressing on Resident #8's left forearm was dated 04/15/25. Interview on 04/22/25 with LPN #124 directly following wound care verified the left forearm dressing was dated 04/15/24 and was ordered to be changed daily. Further review of the physician orders revealed an order for bilateral compression pumps twice daily and every evening shift for circulation with a start date of 03/17/25. Observation and interview on 04/22/25 at 1:00 P.M. with both LPN #124 and Resident #124 revealed no bilateral compression pumps were present in the room, and each denied placement of the compression pumps. Review of the facility policy, Wound Treatment Management dated 02/03/25 documented wound treatments to be completed in accordance with physician orders, including the cleansing method, type of dressing and frequency if dressing change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record reviews, and facility policy, the facility failed to accurately assess wounds and failed to complete treatments as ordered. This affected one (Resident #8) of three residents reviewed for pressure ulcers. The facility census was 66. Findings include: Review of the medical record for Resident #8 revealed an admission date of 07/04/23 with diagnoses including diabetes mellitus, dehydration, depression, non-pressure chronic ulcer of lower leg, and chronic osteomyelitis of her right ankle and foot. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had intact cognition and required extensive one person assistance for bed mobility, transfers, limited assistance with toileting, and supervision for eating. Review of the care plan revealed no current plan of care for a pressure wound. Review of the 03/01/25 skin and wound assessment revealed documentation of type of wound as other and measuring three centimeters (cm) in diameter, scab to the back of the right heel. Scab was intact with scant serous drainage. Review of the 03/04/25 After Visit Summary of the wound care center documented debridement of the right heel. There was no description of the wound, dressing orders were given with a follow up in four weeks. Review of the 03/29/25 skin and wound assessment revealed documentation of type of wound as other and measuring one cm by (x) one cm to right heel. Additional information described a small area from previous surgical procedure, with no drainage or pain. Review of the 04/06/25 skin and wound assessment revealed documentation of type of wound as other and measuring one centimeter (cm) by (x) one cm to right heel. Additional information described a small area from previous surgical procedure, with no drainage or pain. Review of the 04/12/25 skin and wound assessment revealed documentation of type of wound as other and measuring one centimeter (cm) by (x) one cm to right heel. Additional information described a small area from previous surgical procedure, with no drainage or pain. Interview on 04/23/25 at 2:37 P.M. with Wound Registered Nurse #201 revealed Resident #8 had chosen to go to an outside wound clinic for her wounds. She acknowledged the facility wound assessments did not accurately describe the type of heal wound. She acknowledged the current documentation from the wound clinic did not specify the description of the heel wound. WRN #201 acknowledged the facility should obtain information on the type of wound. Review of the wound care center progress note which was obtained by the facility on 04/24/25, revealed Resident #8 was seen on 04/01/25 for a previous ulceration to the posterior aspect of the calcaneus previous wound which had healed. Physical exam revealed a stage three pressure ulcer measuring 0.4 cm x 0.7 cm x 1 cm on the posterior aspect of the calcareous with some slough (yellow/white accumulation of dead cells) and some debris around the margin which was removed and derided. Observation on 04/22/25 at 12:54 P.M. with Licensed Practical Nurse (LPN) #124 of dressing change revealed the dressing removed from Resident #8's right heel was dated 04/17/25. Observation of the dressing revealed an approximately two cm in diameter yellow/green drainage. Interview on 04/22/25 with LPN #124 directly following wound care verified the right heel dressing was dated 04/17/24 and was ordered to be changed three times weekly. Review of the progress note dated 04/22/25 revealed observation of yellowish green drainage on the old dressing to the right heel during the dressing change. Review of the physician orders revealed an order to apply collagen to right heel wound, moisten with normal saline and cover with silicone foam border dressing at bedtime every Tuesday, Thursday and Saturday for wound healing. Review of the facility policy, Wound Treatment Management, dated 02/03/25 documented wound treatments to be completed in accordance with physician orders, including the cleansing method, type of dressing and frequency if dressing change. Treatment changes will be based on the etiology of the wound. Pressure ulcers will be differentiated from non-pressure ulcers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, review of the nursing schedule, and facility policy, the facility failed to ensure sufficient staffing to complete resident's activities of daily living. This affected one resident (#34) of 24 reviewed for sufficient staffing. The facility census was 66. Findings include: Review of the medical record for Resident #34 revealed an admission date of 05/30/23 with diagnoses of congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and cerebral vascular accident (CVA) (stroke). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #34 revealed she was cognitively intact and was dependent for showering. Review of the current physician orders for 04/25 for Resident #34 revealed she had ordered showers on Tuesday and Friday on night shift. Review of the care plan revised 02/25 for Resident #34 revealed she was care planned for self-care deficit related to decreased activities of daily living (ADL) function and activity intolerance with intervention for one to two assist with ADL care. Interview on 04/21/25 at 10:01 A.M. with Resident #34 stated she does not get her showers when the staffing is short. Resident #34 stated when there is only one Certified Nursing Assistant (CNA) to both houses (house pods each house had the capacity to hold 12 residents) the aides do not have time to give her a shower. Resident #34 stated her preference for showers was early in the morning to be done for the day. Review of the physician orders and shower schedule for Resident #34 revealed she should have had a shower on 04/11/25 and 04/18/25 on third shift. Review of the CNA documentation for showers for Resident #34 for the past 30 days revealed on 04/11/25 there was no documentation for Resident #34 getting her shower and on 04/18/25 the documentation indicated not applicable. Interview on 04/24/25 at 12:33 P.M. with the Director of Nursing (DON) verified no documentation to account for a shower for Resident #34 for 04/11/25. The DON further stated if no documentation, then the shower was not completed. Further interview with the DON stated the documentation by the CNA on 04/19/25 at 1:19 A.M. verified the documentation showed the shower as not applicable and she would assume the CNA documented that to reflect the shower was not given. The DON further stated if the shower was refused by Resident #34 the CNA would have documented the refusal. Review of the nursing schedule provided by the DON for 04/18/25 revealed one CNA called for third shift on 04/18/25 leaving one CNA to cover both of the houses that shift. Concurrent interview with the DON verified the nursing schedule for 04/18/25 that reflected one CNA assigned to both of the houses for that shift. Review of the facility assessment dated 10/24 revealed the facilities average daily census was 68 residents. The facility assessment also revealed bathing preferences: a shower schedule for routine showers is maintained at the facility and resident preferences are considered into the schedule. Further review of the facility assessment revealed staffing requirements for third shift are the facility needs five CNAs. Further review of the nursing schedule for 04/18/25 revealed for third shift there were four CNAs that worked and three nurses scheduled. Review of the facility policy titled, Resident Showers, dated 09/24 revealed is it the practice of the facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and facility policy, the facility failed to ensure care plans were accurate. This affected four (#8, #9, #26, #54) of 23 residents reviewed for care planning. The facility census was 66. Findings include: 1. Review of medical record for Resident #8 revealed admission date of 07/04/23 with diagnoses including diabetes mellitus, dehydration, depression, non-pressure chronic ulcer of lower leg, and chronic osteomyelitis of her right ankle and foot. