**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations and policy review, the facility failed to maintain the shower room and resident rooms in a clean and sanitary manner. This affected one (#43) of two residents reviewed for physical environment. The facility census was 124. Findings include: Record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including encounter for orthopedic aftercare, chronic obstructive pulmonary disease, and hypertension. Review of an admission minimum data set (MDS) completed on 03/27/25 revealed Resident #43's cognition remained intact. Interview on 04/21/25 at 3:07 P.M. with Resident #43 revealed sometimes the shower rooms are not cleaned well, and she had a stain on her shower curtain since her admission. Interview and tour on 04/23/25 at 4:01 P.M. with Housekeeping Supervisor (HS) #201 and Maintenance Staff (MS) #567 revealed the first-floor shower room had a quarter-sized, soft bowel movement on the floor next to the drain in the third stall, and a used washcloth hanging over the handrail of the second stall. HS #201 confirmed the findings and stated housekeeping staff mop the floors each morning and scrub the floors once per week, but in between residents, the floor staff should clean the shower room. The tour continued to Resident #43's room where a round stain was noted to the bottom right of her shower curtain. The observation was confirmed by HS #201 and MS #567. Review of a statement dated 04/23/25 with no time provided by Certified Nursing Assistant (CNA) #531 revealed she gave Resident #43 a shower and had taken her back to her room to help her get ready and was going to clean the shower room after. Interview on 04/24/25 at 4:03 P.M. with MS #567 confirmed after observing the first-floor shower room during the tour, Resident #43's room was observed directly after with no sign of a CNA or Resident #43 in her room or the shower room. Review of a policy titled Safe and Homelike Environment dated 01/01/22 revealed the facility will provide a safe, clean, homelike, and comfortable environment and ensure the building and equipment are kept sanitary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and policy review the facility failed to ensure minimum data set (MDS) assessments were completed accurately for falls, dental status, catheter and continence status. This affected three (#86, #104, and #178) of four residents reviewed for accurate assessments. The facility census was 124. Findings include: 1. Record review revealed Resident #178 admitted to the facility on [DATE] with diagnoses including occlusion and stenosis of right carotid artery, peripheral vascular disease, atrial fibrillation, and benign prostatic hyperplasia. Review of a nursing note dated 04/01/25 at 1:00 P.M. by Unit Manager (UM) #595 revealed Resident #178 admitted to the facility with a #16 French (the size of the catheter) indwelling catheter for urinary retention. Review of a Urinary Continence Evaluation dated 04/08/25 at 4:47 P.M. revealed Resident #178 was always continent and did not have a urinary catheter in use. Review of an admission MDS dated [DATE] revealed Resident #178's cognition remained intact, he did not have an indwelling catheter, and his urinary continence was not rated. Review of orders revealed no evidence of orders to care for Resident #178's urinary catheter. Interview on 04/21/25 at 2:23 P.M. with Resident #178 revealed he had been waiting for an appointment with the urologist to remove his catheter and would like an update. Observation on 04/22/25 at 8:31 A.M. revealed Resident #178 was seated in his wheelchair and had a breakfast tray in front of him. A catheter bag was noted. Interview on 04/22/25 at 8:50 A.M. with MDS Nurse #513 and MDS Nurse #564 revealed Resident #178's MDS was coded incorrectly because Resident #178 had a catheter. MDS Nurse #513 and #564 stated they thought Resident #178's catheter had been removed upon admission to the facility. Interview on 04/22/25 at 9:48 A.M. with Director of Nursing (DON) and UM #595 confirmed everyone thought Resident #178's catheter had been removed upon admission. The DON stated he saw Resident #178 daily and is not sure how the catheter was missed. 3. Review of Resident #86's medical record revealed an admission date of 02/01/25, with a re-admission date of 03/30/25 with diagnoses including transient cerebral ischemic attack, diabetes, asthma, atrial flutter, major depressive disorder, hypertension, hyperlipidemia, and hypothyroidism. Review of Resident #86's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) Score of 15 indicating the resident's cognition was intact. Review of Resident #86's medical record revealed a fall on 04/05/25 at 7:19 P.M. Resident #86 was getting up to go to the bathroom and lost her balance resulting in a bruise on the resident's back. Further review revealed no other falls since the 03/30/25 admission and no other injuries from the 04/05/25 fall. In an interview on 04/23/25 at 2:21 P.M. MDS Licensed Practical Nurse (LPN) #540 verified Resident #86 had not had a fall with major injury since the 03/30/25 admission. MDS LPN #540 confirmed that MDS section J1900 C. falls with major injury should not have been marked as a yes. Review of a policy titled MDS 3.0 dated 01/24/24 revealed it is the policy of the facility to utilize the MDS Resident Assessment Instrument (RAI) manual as the source document for any/all MDS scheduling, encoding, completion, submission, correction, and retention requirements as outlined in chapter two through six of the RAI manual. 2. Record review revealed Resident #104 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage with loss of consciousness, tracheostomy status, and severe protein-calorie malnutrition. Review of Resident #104's admission Minimum Data Set (MDS) assessment completed on 01/21/25, revealed section L was marked no for broken natural teeth. Interview on 04/21/25 at 1:28 P.M. with Resident #104 revealed the resident reported broken and missing teeth due to a history of drug use. Interview on 04/22/25 at 2:33 P.M. with Certified Nursing Assistant (CNA) #592 confirmed staff provided oral care for Resident #104 and the resident had several missing and broken teeth. Interview on 04/22/25 at 2:38 P.M. with MDS Licensed Practical Nurse (LPN) #564 confirmed the MDS was incorrect and did not address broken or missing teeth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #104 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage with loss of consciousness, nontraumatic intracerebral hemorrhage, tracheostomy status, and severe protein-calorie malnutrition. Interview and observation on 04/21/25 at 1:28 P.M. with Resident #104 revealed the resident had broken and missing teeth due to history of drug use. Review of Resident #104's current plan of care did not address oral/dental status. Interview on 04/22/25 at 2:33 P.M. with Certified Nursing Assistant (CNA) #592 confirmed staff provide oral care for Resident #104 and the resident has several missing and broken teeth but does not complain of pain during care. Interview on 04/22/25 at 2:38 P.M. with MDS Licensed Practical Nurse (LPN) #564 confirmed there was no care plan to address oral/dental status. Review of a policy titled Comprehensive Care Plans dated 06/30/22 revealed the facility is to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be developed within seven days after the completed of the MDS and will describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and it will be prepared by the interdisciplinary team. Based on observation, record review, interview and policy review the facility failed to maintain comprehensive, resident centered care plans. This affected three (#40, #104, and #178) of four residents reviewed for comprehensive care plans. The facility census was 124. Findings include: 1. Record review revealed Resident #40 admitted to the facility on [DATE] with diagnoses including malignant neoplasm of unspecified part of unspecified bronchus or lung, chronic obstructive pulmonary disease, and atherosclerotic heart disease without angina. Review of a minimum data set (MDS) dated [DATE] revealed Resident #40's cognition was intact and the resident received injections and antibiotics. Review of an order dated 04/23/25 revealed Resident #40 had a PICC (peripherally inserted central catheter) line in place to be removed after the completion of antibiotic therapy. Review of a care plan dated 03/31/25 revealed Resident #40's comprehensive care plan was not completed related to the type of intravenous access she had for her antibiotics. Resident #40's care plan read, resident has an IV (intravenous) (SPECIFY: Central line, Peripherally inserted central catheter (PICC) line, Midline, Peripheral line) related to: (blank). Interview on 04/23/25 at 1:59 P.M. with the Director of Nursing (DON) confirmed Resident #40's comprehensive care plan was incomplete related to her IV status. 2. Record review revealed Resident #178 admitted to the facility on [DATE] with diagnoses including occlusion and stenosis of right carotid artery, peripheral vascular disease, atrial fibrillation, and benign prostatic hyperplasia. Review of a nursing note dated 04/01/25 at 1:00 P.M. by Unit Manager (UM) #595 revealed Resident #178 admitted to the facility with a #16 French (size of the catheter tube) indwelling catheter for urinary retention. Review of a Urinary Continence Evaluation dated 04/08/25 at 4:47 P.M. revealed Resident #178 was always continent and did not have a urinary catheter in use. Review of an admission MDS dated [DATE] revealed Resident #178's cognition remained intact, he did not have an indwelling catheter, and his urinary continence was not rated. Review of a care plan completed on 04/14/25 revealed no evidence of a care plan related to Resident #178's urinary catheter. Review of orders revealed no evidence of orders to care for Resident #178's urinary catheter. Interview on 04/21/25 at 2:23 P.M. with Resident #178 revealed he had been waiting for an appointment with the urologist to remove his catheter and would like an update. Observation on 04/22/25 at 8:31 A.M. revealed Resident #178 was seated in his wheelchair and had a breakfast tray in front of him. A catheter bag was noted. Interview on 04/22/25 at 8:33 A.M. with UM #595 revealed he does complete some care plans, but the MDS nurses' complete most of the care plans. UM #595 stated upon admission, the floor nurse will enter orders, but the unit managers will assist and complete a clinical review to ensure nothing was missed. Interview on 04/22/25 at 8:50 A.M. with MDS Nurse #513 and MDS Nurse #564 confirmed there was not a care plan in place for catheter. Both MDS Nurse #513 and #564 stated they thought Resident #178's catheter had been removed upon admission to the facility. Interview on 04/22/25 at 9:48 A.M. with the Director of Nursing (DON) and UM #595 confirmed Resident #178 did not have a care plan related to an indwelling catheter. The DON stated in conversations with his staff, everyone thought Resident #178's catheter had been removed upon admission. The DON stated he does see Resident #178 daily and is not sure how the catheter was missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record review and missing items log review, the facility failed to ensure missing hearing aides were reported to the appropriate staff and failed to ensure hearing aides were worn as directed to aide in communication. This affected one (Resident #32) of one resident reviewed for vision/hearing. The census was 124. Findings Include: Record review revealed Resident #32 admitted to the facility 09/04/23 with diagnoses including atrial fibrillation, chronic obstructive pulmonary disease, hyperlipidemia, diastolic heart failure, congestive heart failure, hearing loss. Review of Resident #32 care plan completed 08/16/23 and revised 02/10/24 revealed Resident is at risk for impaired communication related to being hard of hearing. Goals include Resident#32 will understand others when communicating through next review. Interventions include Allow ample time for the resident to comprehend what is being communicated and allow time for response, Audiology referral as needed. Encourage conversations in calm, quiet locations with minimal background noise. Maintain eye contact, approach resident from the front, pay attention to resident's body language and facial expressions, Request feedback, when needed, to ensure understanding, Speech Language Pathology screen / eval / treat as needed. Use simple and direct communication (i.e., yes/no questions) to promote understanding, use gestures or pictures if necessary. Record review of the audiology group note for Resident #32 dated 02/03/25 revealed