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she had intact cognition and required extensive one person assistance for bed mobility, transfers, limited assistance with toileting and supervision for eating. Record review revealed there was no plan of care for a pressure ulcer. Review of the 04/01/25 wound center documentation revealed a stage three pressure injury to her right heel. Interview on 04/24/25 at 9:43 A.M. with MDS Nurse #200 verified there was no pressure wound care plan. 2. Review of medical record for Resident #9 revealed admission date of 01/29/24 with diagnoses including diabetes mellitus, stroke, depression and Parkinson's disease. The MDS dated [DATE] revealed she had impaired cognition and required extensive two-person assistance for bed mobility, transfers, toileting and supervision for eating. Record review revealed there was no plan of care for a pressure ulcer. A record review of the 02/24/25 wound note revealed a stage three pressure wound to the left gluteal fold. Interview on 04/24/25 at 9:43 A.M. with MDS Nurse #200 verified there was no pressure wound care plan. 3. Review of medical record for Resident #26 revealed admission date of 08/17/19 with diagnoses including pulmonary hypertension, unspecified dementia without behaviors, peripheral vascular disease and chronic respiratory failure. The MDS dated [DATE] revealed she was cognitively intact and she required set up assistance for eating, dependent for toileting hygiene, substantial assistance for and maximum assistance for transfers. Record review revealed there was no plan of care for a pressure ulcer. Review of the 03/12/25 podiatry notes revealed an unstageable wound to right second toe. Interview on 04/24/25 at 9:43 A.M. with MDS Nurse #200 verified there was no pressure wound care plan until 04/23/25 when the wound was discussed during survey. 4. Review of medical record for Resident #54 revealed admission date of 01/24/25. The resident was admitted with diagnoses including dementia. The MDS dated [DATE] revealed the resident had severe cognitive impairment. The resident was on hospice. Review of the physician's orders revealed the resident was admitted to hospice with diagnosis of senile degeneration of the brain. Review of the care plan revealed no goals or interventions in place for hospice. Interview with MDS #200 on 04/24/25 at 10:22 P.M. verified Resident #54 did not have a care plan for hospice. Review of the facility policy, Comprehensive Care Plans, dated 02/10/25 documented it is the policy of the facility to develop and implement a comprehensive person centered care plan for each resident to meet that includes measurable objectives and time frames to meet the residents medical needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to ensure food preparation and storage was maintained. This had the potential to affect all residents. The facility census was 66. Findings include: Observation during initial kitchen tour on 04/21/25 between 8:20 A.M. to 8:40 A.M. revealed the stand-up freezer had one bag of French fries and one bag of chicken that were opened, unsealed, unlabeled, and undated, the walk-in freezer had two stacks of boxes sitting on the floor of the freezer. The two stacks contained the following food: four boxes were [NAME] frozen cakes and one box of wild caught cod. Concurrent observation revealed [NAME] #201 who prepared and served breakfast was not wearing a hat or hairnet, or hairnet covering his full beard. Interview during initial tour with Assistant Dietary Manager (ADM) #197 verified the boxes on the floor in the walk-in freezer, [NAME] #197 not wearing hairnet, and the opened, unsealed, undated, and unlabeled food in the stand-up freezer. Observations on 04/22/25 between 11:55 A.M. to 12:20 P.M. during tray line revealed [NAME] #200 was serving tacos for lunch and while making the tacos the [NAME] #200 did not use any tongs to add the cheese, lettuce, tomato, or onion to the tacos, she used her gloved hand. Concurrent observations of [NAME] #200 revealed the cook prepared alternate menu options for resident's to include chicken tenders, hamburger, hotdog, and fish filet and during the serving did not use tongs to retrieve any of the items and used her gloved hand and did not change gloves or perform hand hygiene. Additional observations during tray line revealed Maintenance Worker (MW) #196 and Food Service Director (FSD) #224 of which both are males with full beards, entered the kitchen and walked all around the kitchen, including the tray line, during tray line without wearing hairnet covers on their full beards and MW #196 did not wear a hairnet or hat on his head. Interview on 04/22/25 at 12:20 P.M. following tray line with [NAME] #200 verified she did not use tongs for the toppings for the tacos, and verified she did not use tongs to grab a hamburger on three occasions, a hotdog, three chicken strips, and one filet of fish. [NAME] #200 verified she used her gloved hand that she had touched other surfaces with to include the fryer handle, spoon handle for the taco meats, the suction cup handle to retrieve the hot plates and the dishes. Review of the facility policy titled, Maintaining a Sanitary Tray Line, dated 07/24 revealed the facility prioritizes tray assembly to ensure foods are handled safely to prevent the spread of bacteria. During tray line assembly staff shall use utensils such as tongs, serving spoons to handle food as much as possible. Review of the facility policy titled, Date Marking for Food Safety, dated 04/25 revealed food shall be clearly marked to indicate date or day by which the food shall be consumed or discarded. Review of the facility policy titled, Food Safety Requirements, dated 01/25 revealed food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of facility Legionella control measures, and policy review, the facility failed to follow facility control measures for Legionella. This had to potential to affect all resident residing in the facility. Additionally, the facility failed to follow infection prevention procedures during wound care observation. This affected one resident (#8) of two residents observed for wound care dressing change. The facility census was 66. Findings include: 1. Review of the facility's Legionella control measures revealed the facility would obtain resident room water temperatures. Further review of the facility's control measures revealed no empty resident rooms or shower room water flushes if a room is unoccupied. Review of the facility's Legionella log revealed no water temperatures for the resident's rooms and no unoccupied rooms water flushing. Interview on 04/24/25 at 11:05 A.M. with Maintenance Director (MD) #185 stated he does not keep a log of empty resident rooms and does not flush empty resident rooms no matter how long the rooms are empty and verified he does not test residents water temperatures any longer. Concurrent interview with MD #185 revealed the facility does not have a Legionella policy other than the facility control measures. Review of the facility policy titled Infection Prevention and Control Program, revised 02/25 revealed a water management program has been established as part of the overall infection prevention and control program. Control measure and testing protocols are in place to address potential hazards associated with the facility's water systems. 2. Review of medical record for Resident #8 revealed admission date of 7/4/23 with diagnoses including diabetes mellitus, dehydration, depression, non-pressure chronic ulcer of lower leg, and chronic osteomyelitis of her right ankle and foot. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she had intact cognition and required extensive one person assistance for bed mobility, transfers, limited assistance with toileting and supervision for eating. Observation on 04/22/25 at 12:54 P.M. of Licensed Practical Nurse (LPN) #124 completing the dressing change to right heel revealed LPN #124 removed the stocking of right leg of Resident #8. LPN #124 proceeded to remove the dressing from her right heel. She then disposed of the dressing into the trash can. Without removing her gloves, LPN #124 retrieved a bottle of saline with her right hand and a four by four with her left. She placed she held the four by four in her left hand under the heel and used her right hand to pour the saline over the wound to wash it. She then put the saline bottle back onto the table and removed her gloves, without performing hand hygiene she put on a second set of gloves and proceeded to dress the wound. Interview on 04/22/25 at 1:07 P.M. directly following the dressing change, LPN #125 acknowledged she did not remove her gloves after removing the soiled dressing, and when she did remove her gloves after cleansing the wound she did not wash her hands prior to putting on another pair of gloves. Review of the facility policy, Clean Dressing Change, date 02/17/25 documented after removing the dressing to remove gloves, pulling inside out over the dressing, discard, wash hands and put on clean gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of self-reported incidents (SRI's), staff interviews, and review of facility policy, the facility failed to ensure staff timely reported allegations of verbal abuse to the Administrator or designee. Additionally, the facility failed to report allegations of verbal abuse to the State Agency. This affected two (#14 and #73) of three residents reviewed for abuse. The facility census was 70. Findings include: 1. Review of the medical record revealed Resident #14 was admitted on [DATE]. Diagnoses include other fracture of shaft of right fibula subsequent encounter for closed fracture with routine healing, essential (primary) hypertension, unspecified atrial fibrillation, obesity, mixed hyperlipidemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the care plan dated November 2022 revealed the resident was at risk for disturbed body image due to obesity, biophysical/psychosocial factors such as patient's view of self, family subculture encouragement of overeating and control issues. Review of Therapy Staff #207's witness statement dated 11/30/22 revealed on 11/28/22 she was in the therapy room working with Resident #14 and had walked to the sink approximately five feet from Resident #14. Activities Staff #211 approached Therapy Staff #207 with his back to Resident #14, and whispered loudly, When the [explicit term] are you getting her out of here, motioning towards Resident #14. Therapy Staff #207 wrote she had replied, 'not for a while,' and Activities Staff #211 replied, Because I am tired of taking her fat [explicit term] to appointments, and She just sits there and stares at you like a slug. Therapy Staff #207 wrote he made a strange face following the comment and then stated, She won't even attempt to move her fat [explicit term] legs. Interview on 12/16/22 at 12:10 P.M. with Therapy Staff #207 revealed on 11/28/22 Resident #14 was in the therapy room. Activities Staff #211 came in the therapy room and was standing with his back to Resident #14 approximately three to five feet from the resident. It was reported Activities Staff #211 stated something similar to, When are we getting her the [explicit term] out of here because I am tired of taking her to appointments. She just sits there like a slug and does not move her fat [explicit term] legs. Therapy Staff #207 stated she did not know if Resident #14 heard the incident and stated the resident did not appear affected. Therapy Staff #207 stated she reported the allegation to the Administrator. Interview on 12/16/22 at 1:40 P.M. with the Administrator revealed she was aware of the incident on 11/28/22 and had asked Activities Staff #211 about the situation and found that he had inquired about Resident #14 returning home and denied using derogatory terms. It was reported Therapy Staff #207 wavered about what was said. The Administrator also had reason to believe false allegations were made against Activities Staff #211. The Administrator reported Resident #14 was approximately ten feet from the conversation and stated the resident did not hear the conversation, however the Administrator verified she did not interview the resident or other residents to ensure they did not have concerns regarding verbal abuse and did not report the allegation to the State Agency. Interview on 12/16/22 at approximately 3:00 P.M. with the Administrator revealed she had observed the therapy room and Activities Staff #211 was approximately ten feet from Resident #14 when talking to Therapy Staff #207. Interview on 12/16/22 at 3:40 P.M. with Therapy Staff #207 revealed she was mistaken and Activities Staff #211 was approximately 10 feet from Resident #14 during the incident. Therapy Staff #207 verified not reporting the allegation of verbal abuse until the following day when the Administrator approached her regarding the incident. 2. Review of the medical record revealed Resident #73 was admitted on [DATE]. Diagnoses included cystoid macular degeneration, insomnia, essential primary hypertension, hyperlipidemia, functional urinary incontinence, major depressive disorder, generalized anxiety disorder, dementia in other disease classified elsewhere. Review of the MDS assessment dated [DATE] revealed the resident was cognitively impaired. Review of witness statement, dated 11/18/22, written by Housekeeping #208 revealed she was doing Resident #73 hair when she noticed her scalp was bleeding due to dryness and took her to the window to show Licensed Practical Nurse (LPN) #210. Housekeeping #208 wrote they were talking about activities for the day and could not see the television so she had told her (Resident #73) to ask Activities #211 because he was next to LPN #210 talking about appointments. When Resident #73 asked what it was (activities), Activities #211 said what you can't read! Housekeeping #208 wrote she was so offended by the way he said it that it had irritated her. Housekeeping #208 wrote that after it was said she (Resident #73) hung her head down and put her had (hand) on her head. Review of witness statement, dated 11/18/22, from State Tested Nursing Assistant (STNA) #213 revealed she was at the nurses station when Resident #73 finished getting her hair done and Activities #211 was there. STNA #213 wrote Activities #211 never had a conversation with Resident #73. STNA #213 wrote Resident #73 does not communicate with us well and does not ask questions like what is stating was asked. Interview on 12/16/22 at 12:18 P.M. with Housekeeping Staff #208 revealed on an unknown date, she and Resident #73 were at the nurse's station when Resident #41, who was in the dining room, asked what activities were scheduled for the day. Housekeeping Staff #208 stated she could not see the schedule for the day and asked Resident #73 to ask Activities Staff #211 what activities were scheduled. Upon Resident #73 asking, Activities Staff #211 allegedly responded, What, you can't read? and did not further respond to the inquiry. Housekeeping Staff #208 stated Resident #73 heard Activities Staff #211 and put her head down. Housekeeping Staff #208 stated Resident #41 was too far to hear the remark. Interview on 12/16/22 at 3:14 P.M. with the Director of Nursing (DON) verified Housekeeping Staff #208 and her supervisor came to her the following day on 11/18/22 to report the alleged incident. The DON stated she did her due diligence and interviewed Licensed Practical Nurse (LPN) #210 who was in the area completing charting and stated she heard people talking but did not hear the conversation. The DON reported she was contacted by State Tested Nursing Assistant (STNA) #213 who reported she was nearby and stated there was no conversation or communication between Activities Staff #211 and Resident #73. The DON stated she had a written statement from Housekeeping Staff #208 and text messages from STNA #213 but no other written statements or investigation. The DON stated she intended to receive a statement from Activities Staff #211 but did not. The DON reported Resident #73 was not alert and oriented and confirmed she did not interview Resident #73 as she may nod her head but cannot have a conversation. The DON verified a SRI was not completed. Review of the facility's SRI history from August 2022 to current revealed no SRI's completed for these two instances involving Resident #14 and #73, indicating a thorough investigation was not completed. Review of facility policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 2017, verified 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 or designee will notify the State Agency of all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property and injuries of unknown source as soon as possible, but in no event later than 24 hours from the time of the incident/allegation was made known to the staff member. Once the Administrator and the State Agency are notified, an investigation of the allegation violation will be conducted. The investigation will be completed within five working days unless there are special circumstances. Generally the investigation should include interview of the resident, the accused, and all witnesses. Statements from the resident, if possible, the accused, and each witness. Review of the resident's record and review of the accused employees employment records. This deficiency represents non-compliance investigated under Complaint Number OH00138171.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility self-reported incidents (SRI's), staff interviews, and review of facility policy, the facility failed to thoroughly investigate allegations of verbal abuse. This affected two (#14 and #73) of three residents reviewed for abuse. The facility census was 70. Findings include: 1. Review of the medical record revealed Resident #14 was admitted on [DATE]. Diagnoses include other fracture of shaft of right fibula subsequent encounter for closed fracture with routine healing, essential (primary) hypertension, unspecified atrial fibrillation, obesity, mixed hyperlipidemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the care plan dated November 2022 revealed the resident was at risk for disturbed body image due to obesity, biophysical/psychosocial factors such as patient's view of self, family subculture encouragement of overeating and control issues. Review of Therapy Staff #207's witness statement dated 11/30/22 revealed on 11/28/22 she was in the therapy room working with Resident #14 and had walked to the sink approximately five feet from Resident #14. Activities Staff #211 approached Therapy Staff #207 with his back to Resident #14, and whispered loudly, When the [explicit term] are you getting her out of here, motioning towards Resident #14. Therapy Staff #207 wrote she had replied, 'not for a while,' and Activities Staff #211 replied, Because I am tired of taking her fat [explicit term] to appointments, and She just sits there and stares at you like a slug. Therapy Staff #207 wrote he made a strange face following the comment and then stated, She won't even attempt to move her fat [explicit term] legs. Interview on 12/16/22 at 12:10 P.M. with Therapy Staff #207 revealed on 11/28/22 Resident #14 was in the