Resident #32 had profound sensorineural hearing loss of the right eat and severe to profound sensorineural hearing loss of the left ear. Otoscopy revealed the right nor left ear were occluded. Recommendations included bilateral hearing aids, stating Resident #32 decided to try receiver-in-canal (RIC) hearing aids. Recommendations include Resident #32 to wear hearing aids daily, requiring assistance with insertion and manipulation of hearing aid daily. Signed by Certificate of Clinical Competence in Audiology (M.A., CCC-A) #1738 on 02/03/25. Record review of the minimum data set (MDS) completed 02/20/25 section B for hearing speech, and vision revealed Resident #32 has moderate difficulty hearing loss, but does not have hearing aids. Record review revealed a social service progress note dated 03/10/25 revealed Resident #32 answered questions in a low tone and moderate speed. Resident #32 did require social services to repeat questions due to hearing issues. Record review revealed a social services progress note dated 03/24/25 that the resident was seen in house by audiology. Record review of the audiology group note for Resident #32 dated 03/24/25 revealed Resident #32 received right and left hearing aides that fit good. Resident #32 stated she is hearing better with the hearing aids. Consulted as to daily use. Red is for the right ear and blue is for the left ear. Model for right ear hearing aides are BTE/[NAME] laboratories Inc. [NAME] evvolv A1 1000 RIC 312 2025 serial number #250069542. Model for left ear hearing aides are BTE/[NAME] laboratories Inc. [NAME] evvolv A1 1000 RIC 31 2025 serial number #250069553. Signed by M.A., CCC-A #1738 on 03/24/25. Record review revealed no refusal by Resident #32 to wear hearing aids and no evidence hearing aids were missing and not being utilized daily as recommended for Resident #32 to improve communication and understanding. Observation and interview of Resident #32 on 04/24/25 at 9:27 A.M. revealed a hearing aide case sitting on the bedside table. Resident #32 required questions to be repeated and having to raise tone of voice while asking questions so she could hear and understand the conversation. Resident #32 stated she was not wearing hearing aids at this time. She stated one was missing and she didn't know where it was. Resident #32 confirmed it was hard for her to hear and understand what someone was saying due to her hearing loss. Interview on 04/24/25 at 9:55 A.M. with Certified Nursing Assistant (CNA) #598 confirmed one hearing aid was in the box on Resident #32 bedside table and one hearing aid for Resident #32 was missing. Resident #32 stated it had been missing for a while. Interview on 04/24/25 at 11:36 A.M. with CNA #566 confirmed they have not found Resident #32's missing hearing aid and they have looked multiple times today. Interview on 04/24/25 at 11:30 A.M. with Registered Nurse #617 revealed that Resident #32's hearing aids have been missing and confirmed they are still missing at this time. She stated she was unsure who all was aware of this and who had been involved with the missing hearing aids. Interview on 04/24/25 at 11:51 A.M. with social services director #534 stated Resident # 32 did not have hearing aids when she was admitted . The surveyor informed social services that there was a case at Resident #32 bedside with one hearing aide in the case. She stated that the son bought hearing amplifiers at Wal-Mart and that is what those are, and if there is one missing this is the first she has heard about it. Social services director #534 stated she was going to complete a concern form. Social services director #534 confirmed the missing items on the concern log for Resident #32 on 04/09/25 did not include a hearing aid. Social services confirmed, upon review of the audiology note dated 03/24/25, Resident #32 does have bilateral hearing aids from the audiology group. Interview on 04/25/25 at 10:55 A.M. with customer care coordinator #1072 of the Audiology Group confirmed Resident #32 did receive hearing aids dispensed on 03/24/25 and was to wear them daily while requiring assistance to place them. They confirmed thr faciliy has not reached out to the audiology group regarding a missing hearing aid for Resident #32.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review and facility policy review the facility failed to provide a comprehensive treatment plan for altered skin integrity to Resident #48. This affected one resident (Resident #48) of two residents reviewed for non pressure skin conditions. The facility census was 124. Findings include: Review of the medical record for Resident #48 revealed an admission date of 11/05/20 with diagnoses including chronic obstructive pulmonary disorder, diabetes mellitus type two, peripheral vascular disease, congestive heart failure and atrial fibrillation. Review of the plan of care revised on 03/11/25 revealed Resident #48 was at risk for skin impairment with interventions in place to decrease risk. The plan of care did not include interventions for bilateral lower extremities discoloration and dry skin. Review of the Medicare five day Minimum Data Set (MDS) dated [DATE] revealed Resident #48 was cognitively intact with no behaviors. Resident #48 was dependent on staff for toileting hygiene, showers, transfers and dressing. Resident #48 had no skin impairment documented. Review of the physician orders dated 04/25 revealed an order for daily skin checks with care by the Certified Nursing Assistants (CNA) and weekly skin assessment by nursing staff. Review of the nursing weekly skin assessment dated [DATE] revealed Resident #48 had redness to bilateral axilla area. No other skin impairment was noted. Observations on 04/21/25 at 1:47 P.M., and 04/23/25 at 11:12 A.M. revealed Resident #48 had his bilateral lower extremities elevated on a pillow. Bilateral lower extremities were dark blue in color, cool to touch and had dry, flaky skin. Interview on 04/23/25 at 11:12 A.M. with Resident #48 revealed he had a bath on 04/22/25. Resident #48 was not sure if the CNA had applied any lotion or ointment to his bilateral lower extremities. Interview on 04/23/25 at 11:14 A.M. with CNA #577 confirmed Resident #48 had dark blue colored bilateral lower extremities with dry, flaky skin. Interview on 04/23/25 at 1:58 P.M. with Licensed Practical Nurse (LPN) # 517 confirmed Resident #48 bilateral lower extremities were discolored and had dry flaky skin. LPN # 517 stated he would document his findings of Resident #48 skin and notify the physician for orders. LPN # 517 also stated he would update the plan of care to include the discoloration, dry, flaky skin to bilateral lower extremities. Review of the facility policy titled Non Pressure Skin revealed skin impairment would be monitored, assessed and treatment provided as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #178 admitted to the facility on [DATE] with diagnoses including occlusion and stenosis of right carotid artery, peripheral vascular disease, atrial fibrillation, and benign prostatic hyperplasia. Review of a nursing note dated 04/01/25 at 1:00 P.M. by Unit Manager (UM) #595 revealed Resident #178 admitted to the facility with a #16 French (size of catheter) indwelling catheter for urinary retention. Review of a Urinary Continence Evaluation dated 04/08/25 at 4:47 P.M. revealed Resident #178 was always continent and did not have a urinary catheter in use. Review of an admission MDS dated [DATE] revealed Resident #178's cognition remained intact, he did not have an indwelling catheter, and his urinary continence was not rated. Review of a care plan completed on 04/14/25 revealed no evidence of care planning related to Resident #178's urinary catheter. Review of orders revealed no evidence of orders to care for Resident #178's urinary catheter. Interview on 04/21/25 at 2:23 P.M. with Resident #178 revealed he had been waiting for an appointment with the urologist to remove his catheter and would like an update. Observation on 04/22/25 at 8:31 A.M. revealed Resident #178 was seated in his wheelchair and had a breakfast tray in front of him. A catheter bag was noted. Interview on 04/22/25 at 8:50 A.M. with MDS Nurse #513 and MDS Nurse #564 revealed Resident #178's MDS was coded incorrectly because Resident #178 had a catheter, they confirmed there was not a care plan in place for catheter, and there were no orders since admission for Resident #178 to have an indwelling catheter or catheter care. Both MDS Nurse #513 and #564 stated they thought Resident #178's catheter had been removed upon admission to the facility. Interview on 04/22/25 at 9:48 A.M. with the Director of Nursing (DON) and UM #595 confirmed Resident #178 did not have orders, a care plan, or an accurate assessment related to the resident's indwelling urinary catheter. The DON stated in conversations with his staff, everyone thought Resident #178's catheter had been removed upon admission. The DON stated he does see Resident #178 daily and is not sure how the catheter was missed. Review of a policy titled Catheter Care Procedure - Urinary dated 12/28/23 revealed the facility is to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infections while maintaining their dignity and privacy. Residents with indwelling urinary catheters will be provided catheter care in accordance with current clinical standards including each shift, with each bowel movement, as needed and as requested. Based on observation, interview and record review the facility failed to ensure residents received comprehensive and resident centered care related to indwelling urinary catheters. This affected two residents (#28 and #178) of three sampled for catheters. The facility census was 124. Findings include: 1. Review of Resident #28's medical record revealed an admission date of 02/02/18, a re-entry date of 05/21/18 and diagnoses including diabetes, anemia, neurogenic bladder, dementia, bipolar disorder, anxiety, attention-deficit hyperactivity disorder, and mild intellectual disabilities. Review of Resident #28's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact, used an indwelling catheter to empty her bladder and had a diagnosis of neurogenic bladder. An observation of Resident #28 on 04/21/25 at 10:45 A.M. revealed the resident to have a catheter and the catheter bag to be hanging on the positioning rail attached to the resident's bed above the resident's bladder. In an interview on 04/21/25 at 10:46 A.M. Licensed Practical Nurse (LPN) #581 verified the catheter bag was positioned above the resident's bladder. An observation of Resident #28 on 04/22/25 at 10:52 A.M. revealed her catheter bag to be positioned on the floor. In an interview on 04/22/25 at 10:55 A.M. Registered Nurse (RN) #536 confirmed the catheter bag was positioned on the floor. Review of the policy titled Catheter Care - Urinary dated 10/30/20 and revised 12/28/23 revealed the facility was to provide catheter care to all residents in a manner to reduce bladder and kidney infections. Further review revealed catheter were to be maintained to gravity drainage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review the facility failed to ensure nursing staff planned to administer the appropriate dose of medication, without resident intervention, to prevent a potential overdose. This affected one resident (Resident #104) of one residents reviewed for a medication error. The census was 124. Findings Include: Record review revealed Resident #104 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage with loss of consciousness, nontraumatic intracerebral hemorrhage, pneumonitis due to inhalation of food and vomit, and tracheostomy status. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 had a Brief Interview for Mental Status (BIMS) score of 15. Record review revealed on 12/24/24 an order was received for Methadone 10 milligrams (mg): Give two tablets by mouth three times a day However the order was discontinued on 12/24/24. On 12/26/24, an order for Methadone 10 mg give two tablets via nasogastric (NG) tube three times a day however the order was discontinued on 12/26/24. On 12/26/24, an order was received for Methadone HCl Oral Tablet 10 mg give two tablet by mouth three times a day however the order was discontinued on 12/26/24. On 12/31/24 an order for Methadone liquid dated 12/31/24 for 60 mg/7.5 milliliters (ml) by mouth each morning one time a day. Further review of the medical record revealed a medication error which occurred on 12/31/24 for Methadone. Resident #104 was given 30 ml (four of the 7.5 ml bottles) instead of 7.5 ml (one bottle). The possible medication error was not found until the next day 01/01/25 when the morning dose was scheduled to be administered. Review of the medication administration record (MAR) dated 12/31/24 at 8:00 A.M. revealed the nurse documented administration of one Methadone 7.5 ml bottle. The narcotic sheet had four of the 7.5 ml bottles signed out for administration. Review of facility investigation dated 01/01/25, during narcotic count staff nurses found a narcotic discrepancy with the Methadone. The night shift nurse stated they were in a hurry, and they did not unlock the methadone case during the 12/31/24 7:00 P.M. count during sign off. It was discovered the dayshift nurse administered extra bottles of Methadone. On 01/01/25 the medication error was reported to the unit manager, Director of Nursing (DON) and the medical director. Interview on 04/24/25 at 9:13 A.M. with the the Regional Director of Clinical Operations, confirmed the prescription for Methadone was not entered correctly in the computer due to the supply amount from the pharmacy and the nurse thought the resident was to receive four bottles of Methadone instead of one bottle. Interview on 04/24/25 at 9:34 A.M. with the Regional Director of Clinical Operations revealed the first four orders of methadone were what the hospital ordered however were unable to fill the prescription due to the resident's diagnosis and the resident required a referral to a methadone clinic. Oxycodone was ordered until the Methadone was available for the resident. The appointment at the Methadone clinic was on 12/26/24 and they supplied 27 days worth of Methadone (27 bottles). The order was initially transcribed incorrectly and the nurse thought the order meant to administer four bottles and not one to get the ordered dose. When the nurse went to clarify the order, the DON did correct the order in the system however the order entered was set to start the following day and did not appear on the MAR at the time of administration, so the nurse prepared the incorrect dose. The Regional Director of Clinical Operations said the resident only received one dose of the methadone because the resident stopped the nurse and refused to take the additional medication, knowing what the ordered dose was. Interview on 04/24/25 at 4:58 P.M. with Licensed Practical Nurse (LPN) #569 via telephone confirmed she prepared the incorrect dose of Methadone for administration. Review of facility policy titled Medication reconciliation dated reviewed/revised: 01/30/24 states medication reconciliation refers to the process of verifying that the residents current medication list matches the physicians orders for the purposes of providing the correct medications to the resident at all points throughout his or her stay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to thoroughly investigate a potential medication error and the disposition of controlled medications. This affected one resident (#104) of one residents reviewed for a medication error. The facility census was 124. Findings Include: Record review revealed Resident #104 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage with loss of consciousness, nontraumatic intracerebral hemorrhage, pneumonitis due to inhalation of food and vomit, and tracheostomy status. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #104 had a Brief Interview for Mental Status (BIMS) score of 15. Record review revealed on 12/24/24 an order was received for Methadone 10 milligrams (mg): Give two tablets by mouth three times a day However the order was discontinued on 12/24/24. On 12/26/24, an order for Methadone 10 mg give two tablets via nasogastric (NG) tube three times a day however the order was discontinued on 12/26/24. On 12/26/24, an order was received for Methadone HCl Oral Tablet 10 mg give two tablet by mouth three times a day however the order was discontinued on 12/26/24. On 12/31/24 an order for Methadone liquid dated 12/31/24 for 60 mg/7.5 milliliters (ml) by mouth each morning one time a day. Further review of the medical record revealed a medication error which occurred on 12/31/24 for Methadone. Resident #104 was given 30 ml (four of the 7.5 ml bottles) instead of 7.5 ml (one bottle). The possible medication error was not found until the next day 01/01/25 when the morning dose was scheduled to be administered. Review of the medication administration record (MAR) dated 12/31/24 at 8:00 A.M. revealed the nurse documented administration of one Methadone 7.5 ml bottle. The narcotic sheet had four of the 7.5 ml bottles signed out for administration. There was no documentation of the wasted Methadone. Review of facility investigation dated 01/01/25, during narcotic count staff nurses found a narcotic discrepancy with the Methadone. The night shift nurse stated they were in a hurry, and they did not unlock the methadone case during the 12/31/24 7:00 P.M. count during sign off. It was discovered the dayshift nurse administered extra bottles of Methadone. On 01/01/25 the medication error was reported to the unit manager, Director of Nursing (DON) and the medical director. Interview on 04/24/25 at 9:13 A.M. with the Regional Director of Clinical Operations, confirmed the prescription for Methadone was not entered correctly in the computer due to the supply amount from the pharmacy and the nurse thought the resident was to receive four bottles of Methadone instead of one bottle. Interview on 04/24/25 at 9:34 A.M. with the Regional Director of Clinical Operations revealed the first four orders of methadone were what the hospital ordered however were unable to fill the prescription due to the resident's diagnosis and the resident required a referral to a methadone clinic. Oxycodone was ordered until the Methadone was available for the resident. The appointment at the Methadone clinic was on 12/26/24 and they supplied 27 days worth of Methadone (27 bottles). The order was initially transcribed incorrectly and the nurse thought the order meant to administer four bottles and not one to get the ordered dose. When the nurse went to clarify the order, the DON did correct the order in the system however the order entered was set to start the following day and did not appear on the MAR at the time of administration, so the nurse prepared the incorrect dose. The Regional Director of Clinical Operations said the resident only received one dose of the methadone because the resident stopped the nurse and refused to take the additional medication, knowing what the ordered dose was. Interview on 04/24/25 at 04:28 P.M. with the Regional Director of Clinical Operations confirmed the narcotic count was not completed correctly to identify the potential medication error timely (shift to shift count) and confirmed the narcotic log/waste was not completed to identify the second nurse who witnessed the medication waste. The Regional Director also confirmed the investigation did not identify the lack of a second nurse documented as witnessing the disposition of the Methadone not used. LPN #569 was contacted but she could not remember who the second nurse was when the medication was wasted. Interview on 04/24/25 at 4:58 P.M. with Licensed Practical Nurse (LPN) #569 via telephone confirmed she prepared the incorrect dose of Methadone for administration and she flushed the remaining medication in the toilet. Review of facility policy titled Medication-Destruction of Unused Drugs Date Reviewed/Revised: 01/18/24 states prescription drugs shall not be flushed down the toilet in accordance with Environmental Protection Agency regulations. Scheduled II, III, and IV controlled drugs must be destroyed by the Director of Nursing Services and another Licensed Nurse.

Based on review of facility alternative dispute resolution agreements, interview, record review, and policy review, the facility failed to ensure residents understood the agreement they signed. This affected three of three residents reviewed for arbitration agreements (Residents #31, #89, and #178). The facility census was 124. Findings include: 1. Review of the record for Resident #31 revealed an admission date of 01/20/25. Review of a Minimum Data Set (MDS) assessment completed 01/27/25 and 03/06/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of a facility Alternative Dispute Resolution Agreement dated 01/20/25 revealed Resident #31 electronically signed the agreement on 01/23/25. The agreement stated it demonstrated a mutual intention to resolve disputes between them outside of court and to submit their disputes to Alternative Dispute Resolution through mediation and/or arbitration. The form also stated that the resident had been offered to, or had been able to view an audio/visual recorded video that details this agreement and what it includes. Interview with Resident #31 on 04/24/25 at 9:40 A.M. revealed she did not remember signing the agreement. She also stated she did not watch a video explaining the agreement. She stated she did not understand what the agreement was for. 2. Review of the record for Resident #89 revealed an admission date of 6/05/24. Review of a MDS assessment completed 6/13/24 and 02/26/25 revealed a BIMS score of 15, indicating intact cognition. Review of a facility Alternative Dispute Resolution Agreement dated 6/05/24 revealed Resident #89 electronically signed the agreement on 6/14/24. The agreement stated it demonstrated a mutual intention to resolve disputes between them outside of court and to submit their disputes to Alternative Dispute Resolution through mediation and/or arbitration. The form also stated that the resident had been offered to, or have been able to view an audio/visual recorded video that details this agreement and what it includes. Interview with Resident #89 on 04/24/25 at 9:55 A.M. revealed she did not remember signing the dispute resolution agreement. She stated she did not remember doing her electronic signature on an iPad. She stated she was not offered to watch a video explaining the agreement and did not understand what the agreement was. 3. Review of the record for Resident #178 revealed an admission date of 04/01/25. Review of a MDS assessment completed 04/08/25 revealed a BIMS score of 15, indicating intact cognition. Review of a facility Alternative Dispute Resolution Agreement dated 04/01/25 revealed Resident #178 electronically signed the agreement on 04/04/25. The agreement stated it demonstrated a mutual intention to resolve disputes between them outside of court and to submit their disputes to Alternative Dispute Resolution through mediation and/or arbitration. The form also stated that the resident had been offered to, or have been able to view an audio/visual recorded video that details this agreement and what it includes. Interview with Resident #178 on 04/24/25 at 9:30 A.M. revealed he did not remember signing the agreement electronically on an iPad. He stated the agreement was not explained to him and he did not watch a video explaining the agreement. He stated he would not have signed the agreement had he known what it was. He stated he wanted to revoke the agreement. Interview with Admissions Director #599 on 04/24/25 at 10:05 A.M. revealed the agreement is part of the facility admission packet. She stated residents are told it is optional and they are offered a video to watch that explains the arbitration agreement. She stated residents are asked to sign the agreement electronically on an iPad. She stated it is usually just her and the resident in the room at the time (no witness). Review of the facility policy titled Binding Arbitration Agreements dated 07/28/20 and revised 11/01/22 revealed this facility asks all residents to enter into an agreement for binding arbitration. The facility shall explain to the resident or his or her representative in a form and manner that he or she understands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to complete appropriate hand hygiene during medication administration and to maintain contact isolation precautions while in a resident's room with clostridium difficile. This affected two residents (#104 and #178) of five sampled for infection control. The facility census was 124. Findings include: 1. Review of Resident #104's medical record revealed an admission date of 12/24/24 and diagnoses including acute respiratory failure with hypoxia, traumatic subdural hemorrhage, chronic pancreatitis, anemia, pneumonitis due to inhalation of food or vomit, tracheostomy status, and gastrostomy status. Review of Resident #104's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15. Further review revealed the resident was receiving enteral feedings via a gastrostomy tube. Review of Resident #104's orders revealed an order for the resident to be on enhanced barrier precautions (due to the gastrostomy tube, considered an indwelling medical device). An observation on 04/23/25 at 8:20 A.M. of medication