therapy room. Activities Staff #211 came in the therapy room and was standing with his back to Resident #14 approximately three to five feet from the resident. It was reported Activities Staff #211 stated something similar to, When are we getting her the [explicit term] out of here because I am tired of taking her to appointments. She just sits there like a slug and does not move her fat [explicit term] legs. Therapy Staff #207 stated she did not know if Resident #14 heard the incident and stated the resident did not appear affected. Therapy Staff #207 stated she reported the allegation to the Administrator. Interview on 12/16/22 at 1:40 P.M. with the Administrator revealed she was aware of the incident on 11/28/22 and had asked Activities Staff #211 about the situation and found that he had inquired about Resident #14 returning home and denied using derogatory terms. It was reported Therapy Staff #207 wavered about what was said. The Administrator also had reason to believe false allegations were made against Activities Staff #211. The Administrator reported Resident #14 was approximately ten feet from the conversation and stated the resident did not hear the conversation, however the Administrator verified she did not interview the resident or other residents to ensure they did not have concerns regarding verbal abuse and did not report the allegation to the State Agency. Interview on 12/16/22 at approximately 3:00 P.M. with the Administrator revealed she had observed the therapy room and Activities Staff #211 was approximately ten feet from Resident #14 when talking to Therapy Staff #207. Interview on 12/16/22 at 3:40 P.M. with Therapy Staff #207 revealed she was mistaken and Activities Staff #211 was approximately 10 feet from Resident #14 during the incident. Therapy Staff #207 verified not reporting the allegation of verbal abuse until the following day when the Administrator approached her regarding the incident. 2. Review of the medical record revealed Resident #73 was admitted on [DATE]. Diagnoses included cystoid macular degeneration, insomnia, essential primary hypertension, hyperlipidemia, functional urinary incontinence, major depressive disorder, generalized anxiety disorder, dementia in other disease classified elsewhere. Review of the MDS assessment dated [DATE] revealed the resident was cognitively impaired. Review of witness statement, dated 11/18/22, written by Housekeeping #208 revealed she was doing Resident #73 hair when she noticed her scalp was bleeding due to dryness and took her to the window to show Licensed Practical Nurse (LPN) #210. Housekeeping #208 wrote they were talking about activities for the day and could not see the television so she had told her (Resident #73) to ask Activities #211 because he was next to LPN #210 talking about appointments. When Resident #73 asked what it was (activities), Activities #211 said what you can't read! Housekeeping #208 wrote she was so offended by the way he said it that it had irritated her. Housekeeping #208 wrote that after it was said she (Resident #73) hung her head down and put her had (hand) on her head. Review of witness statement, dated 11/18/22, from State Tested Nursing Assistant (STNA) #213 revealed she was at the nurses station when Resident #73 finished getting her hair done and Activities #211 was there. STNA #213 wrote Activities #211 never had a conversation with Resident #73. STNA #213 wrote Resident #73 does not communicate with us well and does not ask questions like what is stating was asked. Interview on 12/16/22 at 12:18 P.M. with Housekeeping Staff #208 revealed on an unknown date, she and Resident #73 were at the nurse's station when Resident #41, who was in the dining room, asked what activities were scheduled for the day. Housekeeping Staff #208 stated she could not see the schedule for the day and asked Resident #73 to ask Activities Staff #211 what activities were scheduled. Upon Resident #73 asking, Activities Staff #211 allegedly responded, What, you can't read? and did not further respond to the inquiry. Housekeeping Staff #208 stated Resident #73 heard Activities Staff #211 and put her head down. Housekeeping Staff #208 stated Resident #41 was too far to hear the remark. Interview on 12/16/22 at 3:14 P.M. with the Director of Nursing (DON) verified Housekeeping Staff #208 and her supervisor came to her the following day on 11/18/22 to report the alleged incident. The DON stated she did her due diligence and interviewed Licensed Practical Nurse (LPN) #210 who was in the area completing charting and stated she heard people talking but did not hear the conversation. The DON reported she was contacted by State Tested Nursing Assistant (STNA) #213 who reported she was nearby and stated there was no conversation or communication between Activities Staff #211 and Resident #73. The DON stated she had a written statement from Housekeeping Staff #208 and text messages from STNA #213 but no other written statements or investigation. The DON stated she intended to receive a statement from Activities Staff #211 but did not. The DON reported Resident #73 was not alert and oriented and confirmed she did not interview Resident #73 as she may nod her head but cannot have a conversation. The DON verified a SRI was not completed. Review of the facility's SRI history from August 2022 to current revealed no SRI's completed for these two instances involving Resident #14 and #73, indicating a thorough investigation was not completed. Review of facility policy, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 2017, verified 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 or designee will notify the State Agency of all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property and injuries of unknown source as soon as possible, but in no event later than 24 hours from the time of the incident/allegation was made known to the staff member. Once the Administrator and the State Agency are notified, an investigation of the allegation violation will be conducted. The investigation will be completed within five working days unless there are special circumstances. Generally the investigation should include interview of the resident, the accused, and all witnesses. Statements from the resident, if possible, the accused, and each witness. Review of the resident's record and review of the accused employees employment records. This deficiency represents non-compliance investigated under Complaint Number OH00138171.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, resident and staff interview and review of facility policy, the facility failed to ensure residents with indwelling catheters had their catheters managed in a dignified manner. This affected two (#222 and #54) of the three residents reviewed for dignity. The facility census was 71. Findings Include: 1. Review of Resident #222's medical record revealed an admission date 07/28/22. Diagnoses included fracture around internal right hip joint subsequent encounter. Review of Resident #222's Minimum Data Set (MDS) revealed an admission MDS was in progress. Review of Resident #222's admission assessment dated [DATE] revealed Resident #222 was admitted to the facility from the hospital following a fall at home. Resident #222 had an indwelling catheter. Resident #222 used a manual wheelchair for mobility. Interview on 08/08/22 at 9:56 A.M. with Resident #222 revealed she had a catheter. Coinciding observation of her catheter bag found it attached under her wheelchair and the bag was not covered. The bag was observed to be partially full of dark yellow/light brown urine. Resident #222 stated she didn't know it wasn't covered as she was not able to manage her catheter bag herself and could not see it under her. Observation on 08/08/22 at 11:16 A.M. of Resident #222 found her out in the common area of the home working with physical therapy. Resident #222's catheter bag was uncovered and her urine was visible to other residents, staff and visitors. Interview on 08/08/22 at 11:18 A.M. with State Tested Nursing Assistant (STNA) #174 verified Resident #222's catheter bag was not covered. STNA #174 reported Resident #222 did not have dignity bag and she was not sure where they could get one. 2. Review of Resident #54's medical record revealed an admission date of 09/02/21. Diagnoses included fracture of left pubis subsequent encounter and obstructive and reflux uropathy (blocked urethra). Review of Resident #54's MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Resident #54 required one person physical assistance with toilet use. Resident #54 had an indwelling catheter at the time of the review. Resident #54 displayed no behaviors during the review period. Review of Resident #54's care plan revised 07/15/22 revealed supports and interventions for risk for infection related to suprapubic catheter and risk for complications related to use of suprapubic catheter due to retention of urine and obstructive uropathy. Interview on 08/08/22 11:18 A.M. with STNA #174 revealed Resident #54 had a catheter bag which had no cover and he was currently out of the facility at an appointment. STNA #174 reported they didn't have catheter dignity bags for Resident #54 and she didn't know where to get them. Observation on 08/08/22 at 11:32 A.M. of Resident #54 found him propelling himself in his motorized wheelchair back into the home. Coinciding interview with Resident #54 verified he was returning home from a medical appointment. Resident #54's catheter bag was uncovered and lying on the footrest of his motorized wheelchair. Resident #54 stated he didn't have a cover for his catheter bag that he knew of. STNA #174 verified Resident #54's catheter bag was not covered and he had been out in public outside the facility. Review of the facility policy titled, Dignity, revised February 2021 revealed staff were to promote, maintain, and protect resident privacy. Urinary drainage bags must be covered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, resident and staff interviews and policy review, the facility failed to ensure hand splints were applied as recommended by therapy and/or ordered by the physician. This affected two (#29 and #30) two residents reviewed for limited range of motion. The facility census was 71. Findings include: 1. Review of Resident #29's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including spastic hemiplegia affecting his left non dominant side, major depressive disorder, osteoarthritis, vascular dementia, seizure disorders, anemia, and diabetes type II. Review of Resident #29's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of six revealing he has a severe cognitive deficits. Resident #29 displayed physical behaviors toward others on one to three days of the assessment. Resident #29 is totally dependent for all activities of daily living except eating which he requires supervision of one person. Resident #29 is non ambulatory. Resident #29 has functional limitation in range of motion to his upper extremities on one side. Review of the plan of care updated 06/07/22 stated Resident #29 is at risk for alteration in comfort and pain related to osteoarthritis of his left hand and history of a stroke with left hemiplegia. Resident #29 has had botox in his left hand in the past. Interventions included a left hand splint at bedtime as tolerated per order and monitor skin for breakdown with application and removal of the splint. Review of a physician order dated 06/01/22 stated to apply a left hand splint. The splint is to be taken off during morning care, applied at lunch, taken off at dinner and applied at bedtime. The order stated to contact occupational therapy with any concerns. Review of the Occupational Therapy Discharge Summary, dated 06/14/22, revealed the OT recommendation was for Resident #29 to have a left hand splint (hand roll) placed eight hours a day per wearing schedule. Observation on 08/09/22 at 2:10 P.M. revealed Resident #29 was in reclining chair at the dining room table with another resident drinking strawberry lemonade. Resident #29's left hand was in a fist with his left arm flaccid lying on his left leg. Resident #29 stated they do not work with his left hand or put a splint on it. Resident #29 stated the only one who does anything with his hand is his son. Observation of Resident #29's room on 08/09/22 at 2:14 P.M. revealed a hand roll splint over the faucet in the sink. Interview with State Tested Nursing Assistant (STNA) #212 on 08/09/22 at 2:15 P.M. verified Resident #29 had a splint for his left hand contracture. STNA #212 stated it had become soiled and she had to wash the splint and let it air dry. STNA #212 verified there was nothing currently in Resident #29's left hand. Interview with Licensed Practical Nurse (LPN) #195 on 08/09/22 at 2:20 P.M. verified Resident #29 was to have a soft hand splint on his left hand placed on after lunch until dinner. The splint is to be off at dinner and on at bedtime then off for morning care. LPN #195 verified Resident #29 did not have anything in his left hand at the time. LPN #195 verified there was no extra splints to use while the original hand splint was drying. F Interview with Certified Occupational Therapy Assistant (COTA) #600 on 08/10/22 at 2:00 P.M. verified Resident #29 was to wear a splint in his left hand to protect the skin on the palm of his hand and prevent the contracture of his left hand from contracting further. COTA #600 verified the splint was a hand roll and should be worn eight hours a day per splint schedule. COTA #600 stated the splint schedule is in the STNA's tasks for instructions and documentation. 2. Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident with left hemiparesis, obsessive compulsive disorder, diabetes hypertension, and peripheral vascular disease. Review of Resident #30's quarterly MDS assessment dated [DATE] revealed the resident scored an eight on the BIMS indicating moderate cognition deficits. Resident #30 displayed physical behaviors one to three days a week during the assessment. Resident #30 requires extensive assistance of two staff for bed mobility, transfers and personal hygiene. Resident #30 is non ambulatory and has limited range of motion on one side of upper extremities. Review of plan of care dated 06/10/22 revealed Resident #30 is at risk for knowledge deficits for use of hand splint for contracture . The interventions included treatment as ordered and keep hand splint clean and dry, and monitor skin under hand splint. Review of a physician order dated 07/23/22 revealed Resident #30 is to have a left hand splint. There were no directions for use. Review of Occupational Therapy Discharge Summary, dated 05/10/22, revealed the recommendations indicated Resident #30 was to wear a left hand splint (hand roll) eight hours a day per wearing schedule. Observation on 08/10/22 at 2:00 P.M. revealed Resident #30 was in bed with her left hand lying on the mattress with her hand in a fist. There was no splint on Resident #30's left hand. Interview with STNA #234 on 08/10/22 at 2:10 P.M. verified Resident #30 was to have a splint to her left hand after lunch off at dinner and back on at bedtime. STNA #234 verified Resident #30 did not have a splint on her left hand at the present time and stated she was unable to find the splint. Interview with COTA 600 on 08/10/22 at 2:00 P.M. verified Resident #30 was to wear a splint in her left hand to protect the skin on the palm of her hand and prevent the contracture of her left hand from contracting further. COTA #600 verified Resident #30's splint was a hand roll and should be worn eight hours a day per splint schedule. COTA #600 stated Resident #30's splint schedule is in the STNA's tasks for instructions and documentation. Review of undated policy titled Contracture Management indicated nursing staff is to follow suggested physician interventions to manage changes in baseline limb movement and prevent further decline. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review the facility policy, the facility failed to provide adequate supervision to ensure a cognitively impaired resident did not elope from the locked unit. This affected one (#41) out of three residents reviewed for elopement. The facility census was 71. Findings include: Review of Resident #41's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include encephalopathy, diabetes, falls, maxillary fracture, chronic kidney disease, heart failure, tremors, dementia without behaviors. Review of Resident #41's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was a one-person assist for Activities of Daily (ADL). Review of the admission wandering risk assessment dated [DATE] revealed Resident #41 was assessed as being a low risk for wandering. Review of Resident #41's progress notes revealed on 06/09/22 the resident's family had concerns for Resident #41's wandering so they requested a Wanderguard. Per the note the physician agreed. Review of the care plans dated 06/08/22 revealed a focus for wandering from facility unattended due to dementia, depression, and anxiety. Interventions include allow the resident to wander in appropriate areas but remove from area if annoying peers, check alarm system to ensure safety, encourage to walk with a buddy to activities, frequent checks, medications per order, redirect attention, one-on-one (1:1) interactions, take on walks, take to common areas if wandering. Review of Resident #41's progress notes dated 07/21/22 revealed at 12:45 P.M. the nurse was notified by the aide that Resident #41 had left the gated patio area she was in with her Assisted Living (AL) visitor. Per the note, the AL visitor was aware he did not have permission to leave the locked unit with Resident #41. Per the note the nurse called the AL unit and the staff had located the resident in the AL. The nurse notified the Licensed Social Worker (LSW) #152, the Administrator, the physician and the resident's family representative. Interview on 08/09/22 at 3:15 P.M. with Licensed Practical Nurse (LPN) #157 revealed Resident #41 does not exhibit exit seeking behaviors by herself. Per LPN #157 she has a friend from the AL she had a relationship with while she was residing on the AL unit that comes to visit her. LPN #157 showed the surveyor the gated patio area Resident #41 and her visitor were visiting when the incident on 07/21/22 occurred. Per LPN #157, the gate has a locking mechanism on the outside that can be reached and unlocked by reaching through the gate and using force to lift the lock and push the gate open. LPN #157 stated Resident #41 was not capable of opening the locked gate by herself due to her condition. LPN #157 verified the resident's AL visitor could open the gate and leave with the resident if