administration by Licensed Practical Nurse (LPN) #628 revealed LPN #628 administered Resident #104's medications via his gastrostomy tube and then changed her gloves to administer his nasal inhaler. LPN #628 did not complete hand hygiene when she changed her gloves and then preceded to administer the nasal inhaler. On 04/23/25 at 8:25 A.M. LPN #628 confirmed she did not complete hand hygiene when she changed her gloves prior to administering Resident #104's nasal inhaler. Review of the policy titled Flushing the Feeding Tube dated 01/01/21 and revised 06/30/22 revealed facility staff should wash their hands after administrating medications via the feeding tube. 2. Review of Resident #178's medical record revealed an admission date of 04/01/25 with diagnoses that included essential hypertension, peripheral vascular disease and contact with and suspected exposure to COVID-19. Physician's orders indicated Resident #178 required contact transmission-based precautions for c-diff (inflammation of the colon caused by the bacteria Clostridium difficile). Observation on 04/24/25 at 12:34 P.M. revealed Certified Nursing Assistant (CNA) # 531 entering Resident #178's room to deliver lunch tray. A sign was posted outside of the room door to Resident #178's room indicating he was on contact precautions and a cart containing personal protective supplies was noted below the sign and outside the resident's room door. Interview on 04/24/25 at 12:35 P.M. with CNA #531 verified the resident had contact precautions in place for C-Diff and she did not wear appropriate personal protective equipment (PPE) while she was in the resident's room. Review of facility policy titled Infection Prevention and Control Program: A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current Center for Disease Control guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility self-reported incident (SRI) including investigation, observations, staff and resident interviews and review of facility Abuse, Neglect, and Misappropriation policy, the facility failed to ensure residents was free from physical and sexual abuse. This affected two residents (#57, #61) of four residents reviewed for abuse. The facility in-house census was 110. Findings included: 1. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, heart failure peripheral vascular disease, anemia, and mental disorder. Review of Resident #61's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's cognition was intact and he had one to three days of other behavioral symptoms not directed towards others. Review of Resident #61's orders and medication administration records dated 02/2024 revealed on 02/08/24 new orders were added to have two staff with care at all times, monitor bruising to right hand first and second digit until resolved and a revised order to monitor target behaviors of refusal of care, refuses to turn and reposition, false accusations with staff, sexually inappropriate, yelling at staff, and inappropriate finger gestures. Resident #61's medications that were due at 6:00 A.M. included Atorvastatin 40 milligrams (mg) once a day for hyperlipidemia, Lasix 20 mg daily for heart failure, Lisinopril 2.5 mg daily for elevated blood pressure, Metoprolol Extended Release (not recommended to crush) 40 mg daily for high blood pressure, Cholecalciferol 1000 units twice daily for supplement, and Eliquis 5 mg twice daily for atrial fibrillation. Further review revealed the resident had six behaviors of refusal to turn and reposition. There was no documented evidence the resident had any other targeted behaviors. Review of Resident #61's behavior plan of care dated 10/15/23 revealed to attempt to redirect when exhibiting behaviors; re-approach when resident had deescalated; communicate care; educate resident on need/benefit of care and risk of refusal, keep resident safe during episodes of behaviors; attempt to redirect, and offer distraction and re-approach later. Review of the facility SRI #243943 including investigation for physical abuse dated 02/08/24 revealed Resident #61 alleged he was provided his morning medication crushed and in pudding by Medication Technician (MT) #119. He stated to MT #119 he no longer received his medication crushed and declined to take the medication in that form. MT #119 left the room with the crushed medication and returned with four pills in a medication cup. Resident #61 stated all his medication was not in the cup and declined to take it until he received all medications that were due. MT #119 stated those were the medications ordered. The resident refused to return the four pills in the medication cup or take the pills until someone addressed his issues. Licensed Practical Nurse (LPN) #233 entered the room to speak to Resident #61 and again he stated he would not take the medications until he was provided all the pills that were due and refused to return the medication cup. Resident #61 stated LPN #233 grabbed his hand to retrieve the cup and caused bruising in the process. Review of LPN #233's statement revealed Resident #61 had refused to take the medication stating not all his medications were there and he would not give the medication back to MT #119. He said he was keeping them to show the dayshift nurse he was missing medications. LPN #233 went in and reviewed all medications with him reassuring him that all the medication ordered for that morning was there. He again refused. LPN #233 told him if he wasn't taking the medication, she would need them back because she was not allowed to leave them in the room. The LPN went to grab the cup and Resident #61 grabbed her right wrist and started twisting and wouldn't let go. MT #119 told the resident to let go. LPN #233 reported she did not touch the resident in any way that would potentially cause harm because he had a hold of her right arm, and she had another resident's medication in her left hand. Review of MT #119's statement was consistent with LPN #233's statement. MT #119 reported LPN #233 had grabbed the medications and the Resident (#61) grabbed her by the right wrist and started twisting her arm and would not let go. MT #119 further stated she had to tell the resident he couldn't do that before he finally let go of LPN #233. Review of a skin and pain assessment conducted on Resident #61 revealed a bruise noted on his 1st and 2nd digit on the right hand. It was important to note Resident #61 was on blood thinners causing him to easily bruise. A whole house staff education on abuse was conducted as well as one on one with LPN #233. The resident was able to provide meaningful information when interviewed and the resident (#61) had no effect noticed as a result of the incident. There were two witnesses identified (Stated Tested Nurse's Aide (STNA) #137 and MT #119). The SRI was unsubstantiated as there was no evidence that indicated abuse had occurred. Further review of the investigation revealed no evidence of written statements from LPN #233 and MT #119. Review of STNA #137's statement dated 02/08/24 at 8:05 A.M., revealed Resident #61 informed me about what happened last night when I went to change him this morning. LPN #233 said he took his pills crushed and not whole, but he had been taking them whole for a long time and when she went back there were only four or five pills and he takes about seven. LPN #233 told him if you aren't going to take them, you're not getting any at all. She went to put his pills in his hand and grabbed his right index finger and that's when he grabbed her wrist and told her to get out of here. So, STNA #137 looked at this right index finger and it was red and bruised. STNA #137 informed her nurse and unit manager when he told her, and the nurse went to look at it and talk to the resident. Review of STNA #146's statement dated 02/08/24 revealed when she first arrived at work, she overheard LPN #233 talking about an altercation with a resident to MT #119. LPN #233 told her she went to take Resident #61's pills and had crushed them, but he was upset about it, so she got him new that were whole. LPN #233 stated that he told her they still were not correct and wanted to keep hold of them anyway and she wouldn't let him. She then said she went to grab the pill to take them to be discarded and said the resident grabbed her arm and started to twist it. MT #119 then said he only let go of LPN #223 because MT #119 told him to. Further review of the staff questionnaires revealed the staff interview questions asked if they were aware of any incidents that happened with Resident #61, when were you notified of the incident and by whom, and if notified by the Resident, what did he say. The statement was answered yes or no for the first question, date and time and name for the second question and if there was a statement if the resident said anything. Review of the staff questionnaires revealed the surveyor could not determine the last name on the questionnaire dated 02/08/24 that revealed Resident #61 reported LPN #233 had brought his pills in crushed and he takes them whole. He gets about seven pills, and she only gave him four pills. The LPN told him to take it or leave it. He had the pill cup in his hand and wanted to show someone it wasn't his complete morning meds and LPN #233 had grabbed it out of his hands. Review of the facility investigation revealed interviewable residents were asked if they experienced abuse, and if so explain, and if they felt safe in the facility. There was no evidence skin assessments were completed on not interviewable residents. Review of LPN #186's questionnaire revealed the resident reported his medications were crushed and the medication tech had brought in the cup of medications. He held the cup of medication to ask LPN #233 which pills were missing. He said she stated take it or not. Then she took the pill cup from him. He stated she bruised his fingers. The unit manager was notified. Review of the incident report completed by the Director of Nursing (DON) on 02/08/24 revealed an STNA reported that a resident (#61) stated the nurse on the previous shift grabbed his hand trying to take the cup of pills away. Resident stated that the med tech brought in his morning medications, and they were crushed in pudding. He told the med tech he doesn't take them crushed. States the med tech asked if he was refusing. He replied, no I just don't take them crushed. The med tech left the room and returned with his meds whole in a cup. Resident stated there were only four pills in the up and told the med tech that wasn't all his medications. Med tech stated that was what was ordered. Resident says he told her he was not taking them and was waiting to show someone that his wasn't medication wasn't correct. Med tech told the resident she cannot leave unless you return the meds or take them. The resident refused and the Med tech left. LPN #233 came in and moved the resident's tray table and attempted to take the cup of pills from the resident's hand. The resident turned away and she grabbed my hand. The resident had bruises on the 1st and 2nd digits on the right hand. Pain medication offered but declined. Per the incident report, LPN #233 reported to the DON the resident's medications had always been crushed in pudding. So, she got his meds and crushed them in pudding. MT #119 went to give him his medication and he refused them stating he takes them whole. LPN #233 went in and spoke with him and said you've always taken your pills this way. He replied, I have never taken my pills crushed in pudding. LPN #233 left the room and MT #119 returned with his meds whole in a cup. She told me he refused to take the medications stating not all his meds were there. He wouldn't give the meds back to MT #119. He said he was keeping them to show the dayshift nurse he was missing meds. LPN #233 went in and reviewed all medications with him reassuring him that all the meds ordered for this morning were there. He again refused. LPN #233 told him if he wasn't taking the meds, she needed them back because she is not allowed to leave the meds in the room. LPN #233 went to grab the cup and the resident grabbed her by her right wrist and started twisting her wrist. He wouldn't let go. MT #119 had come in and told him to let go of my arm. The LPN #233 reported she did not touch him in any way to cause harm because he had her right arm, and she had other residents' medications in her left hand. She did not notice any bruising to the resident. Per the incident report, MT #119 reported to the DON she went to give Resident #61 his medications crushed in pudding. The resident stated he doesn't take the crushed in pudding. She went out and told LPN #233. MT brought back the resident meds whole in a cup. The resident still refused