the staff did not supervise the visitation. LPN #157 stated the AL visitor did not have permission from the facility or the family of Resident #41 to leave the locked unit with the resident. LPN #157 stated the AL visitor visited Resident #41 on a daily basis but was to be supervised by staff. LPN #157 stated she assessed Resident #41 after the incident on her shift and found the resident to have no injuries and did not appear to be any distress after the incident. Interview on 08/09/22 at 4:26 P.M. with Licensed Social Worker (LSW) #152 and the Administrator revealed on 07/21/22 around 12:30 P.M. Resident #41 and a visitor, a resident from AL unit were visiting and staff let the resident and her visitor out to the gated patio connected to the locked dementia unit. Per the Administrator Resident #41 had a previous relationship with the AL resident who was visiting her in the locked unit and did so on a daily basis. The Administrator stated staff went to check on Resident #41 and the AL resident around 12:45 P.M. when they noticed the resident and the visitor were no longer in the gated patio area. The Administrator stated the aide immediately notified the nurse who began the missing person procedure. The aide was instructed to go to the AL unit to search for Resident #41 as she had been a previous resident on the AL unit and may have been going back to the AL unit with her visitor. Per the Administrator the nurse notified staff on the AL unit and the staff began to search for Resident #41. The Administrator and LSW #152 stated they had been notified by the nurse of the resident leaving the patio area with her AL visitor. Per the Administrator the resident had been gone for less than 10 minutes from the patio before being found in the AL unit. The LSW stated the nurses assessed the resident and found her to have no injuries and to be in no distress. LSW #152 verified the AL visitor was not given permission from the facility or Resident #41's family to take the resident out of the SNF unit to the AL unit. The Administrator verified the staff were to supervise visitations with Resident #41 and her AL visitor. Review of the facility policy titled, 'Missing Person', dated 08/2018 revealed staff are to monitor residents at risk for wandering and elopement, precautions are to be taken to prevent the residents from eloping. This deficiency substantiates Complaint Number OH00131650.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of facility policy, the facility failed to ensure the physician responded to the pharmacist's recommendations for a gradual dose reduction and a end date for an as needed medication. This affected one (#2) out of five residents reviewed for unnecessary medications. The facility census was 71. Findings include: Review of Resident #2's medical record revealed the resident was admitted to the hospital on [DATE]. Diagnoses include anxiety, hemiplegia, hypotension, mood affective disorder, dementia with behaviors, depression and falls. Review of Resident #2's Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had impaired cognition and was receiving anticoagulant, antipsychotic, anti-anxiety, and opioid medications for seven days. Review of care plans for Resident #2 dated 12/2018 revealed a focus for potential for adverse effect related to anti-psychotic, antidepressant, anti-anxiety, and medications that stabilize her mood. Interventions include medication increased due to increased behavior, administer antipsychotic medications, assure medications are swallowed, monitor effected of medications and update physician if having behaviors, monitor for side effects of medications, pharmacist/physician to review medications routinely to assure lowest effective dose. Review of Resident #2's physician prescribed medications revealed on 01/31/21, the resident was receiving Lorazepam 0.5 milligrams (mg) every two hours as needed for anxiety. On 04/09/21 the resident was to receive Risperdal 0.25 mg two times a day for behaviors and mood disorder. Review of the pharmacy reviews revealed on 01/19/21 the pharmacist recommended the physician re-evaluate the medication for need and provide a stop date for the as needed medication. No documentation of a physician response to the recommendation was noted in the resident's record. Review of the pharmacy reviews revealed on 09/17/21 the pharmacist sent a recommendation to the physician to review the Risperdal 0.25 mg twice a day for mood disorder for a possible gradual dose reduction. Further medical record review revealed there was no documented physician response was noted in the resident's record. Interview on 08/11/22 at 8:30 A.M. with the Director of Nursing (DON) verified there were no documented physician responses to the pharmacist's recommendations on 01/19/21 and 09/17/21 for the Lorazepam and the Risperdal. Review of the facility policy titled 'Antipsychotic Medication Use', dated 12/2016 revealed all antipsychotic medications are to be prescribed at the lowest dose for the shortest period of time and are subject to gradual dose reduction and re-review. The physician shall respond appropriately by changing the medications or by clearly documenting the rationale for continued use of the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed ensure a resident was free from unnecessary psychotropic medication usage when the facility failed to have an adequate indication for use for an antipsychotic medication. This affected one (#32) of five residents reviewed for unnecessary medications. The facility census was 71. Findings Include: Review of Resident #32's medical record revealed an admission dated of 05/14/21 and a readmission date of 04/13/22. Diagnoses included history of heart failure, rapid heart rate, dementia with Lewy bodies, epilepsy, dysphagia, major depressive disorder, and cognitive communication deficit. Review of Resident #32's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #32 was cognitively intact. Resident #32 required extensive assistance with transfer, dressing, toilet use, and personal hygiene. Resident #32 required physical help in part of the bathing activity. Resident #32 displayed no behaviors during the review period. Resident #32 had depression and no psychotic disorder at the time of the review. Review of Resident #32's care plan revised 07/27/22 revealed supports and interventions for use of antidepressant medications related to major depressive disorder and risk for potential side effects related to psychotropic medication use. It was noted Resident #32 received antipsychotic medications to stabilize her mood. Review of Resident #32's physician orders revealed an order dated 04/13/22 and discontinued 06/22/22 for Seroquel (antipsychotic medication) 25 milligrams (mg)-give 0.5 mg tablet by mouth at bedtime for cognitive communication deficit. An order dated 06/28/22 for Seroquel 25 mg-give 0.5 mg tablet by mouth at bedtime for cognitive communication deficit. Review of Resident #32's Psychiatric Reviews dated 06/09/22 and 07/06/22 revealed Resident #32 was receiving Seroquel 12.5 mg at bedtime for cognitive communication deficit. Interview on 08/11/22 at 8:12 A.M. with the Director of Nursing (DON) verified cognitive communication deficit was not an appropriate diagnosis for the use of the antipsychotic medication Seroquel. Review of the facility policy titled, Antipsychotic Medication Use, revised December 2016 revealed residents would only receive antipsychotic medications when necessary to treat a specific condition for which they were indicated and effective. Antipsychotic medication shall generally be used only for the following diagnoses as documented in the record, consistent with the definitions in the Diagnostic and Statistical Manual of Mental Disorders: schizophrenia, schizoaffective disorder, delusional disorder, mood disorders, psychosis in the absence of dementia, medical illness with psychotic symptoms and or treatment related psychosis or mania, Tourette's disorder, Huntington Disease, hiccups, or nausea and vomiting associated with cancer or chemotherapy. Antipsychotic medications will not be used if they only symptoms were one or more of the following: wandering, poor self-care, restlessness, impaired memory, mild anxiety, insomnia, inattention or indifference to surroundings, sadness or crying that is not related to depression or other psychiatric disorders, fidgeting, nervousness or uncooperativeness.

Based on observations, resident and staff interviews and policy review, the facility failed to accommodate resident needs by ensuring the resident's call lights were within reach. This affected four (#24, #30, #34, and #122) out five residents sampled for accessibility of call lights. Facility census was 71. Findings include: Observation on 08/08/22 at 4:55 P.M. revealed Resident #122 was sitting up in bed with her dinner tray in front of her. Resident #122 stated she did not like what they served her for dinner. When asked if she had told staff she stated she couldn't tell staff due to no being able to reach her call light. Resident #122's call light was on the bottom bar of the enabler side rail with the button pointing to the floor out of the reach of the resident. On 08/08/22 at 5:00 P.M. an interview with State Tested Nursing Assistant (STNA) #224 verified Resident #122 could not reach her call light. On 08/09/22 at 2:10 P.M. observations revealed Resident #30 was lying in bed. Resident #30 stated she had a wet depends on that she couldn't get rid of. When asked if her depends needed changed she stated yes. The soft touch call light was hanging off the bed on the bottom bar of her right enabler side rail out of the reach of the resident. Interview with STNA #234 on 08/09/22 at 2:15 P.M. verified Resident #30 was not able to reach her call light. On 08/10/22 at 7:15 A.M. observation of Resident #24, #30, #34, and #122 revealed call lights were draped around the bottom bar on the enabler side rails hanging down towards the floor out of the reach of the residents. On 08/12/22 at 7:25 A.M. an interview with Licensed Practical Nurse (LPN) #240 verified Resident #24, #30, #34 and #122 call lights were out of reach. LPN #240 stated the call lights needed to be clipped to the resident's clothing as this is their direct line to access staff. Review of an undated policy titled Call Light revealed staff should keep nurses' call system within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview; facility failed to ensure advanced directives being stored in the hard chart and the electronic health record (EHR) were consistent. This affected one (#2) of 24 residents reviewed for consistency of advanced directives. The census was 65. Findings include: Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE]. Diagnoses include obesity, anemia, hemiplegia, hemiparesis, cerebral edema, mixed receptive expressive language disorder, disorder of bone density, insomnia, fatigue, dizziness, neoplasm of soft tissue and skin, hyperlipidemia, vascular dementia with behavioral disturbances, constipation, cognitive communication deficit, hypertension, major depressive disorder, anxiety, bipolar disorder, and hypothyroidism. Review of Resident #2's electronic health record revealed the resident code status was do not resuscitate (DNR) comfort care (CC). The DNR-CC physician order in the electronic health record was dated 02/04/19. Review of Resident #2's hard chart revealed a document titled, DNR Identification Form dated 02/06/19. The DNR identification form revealed the resident's code status was DNR-CC arrest. Interview on 08/21/19 at 8:51 A.M. with licensed practical nurse (LPN) #750 verified that the advanced directive located in Resident #2's hard chart and the electronic health record were not consistent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident financial records, interview with facility staff and review of facility policy revealed the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF/ABN) for one (#41) of three residents reviewed for appropriate SNF/ABN notifications. The census was 64. Findings include: Review of the medical record of Resident #41 admitted to the facility on [DATE] with diagnoses including cerebral infarction, cellulitis, major depressive disorder, anemia, arthritis, morbid obesity, sleep apnea, anxiety, and hyperlipidemia. Her most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 has a Brief Interview of Mental Status (BIMS) score of 08, indicating she has a moderate cognitive impairment. Review of Resident #41's Notice of Medicare Non-Coverage (NOMNC) revealed her last covered day of skilled services was 06/27/19. Resident #41's financial Power-of-Attorney (POA) was notified on 06/24/19 via phone. Resident #41 continued her stay in the facility and a SNF/ABN was necessary. Review of the SNF/ABN revealed Resident #41 signed the SNF/ABN on 08/21/19. During an interview on 08/22/19 at 9:43 A.M., Director of Residential Services confirmed Resident #41's SNF/ABN was not signed until 08/21/19. Director of Residential Services stated she had been on vacation when Resident #41 was issued her NOMNC and the staff member covering for her did not issue the SNF/ABN.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy and staff interview, the facility failed to provide documentation residents and responsible parties were provided a notice of transfer upon transfer from the facility. This affected two residents (#7, #41) of three residents reviewed for hospitalization. The facility identified three residents who had transferred from the facility in the last 30 days. The facility census was 65. Findings include: 1. Review of the medical record for Resident #7 revealed the resident was admitted to the facility on [DATE]. Diagnoses include altered mental status, acute kidney failure, osteoarthritis, falls, neuralgia and neuritis, pain right shoulder, gastro-esophageal reflux disease, disorientation, obstructive uropathy, sepsis, difficulty walking, bursitis of hip,muscle weakness, infection and inflammation due to indwelling urethral catheter, muscle weakness, anxiety, transient ischemic attack ( mini-stroke), urinary tract infection, urine retention. sciatica and gout. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive deficits and verbal and behavioral symptoms. Extensive assistance was required for all activities of daily living except for supervision with eating. Review of a progress note dated 05/04/19 at 8:40 A.M., revealed Resident #7 was found unresponsive and was sent to the emergency room. Review of a Transfer notice dated 05/04/19 revealed Resident #7 was sent to the hospital due to an emergency. The Ombudsman's name was listed and it revealed the notification was sent to the Ombudsman. Review of Lima convalescent Home Transfer/discharge Notice signed 09/29/17 revealed the Administrator was to notify the resident and resident's sponsor in writing by certified mail, return receipt requested in advance of any proposed transfer or discharge from the home. Further review of the medical record for Resident #7 revealed no documentation was available regarding providing a notice of transfer to the resident's responsible party. Interview with Medical Records Clerk #200 on 08/22/19 at 9:20 A.M., revealed she filled out a transfer notice and sent it to the Ombudsman when Resident #7 was sent to the hospital. She stated she had been instructed to copy the notice and send it to the family. She stated she did not keep any documentation of any notifications she had sent. She stated she emailed the Ombudsman with each transfer and did not have a monthly notification. 2. Review of the medical record for Resident #41 revealed the resident was admitted to the facility on [DATE]. Diagnoses includes acute embolism of the left femoral vein, mild cognitive impairment, heart failure, hyperlipidemia, lymphedema, and severe protein calorie malnutrition. Review of the progress notes dated 08/03/19 at 7:06 P.M. revealed Resident #41 was sent the hospital for evaluation and treatment related to lymphedema of the left lower extremity. Continued review of the progress notes revealed the resident was admitted to the hospital. The resident returned to the facility on [DATE]. Review of the medical record for Resident #41 revealed no evidence the resident or the resident representative was given notice of the reason of transfer to the hospital in writing. Interview on 08/22/19 at 8:59 A.M. with the director of nursing verified the facility did not give Resident #41 or the resident's representative notice of the reason for the transfer to the hospital in writing on 08/03/19. Review of an undated discharge notice form revealed the facility must notify the resident and representative in writing of the reason for transfer or discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy and staff interview, the facility failed to provide residents and responsible parties with a bed hold notice upon transfer from the facility. This affected two residents (#7, #41 ) of three residents reviewed for hospitalization. The facility identified three residents who had transferred from the facility in the last 30 days. The facility census was 65. Findings include: 1. Review of the medical record for Resident #7 revealed the resident was admitted to the facility on [DATE]. Diagnoses include altered mental status, acute kidney failure, osteoarthritis, falls, neuralgia and neuritis, pain right shoulder, gastro-esophageal reflux disease, disorientation, obstructive uropathy, sepsis, difficulty walking, bursitis of hip,muscle weakness, infection and inflammation due to indwelling urethral catheter, muscle weakness, anxiety, transient ischemic attack ( mini-stroke), urinary tract infection, urine retention. sciatica and gout. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive deficits and verbal and behavioral symptoms. Extensive assistance was required for all activities of daily living except for supervision with eating. Review of a progress note dated 05/04/19 at 8:40 A.M. revealed Resident #7 was found unresponsive and was sent to the emergency room. Review of a Bed-holding Agreement signed 09/27/17 revealed the resident responsible party was informed of abed hold policy on 09/27/17. Further review of the medical record for Resident #7 revealed no documentation was available regarding providing a bed hold policy being provided to the resident's responsible party. Interview with Director of admission #250 on 08/22/19 at 10:30 A M. revealed residents/responsible parties were informed of the bed hold policy on admission and signed the form at that time. He verified the bed hold agreement/policy was not reviewed each time the resident was transferred from the facility. He further verified the responsible party for Resident #7 was not provided a bed hold policy upon the resident's transfer to an acute care hospital on [DATE]. 