to take them stating there were meds missing. MT #119 tried to explain that they were all there and he declined. MT #119 told him if he wasn't going to take them, she needed them back because she is not allowed to leave medication in a room. He refused. MT #119 went and told LPN #233. She came in to tell the resident the same thing. She went to grab the medication and he grabbed her by the right wrist and started twisting her arm. He wouldn't let go. MT #119 had to tell him he couldn't do that before he finally let go. Review of Resident #61's pertinent charting note-behavior and nursing progress note dated 02/08/24 at 6:26 A.M. revealed when administering morning medications, this nurse crushed resident's meds as have done any other time this nurse has given meds to this resident. Resident refused to take the medication. This nurse then gave the resident whole pills and resident refused to take them stating they were not all there. This nurse explained they were all there and went through every medication he was to have, and the resident began yelling at this nurse and refused to take them again. When this nurse went to take cup of meds back due to refusal, resident grabbed this nurse's right arm squeezing and twisting. Review of Resident #61's pertinent charting for change of condition dated 02/08/24 revealed the resident had maroon colored bruising to the right-hand 1st and 2nd digit. The reported nurse grabbed right hand to try and take the cup of pills from him. Investigation initiated, nurse suspended, and pain and skin assessment completed. Review of Resident #61's psychosocial note dated 02/12/24 revealed the resident stated that he wasn't having difficulty sleeping but doesn't think about the incident often. The resident would be observed for seven days per the abuse policy related to psychosocial. Review of Resident #61 charting dated 12/01/23 to 02/20/24 revealed only two behaviors noted. One on 12/04/23 for refusing to have barrier between skin and the bed and the incident on 02/08/24 with LPN #233. Interview on 02/20/24 at 9:54 A.M., with Resident #61 revealed the resident resided next to the window. When the surveyor asked the resident if he had ever been abused, the resident reported yes. The surveyor asked the resident to explain the abuse. The resident reported on February 8th, 2024, the unit manager Licensed Practical Nurse (LPN) #233 was preparing the medications and having Medication Technician (MT) #119 administering the medication to the residents. MT #119 entered his room and placed a medication cup on his bedside table. The medications were crushed in pudding. The MT #119 reported LPN #233 had prepared his medication and she was supposed to bring it to him. The resident responded, I don't take my medication that way, I take them whole. The resident explained to the surveyor that one of the medications was extended release and he was told it could not be crushed. The MT replied, Are you refusing to take them?. The resident replied No, I just need them the way I'm supposed to take them. The MT took the medication cup and left the room. She then returned with the medication cup with the crushed medication and said, You need to take them, or we will chart you refused them. The resident requested that the MT provide him with her name, however he reported she refused to provide it and stated, I don't have to give you my name. He asked her again for her name and she responded Puddin Tane and then she said LPN #233 first name. The MT took the medication cup with the crushed medication and left the room again. MT #119 returned to his room with a medication cup with four whole pills in the cup. The resident told the MT he was supposed to have six pills. The MT reported she would ask the nurse and she came back in and said, This is what the nurse said you are going to get. The resident reported he had the medication cup in his right hand when the MT asked for them back if he wasn't going to take them. The resident reported he was going to keep them until he could show the nurse. At that time LPN #233 stormed in and pushed his bedside tray out of the way and attempted to grab the medication cup out of his hand. The resident reported he moved his right arm over his abdomen towards the window to prevent the nurse from grabbing the medication cup from his hand. The LPN held his arm and leaned over him attempting to get the medication cup out of his hand. The resident reported the LPN was squeezing his hand so hard the cup was pressing into his hand and causing pain. He used his other hand (left hand) to grab her arm and was told to let go so he did, and the LPN took the medication cup and left the room. The resident reported the LPN had squeezed his hand so hard it left bruises on two of his fingers where he was holding the medication cups. The resident showed the surveyor there was still a red mark on this thumb and the pointer finger bruise had resolved. The resident reported one of pills that was missing was red/orange in color, but he did not know the name of the medication. At 11:00 A.M. he finally got all his medications. He has spoken to Social Service and the Administrator; however, he feels the Administrator should be protecting the residents and not the staff. He had recently found out from other staff and residents that LPN #233 had been rude to other people. He was considering filing charges against the nurse and was still very upset about the situation and was concerned about other residents residing in the facility due to LPN #233 had physically abused him. He has requested that LPN #233 not provide care to him and was told she was suspended but she was back to work already. Review of Quality Assurance Form completed on 02/16/24 (completed because of an abuse allegation that occurred on 02/14/24 between resident to resident) revealed Resident #61 told admission Staff #194 he did not feel safe due to issues with a staff member a couple days ago LPN #233. Interview on 02/20/24 at 10:28 A.M., with the Administrator and DON revealed LPN #233 was suspended after the allegation was reported until the following Monday. The resident did not have an order to crush his medication and the LPN should have administered his medication whole and since she had prepared the medication, she should not have had the MT administer the medications she prepared. The LPN had one on one education on abuse and medication administration. The Administrator and DON reported they unsubstantiated the abuse allegation based off staff statements were consistent. The DON reported she determined the bruises were a result of the resident twisting the staff's arm and, on a blood, thinner, not caused by the resident holding the pill cup in his hand. Interview on 02/20/24 at 11:11 A.M., with LPN #233 and DON revealed she was working midnights on the third floor due to there was a call off, but usually works day shift as a unit manager on the first floor. The LPN reported she was administering morning medication and had provided care to Resident #61 a year ago when she worked the 3rd floor and he had received his medication crushed at that time, so she thought he was still a crushed med. The LPN confirmed the resident did not have an order to crush meds. She could not recall which meds he was on but remembers crushing five or six meds. The LPN confirmed she had prepared the meds but handed them to the med tech to administer. LPN #233 reported she was standing outside the door preparing the next resident's medications and the med tech came back out of the room and reported the resident didn't take his medication crushed. She went into the room and the resident told her that he took them whole now. She went back out to get all the new meds and gave them to the med tech to administer. She heard the resident say they were not all there, so she wrote all his meds down and went back into the room and read off the medication he was to receive. Resident #61 kept saying they were not the right medication and she reassured him they were correct. He refused to take them until the nurse came in. She explained she had to stay with him until he took them. He placed the cup on the bed beside his leg by his knees. She reached across his knees to get the med cup and he grabbed her right arm and hand and started to twist it. She had a pill cup and glucometer in her other hand so there was no way she could have touched him. She grabbed the pills with her right hand. The LPN denied squeezing the resident's hand. The LPN reported she was provided education on abuse and med administration. She was suspended on the 8th and was off the weekend anyway and returned on Monday. She was aware the resident requested that she not provide him service/care in the future. Interview on 02/21/24 at 8:46 A.M., with the DON revealed she did not have any written statements from LPN #233 or MT #119 regarding the incident with Resident #61. The DON confirmed she had received verbal statements and typed the statements on the incident report. She was not aware until yesterday the resident and staff had reported to Resident #61 that LPN #233 had been mean to others. Interview on 02/21/24 at 10:35 A.M. with STNA #117 and Registered Nurse (RN) #197 revealed they were unaware of Resident #61 making false accusations against staff. RN #197 and STNA #117 reported the resident is particular about his care. Usually if he refuses care, if you re-approach him, he was usually pretty complaint. He has never been combative with care. Interview on 02/21/24 at 11:42 A.M., with Resident #61 and the Administrator revealed the resident denied that the LPN #233 reviewed his medication with him on February 8th (2024) when he had voiced concern that he did not receive all his morning medication per LPN #233 interview. The resident voiced concerns to the Administrator that he felt the Administrator was more concerned about the food menu the day they spoke instead of the assault. The Administrator confirmed she had spoken to him regarding the alterative menu. The resident reviewed the resident statement that was taken on 02/20/24 at 9:45 A.M. by the surveyor for accuracy. The resident confirmed with the Administrator and surveyor that the statement taken by the surveyor on 02/20/24 at 9:45 A.M. was an accurate timeline of events that occurred on February 8th with LPN #233 and MT #119. Interview via phone on 02/21/24 at 3:12 P.M., with MT #119 revealed she was working the midnight shift and had finished administering her medication and was helping LPN #233 administer medication on her unit. LPN #233 had prepared Resident #61's medications and she took the medication into the resident's room to administering them. She thought his pills looked funny because she had never crushed his pills before when she had administered his medication, but she took them into the resident anyway. The resident reported to her he doesn't take his medication crushed. The MT reported she took the medications back out to LPN #233 and LPN #233 told her to tell the resident that that's all he had. MT reported she took the crushed medication cup back into the resident's room and told him the nurse said that's all he had, and he refused to take them, so she took them back out to LPN #233. LPN #233 then popped out 3-4 pills into a medication cup and gave them to her to administer to the resident. The MT reported Resident #61 usually takes 5-6 meds in the morning, however LPN #233 only gave her 3-4 (pills) to give him. The resident refused to take them again because there were some medications missing. LPN #233 came into the resident's room and leaned over the resident and took the medication out of the resident's right hand. When the surveyor asked MT #119 if this was abuse, MT #119 confirmed LPN #233 was aggressive with the resident and she would have never done that. MT #119 reported she doesn't recall LPN #233 having anything else in her left hand when asked and the resident had the medication cup in his right hand not on the bed when LPN #233 removed them when asked for clarification by the surveyor. The resident grabbed the LPN's arm when she was leaning over him trying to get the medication cup, however he released his hand when asked to let go. MT #119 confirmed she did not provide a written statement and the Director of Nursing (DON) called her about the incident after she had left the facility when her shift ended. Reviewed interview for accuracy and MT #119 confirmed interview statement was accurate. 2 Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including dementia, unspecified severity, with agitation, concussion with loss of consciousness, history of traumatic brain injury, insomnia, anxiety, depression, cognitive deficit, and amnesia. Review of quarterly minimum data set (MDS) assessment dated [DATE] revealed moderately impaired cognitive skills for daily decision making. The resident was noted to have one to three days of other behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming or disruptive sounds). The resident did not reject care or had wandering. The resident had no impairment in upper or lower extremity and used a wheelchair for mobility. Review of Resident #57's treatment administration record (TAR) dated 02/2024 revealed to monitor target behaviors of sexual inappropriateness, restless, refusal of meds/showers, tearful, and sleepless. The non-pharmacological interventions included food/fluids and distraction. The resident had no sexual inappropriateness behaviors documented in February 2024. Review of care plan dated 10/02/23 revealed Resident #57 was a two person assist with bed mobility and one person assist with dressing, hygiene, toileting, and transfers. Review of behavior plan of care dated 10/02/23 and revised on 02/19/24 revealed the resident has behavior(s) related to dementia and traumatic brain injury as evidenced by refuses medications, refuses showers, sexually inappropriate toward other residents (flashes others), refuses to let staff cut fingernails, refuses to be weighed at times, refuses to let staff take vital signs at times. On 02/19/24 strips off clothes was added. Interventions included to administer medication as ordered, approach resident in a calm manner to avoid frustration and behavior escalation, keep resident safe during episode of behavior, observe, and document inappropriate behaviors and notify physician when behaviors persist or won't de-escalate, distract with food/fluids, and refer to psychologist/psychiatrist services as needed. On 02/15/24 15-minute checks for 72 hours was added and on 02/17/24 the intervention was revised to discontinue the abdominal binder over breast and added to ensure the resident had appropriate size garments on upper body to prevent from sliding up. Review of Resident #57's pertinent charting dated 01/12/24 revealed resident roaming up and down halls stops at male rooms and rooms that people have snacks in. Male resident reported she tries to show him her chest but had a white under shirt on. Review of Resident #57 pertinent charting dated 01/13/24 revealed staff reports resident sitting in front of male resident's door with shirt up, fondling her breast making moaning and groaning sounds. The resident was removed from the male resident's doorway and taken to her room. This is an ongoing issue with resident with male residents. Resident takes binder off after staff places it on her. Review of Resident #57's physician note dated 01/15/24 revealed the [AGE] year-old female with a history of anoxic brain injury with dementia and behaviors, being seen today due to continuously pulling up her shirt. She does have hypersexual behaviors at times and that has increased. She does wear an abdominal binder to help prevent her from pulling up her shift, and easily flashing people, but she had started to do it more again. Review of Resident #57's psych note dated 01/17/24 (signed on 02/21/24) and not in the resident medical record revealed the resident continues to make very sexualized advances and exhibits very sexualized behaviors towards others. The patient was observed to be raising her shirt towards other people, male or female, staff, and residents. The resident very sexualized in her verbalization. The patient appeared to be unaware of the impact she was having on those around her and voiced no concerns for her current behavior. Plan to increase her Effexor to 75 milligrams daily to see if that helps. Continue the Tagamet that she is already on and the Ativan. Review of progress note dated 02/14/24 revealed RN #234 was walking down the hall when she observed Resident #57 and a male resident sitting in the hallway, both in their wheelchair. RN #234 noted that Resident #57's brief was unfastened, and male resident (#113)'s hand was noted to be flat palmed inside the brief up to the 1st set of knuckles. RN #234 immediately intervened and separated the residents. The power of attorney was notified and declined to have the resident be sent out for evaluation. Further review of Resident #57's medical record after the incident on 02/14/24 revealed: On 02/15/24 the resident refused a bath. On 02/17/24 the resident was removed from male resident rooms twice today; has a history of inappropriate sexual behaviors. On 02/17/24 abdominal binder intervention removed today due to resident persistently removing it. On 02/18/24 the resident was noted wheeling self-down hallway completely naked. 02/18/24 the resident had noted increased anxiety and was yelling out to men. Place on 15-minute checks for 72 hours. Record review revealed Resident #113 was admitted [DATE] with diagnosis including mild cognitive impairment, sexual dysfunction not due to a substance of known psychological condition, depression, vascular dementia, mood disorder, history of traumatic brain injury, and diabetes. Review of Resident #113 room census revealed he was admitted to the 3rd floor in a semiprivate room on 01/31/24. He was moved on 02/05/24 to a room on the first floor. On 02/06/24 he was moved back to the third floor and on 02/15/24 until 02/16/24 (discharged ) he remained in that room. Review of Resident #113's social service progress note dated 02/01/24 revealed the resident entered the facility from another skilled nursing facility on 01/31/24. BIMS was assessed at a five showing a severe cognitive impairment. The resident was very concerned that people don't think of him as crazy. Review of the admission MDS dated [DATE] revealed his BIMS was 12 (cognition intact), the resident did not have any behaviors or moods, psychosis present. He had verbal symptoms directed towards other and not directed towards others 1 to 3 days no rejection of care. He had been wandering for one to three days. He had no functional limitation in range of motion and used a walker and wheelchair mobility devices. He was independent with eating, dependent with shower, toileting, and required substantial/maximal assistance with dressing upper and lower body. He had diagnoses of persistent mood disorder and other sexual dysfunction not due to a sub or known physiological condition. Review of Resident #113's admission orders revealed Estradiol 1 milligram (mg) daily for hypersexuality and have psych see resident regarding dementia and sexual behaviors. Review of Resident #113's behavior plan of care dated 02/05/24 revealed the resident was sexually inappropriate towards staff. Interventions included communicating care to residents before starting task, keeping resident safe during episodes of behavior and attempt to redirect. Observe and document episodes of inappropriate behaviors; notify physician when behaviors persist or won't de-escalate; redirect, reposition, one on one, food/fluids. Review of Resident #113's psych note dated 02/09/24 (signed 02/21/24) revealed nursing staff reported increased hypersexual like behaviors and patient did not deny these but attempted to minimize the severity of which it was described. Patient openly acknowledged his willingness to be more mindful in his interactions with others. Review of Resident #113's TAR dated 02/01/24 to 02/16/24 (discharge date ) revealed on 02/05/24 the resident targeted behaviors were sexually inappropriate and verbally aggressive with staff, wandering, agitation, refuses care, restless, and sleepless. The non-pharmacological intervention included reposition, redirection, and offer food and fluids. The resident had behaviors of agitation and wandering, however no evidence he was sexually inappropriate. Review of Resident #113's task for the last 30 days revealed on 02/13/24 the facility started monitoring target behavior of agitation, sexually inappropriate with staff. Review of Resident #113's medical record revealed no evidence the reside[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the probate court local rules of practice, and interview the facility failed to ensure a resident had a legal guardian when the resident no longer had the ability to maintain capacity. This affected one resident (#7) of two residents reviewed for advance directives. Findings included: Record review revealed Resident #7 was admitted to the facility initially on [DATE] with diagnoses including cognitive communication deficit (added [DATE]), intellectual disabilities (added [DATE]), dementia with mild psychotic disturbance (added [DATE]), major depression, bipolar, anxiety, chronic obstructive pulmonary disease, multiple sclerosis, chronic respiratory failure with hypoxia, asthma, hemiplegia, peripheral vascular disease, plasma-protein metabolism, calculus of gallbladder, spinal stenosis, wedge compression fracture of second lumbar vertebra, nontoxic single thyroid nodule, constipation, contracture of right upper arm, dysphagia, hypertensive heart, gout, hyperlipidemia, gastro-esophageal reflux disease, and chronic kidney disease. Review of Resident #7's face sheet (undated) revealed the resident had no guardian or contact person. The resident resided on the facility's secure/dementia unit. Resident #7 was covered by Medicaid and Medicare insurance. Review of Resident #7's Minimum Data Set (MDS) 3.0 assessments dated [DATE] to [DATE] revealed the resident's brief interview for mental status (BIMS) score on [DATE] was nine (moderately impaired cognition impairment). On [DATE] the resident had a significant change MDS that indicated the resident BIMs could not be conducted due to the resident being rarely or never understood. The resident's five-day MDS dated [DATE] also indicated the BIMS could not be conducted due to the resident being rarely or never understood. Review of Resident #7's Preadmission Screening and Resident Review Results Notice dated [DATE] revealed the resident had a significant change in condition (decline). The resident had dementia, serious mental illnesses (mood disorder and pain or other severe anxiety disorder) and physical or mental disability (intellectual disability). The resident had indications of substantial functional impairment. The resident did not have a court appointed legal guardian or legal representative. Review of email correspondence dated [DATE] to [DATE] revealed on [DATE] the facility Social Worker (SW) #121 sent an email to Advocacy and Protective Service, Incorporated (APSI) requesting the need for a guardian for Resident #7 because she was not able to make medical decisions and had no family. APSI responded on [DATE] and instructed the SW to complete the referral application along with a copy of the resident's birth certificate, social security card, and proof of eligibility for county board of developmental disabilities services. Review of email correspondence dated [DATE] revealed SW #121 responded back from [DATE] email indicating she had completed the referral and the resident needed a guardian in place as soon as possible. On [DATE] APSI responded they still needed the resident's birth certificate, social security card, and proof of eligibility from the county board. There was no evidence of further communication between the facility and APSI. Review of the APSI referral application form dated [DATE] revealed Resident #7 had no living will, power of attorney, or existing advance directives, or burial plan. The resident was difficult to understand and had no court appointed guardian. The resident was unable to make her own medical decision and had no family or friends. The instructions on the APSI referral application included all the following documents MUST be included with the completed APSI guardianship referral form to process the referral: eligibility determination instrument, birth certificate, social security card, and statement of expert evaluation. There was no evidence the facility obtained the resident's birth certificate or social security card. Review of Statement of Expert Evaluation dated [DATE] revealed the resident was not capable of making decisions regarding medical and financial decisions and guardianship should be established. Review of the probate court local rules of practice for guardianship dated [DATE] revealed an application must be completed and filed by the guardian. If the resident had adult children who are known to reside in Ohio their address must be provided, and the court would send notice of the hearing to those children. If emergency guardianship was required, the person desiring to be appointed must prepare and file all documents. Further review of Resident #7's medical record revealed the facility had the resident sign consent to decline pneumococcal vaccine on [DATE] after she was declared not capable of making medical decisions by a physician ([DATE]). Review of Resident #7's personal funds account dated [DATE] to [DATE] revealed the facility had bought the resident a google [NAME] that cost $107.23 on [DATE] and paid $1,200.00 to a funeral home on [DATE]. The resident was not able to make financial decisions at that time per the resident's MDS assessments. Interview on [DATE] at 9:45 A.M. and 10:18 A.M., with SW #121 revealed she had contacted APSI, and they would not assist her with guardianship due to the facility didn't have the resident's social security card or birth certificate. The SW indicated she wasn't sure how to apply for emergency guardianship or whom to contact. The SW reported the resident's husband was a resident at the facility but had expired years ago at the facility and she wasn't aware of any other family members. The resident had been a resident at the facility since 2006 and no one had obtained a copy of the resident's social security card or birth certificate. She had contacted probate court but did not document the conversation but stated she was told there was no one in the area taking new residents for guardianship and the local health department confirmed the resident was not born in Ohio. SW #121 confirmed she had not reached out to any attorneys to see if they could assist or would be willing to accept guardianship for the resident. Interview on [DATE] at 7:45 A.M., with SW #121 revealed she had discovered yesterday that Resident #7 had two children. The facility was going to try to reach out to the daughter because she thought the resident other child (son) had expired. Interview on [DATE] at 7:51 A.M. with Resident#7 revealed she could not recall what state she was born in, however when asked if she had two children she replied yes. The resident was not able to provide reliable information. Interview on [DATE] at 8:21 A.M., with State Tested Nurse's Aide (STNA) #131 and STNA #167 revealed the resident had severe cognition impairment and she hardly talked but would scream when she wanted anything. She has a call button but doesn't know how to use it and tries to get up on her own. The resident needs a guardian due to not being able to make medical or financial decisions. The STNA's reported they thought the resident was adopted and her husband was resident at the facility years ago but had expired. Interview on [DATE] at 10:53 A.M. with the Probate Court Personnel #400 revealed it was the facility's responsibility to find a guardian and to submit the proper paperwork to the courts. The courts don't have a list of people that were willing to accept residents, however there was an agency in the community that may be able to help such as APSI and sometimes local attorneys. Interview on [DATE] at 11:03 A.M., with local attorney office Secretary #401 confirmed that Attorney #402 accepts residents for guardianship as well as Attorney #403 who was also a local attorney in town. Interview on [DATE] at 8:29 A.M. and 2:50 P.M., with the Administrator, revealed the facility legal department was now involved in helping the facility find guardianship for Resident #7. The facility found out the resident was born in Virginia, and the facility was in the process of obtaining the birth certificate. The Administrator confirmed in [DATE] the resident was not capable of making financial decisions, however her funds were over the allowed amount and the facility had to help the resident spend down the account, so she did not lose her funding. Interview on [DATE] 9:22 A.M., with the Director of Nursing (DON) confirmed she had Resident #7 sign the pneumococcal vaccine consent even though she was not capable of making medical decisions due to the corporate office requires the form to be completed so they can track immunizations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident was afforded the right to choose how often they bathed and received the type of bathing activity they preferred. This affected one resident (#83) of two residents reviewed for choices. Findings include: A review of Resident #83's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Parkinson's disease, need for assistance with personal care, and major depressive disorder. A review of Resident #83's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to have displayed any behaviors or reject care during the seven day assessment period. She had a functional limitation in her range of motion of her bilateral lower extremities. A partial/ moderate assist was needed with showers/ bathing. A review of Resident #83's care plans revealed she had an activities of daily living (ADL) self-care performance deficit related to myopathy and left foot drop. The goal was for her ADL needs to be met through the next review date. The interventions indicated the resident preferred showers as her bathing activity of choice and wanted them on the afternoon shift every Monday, Wednesday, Friday, and as needed. A review of Resident #83's shower documentation under the task tab of the electronic medical record (EMR) for the past 30 days (12/11/23 through 01/08/24) revealed her preference was for showers and they were to be provided on the afternoon shift every Monday, Wednesday, Friday, and as needed. She was documented as having received a shower on all her scheduled shower days during that 30 day period, with the exception of 12/13/23, 12/25/23, and 12/29/23. A bed bath was documented as having been given on those three days in place of a shower, which was her preferred bathing activity. A review of Resident #83's nurses' progress notes revealed there was not any documentation to support why a bed bath had been given on 12/13/23, 12/25/23, and 12/29/23 in place of a shower. There was no indication that a shower had been offered and refused by the resident on those days. On 01/02/24 at 2:11 P.M., an interview with Resident #83 revealed it was her preference to be showered three times a week. She stated she was only getting two a week, if that. On 01/09/24 at 12:58 P.M., an interview with State Tested Nursing Assistant (STNA) #115 revealed Resident #83 required an extensive assist for her ADL's. She was not sure what the resident's preference was regarding the type of bathing activity she received. She was also not sure what shift the resident was showered/ bathed on. The frequency in which a resident was showered/ bathed depended on the resident's preference. The activity assistance put the resident's preference into the computer so they aides knew when they were to be showered/ bathed. She reported, when she offered the resident a shower, the resident would not refuse. She had not known the resident to decline a shower and want a bed bath instead. On 01/09/24 at 1:24 P.M., an interview with Licensed Practical Nurse (LPN) #211 revealed Resident #83 required assistance with personal care and had the use of a Hoyer lift for transfers. She was not aware of what the resident's preference was for bathing. She was not aware of the resident having refused any showers when offered. Documentation of showers were done by the aides and entered into the computer. The aides worked 12 hour shifts so if a resident was an afternoon shower it could be done at the end of the day shift or the beginning of the night shift. Aides were supposed to notify the nurse if showers were refused and she would document the refusal in the progress notes. She was not able to explain why bed baths were given to the resident on the three days she was marked as having received them when showers should have been given according to her preference. A review of the facility's policy on Promoting/ Maintaining Resident Dignity (revised 10/26/23) revealed it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members were involved in providing care to residents to promote and maintain resident dignity and respect resident rights. During interactions with residents, staff must report, document and act upon information regarding resident preferences. The resident's former lifestyle and personal choices would be considered when providing care and services to meet the resident's needs and preferences. They were to groom and dress residents according to resident preference.

Based on review of resident financial records and staff interview, the facility failed to notify a resident that received Medicaid benefits when the amount in the resident's account reached $200 less than the SSI resource limit for one person, and that, if the amount in the account, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI. This affected one of six residents whose financial records were reviewed (#59). The facility handled the funds for 62 residents. The facility census was 97. Findings include: Review of the financial records for Resident #59 revealed the facility managed her funds. Review of a statement landscape revealed the balance in the resident's account had been greater than $1800.00 since 05/31/23. On 05/31/23 the balance was $1819.35. The current balance in the account was $1920.74. Interview with Business Office Manager #135 on 01/10/24 at 9:04 A.M. confirmed Resident #59 received Medicaid benefits. She further revealed Resident #59's power of attorney was sent a letter on 06/16/23 notifying her that the balance was within $200 of the resource limit. However, the power of attorney had not acknowledged receiving the letter and the facility had no evidence it was received by the power of attorney. Business Office Manager #135 confirmed there had been no further attempts to notify the power of attorney that the balance had remained within $200 of resource limit since 06/16/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, interview, and facility policy review, the facility failed to ensure a resident's advanced directives were clear and consistent. This affected one resident (#25) of two residents reviewed for advanced directives. The facility census was 97. Findings included: Review of Resident #25's medical record revealed she was admitted to the facility on [DATE] with diagnoses including acute kidney failure, type two diabetes with diabetic neuropathy, morbid (severe) obesity due to excess calories, and unsteadiness on feet. Review of Resident #25's quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed she was cognitively intact. Review of Resident #25's electronic medical record face sheet revealed she was a full resuscitation in case of an emergency for her advanced directives. Review of Resident #25's physician order, dated [DATE], identified she was a full resuscitation. Review of Resident #25's plan of care, dated [DATE], revealed her advanced directives were Do Not Resuscitate - Comfort Care (DNR-CC) code status. Review of Resident #25's paper medical record revealed a Cardiopulmonary Resuscitation (CPR) form identified the box beside NO CPR was marked with an X and it was signed by Resident #25 on [DATE]. Review of Resident #25's paper medical record revealed a State of Ohio Do Not Resuscitate (DNR) Comfort Care form, signed and dated by Resident #25 and her physician on [DATE]. Interview on [DATE] at 3:05 P.M. with Resident #25 verified she did not want CPR performed on her in case her heart stopped beating, or she stopped breathing. Interview on [DATE] at 3:09 P.M. with Unit Manger (UM) #300 verified Resident #25's electronic medical record identified she was a full resuscitation and her paper record revealed she was a DNR-CC. UM #300 verified the guidance was contradictory and staff would not know what to do if Resident #25's heart stopped or she stopped breathing. UM #300 verified Resident #25's advanced directives would need to be clarified and there needed to be clear and consistent documentation. Review of the facility policy titled, Residents' Rights Regarding Treatment and Advance Directives, (reviewed/revised [DATE]), revealed it was the policy of the facility to support and facilitate resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Further review revealed any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of self-reported incident (SRI), review of grievance/concern log, interviews, and policy review the facility failed to resolve a resident's grievances. This affected one resident (#65) of two residents reviewed for personal property. Finding include: Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, paraplegia, atrial fibrillation, pressure ulcer, heart failure, neuromuscular dysfunction of the bladder, and chronic pain. Interview on 01/02/24 at 9:39 A.M., with Resident #65 revealed someone had stolen $60.00 the first part of December (2023) out of his room while he was at an appointment. The resident also reported his transfer board was missing as well. He had to buy a new transfer board to leave the facility for Christmas due to the facility couldn't find his and the therapy would not let him borrow one from the facility. The facility had completed an investigation regarding the stolen money; however, they haven't investigated the missing transfer board that he was aware of. The resident reported he was supposed to be reimbursed for the money, but the facility has not paid him yet and he would like to be reimbursed for the transfer board as well. Review of the grievance/concern log dated 12/2023 revealed Resident #65 had reported $60.00 missing on 12/11/23 and the resolution was the resident was reimbursed on 12/20/23. There was no evidence of Resident #65's missing transfer board. Review of the facility SRI dated 12/13/23 revealed Resident #65 reported $60.00 missing on 12/11/23 to the Social Worker (SW) #121. The allegation of abuse was unsubstantiated; however, the resident's money would be replaced, and he would be offered a lockbox. Further review revealed no evidence of an investigation for the resident's missing transfer board. Interview on 01/02/24 at 9:26 A.M. and 4:36 P.M. with the Administrator confirmed the resident had not been reimbursed for the $60 at this time due to the reimbursement form was completed, however it was never sent to the corporate office for some unknown reason. The Administrator reported she was not aware of the missing transfer board and would start a SRI and an investigation. The Administrator reported she spoke to the Corporate Office today to have the $60.00 and $54.31 for the transfer board expedited so they could pay the resident even though there was no evidence the money was misappropriated, or the resident even had a transfer board. She reviewed the residents inventory sheet today and there was no evidence the resident had a transfer board when he was admitted . Interview on 01/03/24 at 9:00 A.M., with the Director of Nursing (DON) confirmed she was aware of the allegation of the missing transfer board, however she had called Resident #65's friend and it was determined the transfer board was left at the previous facility the resident had resided at. Therapy had reported the resident never had his own personal transfer board at the facility. The facility was still going to reimburse the resident for the transfer board since he had already bought one. Review of the facility policy titled Complaint and Grievance Process (dated 01/01/22) revealed any individual may file a complaint either directly to the facility or the Secretary of Health and Human Services. The facility would assist the individual with the complaint and grievance process. Complaints and their disposition will be documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the resident or their representative was provided with a written summary of the baseline care plan. This affected one residents (#88) of 27 sampled residents. The facility census was 97. Findings include: Review of the closed medical record for Resident #88 revealed an admission date of 09/29/23. The resident had diagnoses including malignant neoplasm of the prostate, liver, colon, and bone. He went home on [DATE] but was readmitted on [DATE] as he was unable to care for himself at home. He remained at the facility until 11/20/23, when he was transferred to the hospital. He did not return to the facility. Record review revealed a care plan meeting was held on 10/02/23 with the resident and his daughter. There was a section of the care plan meeting form to indicate who a copy of the care plan was provided to. It stated upon request. An additional care plan meeting was held on 10/19/23 with the resident. There was a section of the care plan meeting form to indicate who a copy of the care plan was provided to. It stated upon request. There was no evidence a written copy of the baseline care plan had been provided to the resident or his daughter. There was no evidence they refused a copy. Interview with Social Service Worker #125 on 01/09/24 at 10:55 A.M. revealed she conducted the care plan meetings for the baseline care plan. She stated that either a copy of the baseline care plan was provided or they refuse it. However, she stated she did not document this and usually just documented upon request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the concern log, review of invoice, observation, and interview the facility failed to ensure a resident had a comprehensive plan of care for vision. This affected one resident (#70) of two residents reviewed for sensory needs. Findings include: Medical record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit. Review of the grievance/concern log dated 02/23/23 and 06/07/23 revealed Resident #70's glasses were missing. The resolution on 02/23/23 indicated the glasses would be replaced. There was no documentation regarding the resolution of resident's missing glasses for 06/07/23. Review of Resident #70's vision note dated 03/07/23 revealed the resident had 20/30 vision in bilateral eyes and required glasses. There was an additional note to encourage the resident to wear the glasses part-time for reading. Review of Resident #70's eye glass invoice dated 03/07/23 revealed the resident received a pink pair of glasses. Review of Resident #70's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had adequate vision without corrective lens. Review of Resident #70's current plan of care revealed no evidence of a vision plan of care. Interview on 01/03/24 at 11:07 A.M., with Resident #70's daughter via phone revealed the residents' glasses were missing again. Observation on 01/04/24 at 8:32 A.M., with State Tested Nurse's Aide (STNA) #131 and #167 revealed no evidence Resident #70's glasses were in her room. Interview on 01/04/24 at 9:08 A.M. with Social Worker (SW) #121 revealed she had Resident #70's glasses in her office due one of the staff gave them to her because the resident was refusing to wear them. The SW confirmed the resident did not have a plan of care for vision nor a plan of care for refusal to wear the glasses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to revise comprehensive care plans and failed to have quarterly care conferences. This affected three residents (#18, #65, and #70) of four residents reviewed for care planning. The facility census was 97. Findings include: 1. Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, atherosclerotic heart disease, congestive heart failure, and type II diabetes. Review of a quarterly minimum data set (MDS) assessment completed on 06/06/23 revealed Resident #18 had intact cognition and had no behaviors. Review of an assessment titled Care Plan Conference Summary revealed Resident #18 had a care conference on 12/08/22, then had a care conference on 07/27/23. Review of the MDS schedule revealed Resident #18 had a quarterly MDS on 12/02/22, a quarterly MDS on 03/03/23, a quarterly MDS on 06/02/23, a quarterly MDS on 06/06/23, a discharge MDS on 07/03/23, an annual MDS on 08/23/23, and a quarterly MDS on 11/22/23. Interview on 01/02/24 at 11:29 A.M. with Resident #18 revealed she did not have any care planning conferences. Interview on 01/08/24 at 1:59 P.M. with Licensed Social Worker (LSW) #125 revealed care conferences should be completed once per quarter and she keeps track of when care conferences are due for each resident by looking at the assessments which are triggered by the MDS staff because the care conferences and MDS' do not always fall in the same timeframe. LSW #125 reported she invites residents and families to care conferences by sending them letters with the date and time of the conference. LSW #125 stated she could not provide any documentation to show Resident #18 had been invited to any care conferences. LSW #125 stated Resident #18 had not had a care conference since July 2023 because the assessment did not repopulate on the assessment board, but a care conference was scheduled for January 2024. LSW #125 confirmed Resident #18 did not have quarterly care conferences. Review of a policy titled Comprehensive Care Plans (dated 06/30/22) revealed comprehensive care plans will be prepared by an interdisciplinary team which includes a resident or representative to the extent practicable. Additionally, the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, every effort will be made to schedule a care plan meeting at the best time of the day for the resident and family or Ombudsman if they resident wishes to invite them in lieu of family, and a summary of the comprehensive care plan will be given to the resident and will include initial goals of the resident, summary of the resident's medication and dietary instructions, services and treatments, and any updates completed at the care plan meeting. 2. Record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance with psychotic disturbance, mood disturbance, and anxiety, moderate protein-calorie malnutrition, hypertension, anemia, anxiety, heart disease, inguinal hernia, esophagitis, hypokalemia, reflux disease, depression, insomnia, cognitive communication deficit, dysphonia, hypothyroidism, adult failure to thrive, hyperlipidemia, and right wrist fracture. Review of Resident #70's admission assessment dated [DATE] revealed the resident had top dentures. Review of Resident #70's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognition impairment. Review of Resident #70's face sheet (undated) revealed the resident's daughter was listed as power of attorney. Review of Resident #70's dental plan of care dated 10/13/23 revealed no evidence the resident had dentures. Review of Resident #70's care plan conference worksheet dated 11/22/23 revealed the sheet was incomplete/blank. Further review revealed the last documented care conference was 08/16/23, however there was no evidence the resident or her daughter attended. Review of Resident #70's social service note dated 7/27/23 revealed a quarterly care conference invite was mailed to the resident's daughter on this date. The care conference is to take place on 08/24/23 at 1:45 P.M. Social Worker continues to follow to assist as needed. There was no documented evidence the resident's daughter was notified the care conference was changed to 08/16/23. Interview on 01/03/24 at 11:11 A.M., with Resident #70's daughter revealed she had not been invited to attend a care plan conference every quarter. In addition, Resident #70's daughter revealed her mother's dentures are missing. Observation on 01/04/24 at 8:29 A.M. with State Tested Nurse's Aide (STNA) #167 revealed Resident #70 had top dentures in a denture up in her bathroom with her name on them. Interview on 01/04/24 at 11:33 A.M., with Social Worker (SW) #125 confirmed she notified Resident #70's daughter of the care conference on 08/16/23, however the letter sent out to the family indicated the care conference would be on 08/24/23. SW #125 confirmed there was no documented evidence that the resident or her daughter was notified of the change of date for the care conference. SW #125 reported she had just started in July of 2023 and in December of 2023 she had COVID and got behind. The SW confirmed there should have been a care conference in November of 2023, however there wasn't one on her schedule. The SW reported she just emailed the daughter to set up a care conference this month. Interview on 01/04/24 at 2:08 P.M., with Minimum Data Set Nurse #219 confirmed Resident #70's dental plan of care did not reflect the resident's upper dentures and she would revise the plan of today to reflect the upper dentures. Review of the facility policy titled Participation 77 Care Review-Assessment/Care Plans (dated 10/20/20 and revised on 01/01/22) revealed each resident and his/her family member are encouraged to participate in the development of the resident's comprehensive assessment and care plan. The resident and his/her family or legal representative are invited to attend and participate in the resident's assessment and care planning conference. The comprehensive care conference was scheduled after the completion of the comprehensive care plan and quarterly. The care conference would be attended by Social Service Dietary and Activities, and Nursing. A seven-day advance notice of the care planning conference to the resident and interested family member for all conferences. Such notice was made by mail or telephone. The social services director of designee was responsible for contracting the resident family and for maintaining the record of such notices including input form the family members when that are not able to attend. 3. Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, Stage 4 pressure ulcers (full-thickness tissue loss) to left and right buttocks, paraplegia