2. Review of the medical record for Resident #41 revealed the resident was admitted to the facility on [DATE]. Diagnoses includes acute embolism of the left femoral vein, mild cognitive impairment, heart failure, hyperlipidemia, lymphedema, and severe protein calorie malnutrition. Review of the progress notes dated 08/03/19 at 7:06 P.M. revealed Resident #41 was sent the hospital for evaluation and treatment related to lymphedema of the left lower extremity. Continued review of the progress notes revealed the resident was admitted to the hospital. The resident returned to the facility on [DATE]. Review of the medical record for Resident #41 revealed no evidence the resident or the resident representative was notified of the facilities policy for bed hold. Interview on 08/22/19 at 8:59 A.M. with the director of nursing verified the facility did not give Resident #41 or the resident's representative the facilities policy for bed hold. Review of a policy titled, Bed Hold revised 12/18, revealed information about the facilities bed hold policy will be provided in writing at the time of a transfer for hospitalization or therapeutic leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview; the facility failed to ensure minimum data set (MDS) assessments were accurate. This affected two (#4 and #59) of 18 residents reviewed for accuracy of the assessment. The census was 65. Findings include: 1. Review of the medical record for Resident #4 revealed the resident was admitted to the facility on [DATE]. Diagnoses include dementia with behavioral disturbance, lack of expected normal physiological development, mood affective disorder, retention of urine, hyperlipidemia, anxiety, major depressive disorder, and convulsions. Review of the medication administration record dated 07/19, revealed Resident #4 was administered Xarelto (anticoagulant medication) 20 milligrams on 07/24/19, 07/25/19, 07/26/19, and 07/27/19. Review of a quarterly MDS assessment dated [DATE], revealed no assessment of the anticoagulant medications administered to Resident #4 during the seven day reference period. Interview on 08/21/19 at 2:26 P.M. with registered nurse (RN) #560 revealed Resident #4 was administered anticoagulant medication on 07/24/19, 07/25/19, 07/26/19, and 07/27/19. RN #560 verified the Resident #4's quarterly MDS assessment dated [DATE], was not accurate. 2. Review of the medical record of Resident #59 revealed an admission date of 05/05/19 and a discharge date of 05/31/19. Diagnoses included pneumonia, benign neoplasm of pancreas and acute respiratory failure with hypoxia. Review of the discharge summary note dated 06/27/19 revealed Resident #59 was admitted on [DATE] from acute care for follow up care related to septic pneumonia with the goal to return home. Elder received therapy services, medication management, respiratory support, lab monitoring for low hemoglobin and hematocrit, and activity of daily living support. Home evaluation completed, discharged home on [DATE] with home health services and follow up appointments with doctors. Review of the Minimum Data Set (MDS) dated [DATE] revealed in the identification information section (A) revealed the resident was coded as discharge return not anticipated, with discharge status as acute hospital. Interview with 08/22/19 at 8:10 A.M. with the Assisted Director of Nursing #600 verified for Resident #59 the information in the MDS dated [DATE] was an error due to her being discharged to home and it will need to correct it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, interview with facility staff, and review of facility policy, the facility failed to provide a final summary of residents status and reconcile medications for one (Resident #57) of one residents reviewed for discharge. The census was 65. Findings include: Review of Resident #57's medical record revealed an admit date on 05/23/19, with diagnoses including: hernia with obstruction, osteoarthritis, kidney disease, sleep apnea, obesity, congestive heart failure, mixed incontinence, dementia, and hypertensive heart and chronic kidney disease. Resident #57 discharged to an adjoining Residential Care Facility on 06/08/19 with his wife. Resident #57's most recent Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview of Mental Status of 07, indicating a severe cognitive impairment. The MDS also revealed he required extensive assistance with his activities of daily living. Review of a form titled Resident Discharge summary, dated [DATE], revealed the functional status, level of assistance needed and condition upon discharge were left blank. Where the form stated Discharging to: was left blank, as well as home health services and outpatient services. Future appointments were listed. Labs to be drawn after discharge were also included. The form also revealed a medication reconciliation was not performed. Resident #57's wife signed the discharge summary. During an interview on 08/22/19 at 8:58 A.M. with Licensed Practical Nurse (LPN) #500 revealed she was the nurse who discharged Resident #57. LPN #500 confirmed the following areas on Resident #57's discharge summary were left blank: functional status, level of assistance, condition upon discharge, discharge location, home health and/or out patient services and verified there was no evidence medication reconciliation was completed. Review of a facility policy titled, Transfer and Discharge, last revised 12/03/18 revealed the resident or representative would received verbally and in writing, a copy of the post-discharge plan which would include the current medication list, current treatments, diet recommendations, and any post-discharge medical and non-medical services. Review of a facility policy titled, Advanced Beneficiary Notice, updated 12/05/18, revealed the resident or resident representative would be notified of the last day to be covered by Medicare at least two days in advance of the last covered day.

Based on medical record review and staff interview, the facility failed to ensure as needed (prn) medication used longer than 14 days were reevaluated by a physician. This affected one (#47) of five residents reviewed for unnecessary medications The facility census was 65. Findings include: Review of medical record for Resident #47 revealed an admission date of 05/02/19 with diagnosis that include depression, mental disorders, diabetes, hallucinations, and anxiety. Review of the most recent quarterly Minimum Data Set (MDS) assessment for Resident #47 dated 07/12/19 revealed impaired cognition. The resident required extensive assist for bed mobility, transfers, dressing, toileting and personal hygiene. Further investigation of MDS revealed anxiety medication was administered during the look back period. Review of physician orders for the month of May 2019 for Resident #47 revealed an order dated 05/23/19 for Ativan (name brand anxiety medication) 0.5 milligrams (mg) take one tablet by mouth every eight hours as needed for anxiety for the next two months. Review of the physician progress notes for Resident #47 dated 5/23/19 and 06/30/19 were silent for documentation regarding the rationale for the two month order for antianxiety medication. Interview with Director of Nursing on 8/21/19 at 11:58 A.M., verified that the physician did not re-evaluate the prn Ativan every fourteen days.

Based on medical record review, staff interview and review of the manufacturer's instructions, the facility failed to ensure insulin was given per physician's order by ensuring the insulin Kwik Pen was primed prior to administrating the dosage of medication. This affected one (#51) of two residents observed for insulin administration. The census was 65. Findings include: Record review of Resident #51 revealed an admission date of 07/12/19. Diagnosis include Diabetes Mellitus. Review of the physician's orders for Resident #51 revealed an order for Humalog mix 75/25 Kwik Pen Suspension (75/25) 100 units per milliliter (ml), to inject 40 units subcutaneously two times a day with meals. Observation on 08/21/19 at 8:05 A.M. of medication administration on Resident #51 with Licensed Practical Nurse (LPN) #500 revealed she cleaned the Kwik Pen Humalog 75/25 with alcohol, placed a new needle on it. She rolled the pen until it was evenly distributed then dialed up 40 units. She did not prime the pen, but gave the 40 units in the right upper arm. Interview with LPN# 500 on 08/21/19 at 8:36 A.M., verified she did not prime the needle prior to dialing up the 40 units also she was told to only prime the quick pens when they were new. She then realized she did not give the full dose of 40 units and actually injected her with two units of air. Interview with the Director of Nursing on 08/21/19 at 9:58 A.M. verified she had spoken to the doctor on the phone regarding LPN#500 whom did not prime the Kwik Pen during administration of insulin to Resident #51. The doctor did not want any actions to be taken but agreed this should have been primed prior to administration which resulted in inaccurate dose being given. Review of the manufacture's instructions for use Humalog Kwik Pen revised date of 12/2018 revealed to prime before each injection. Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin.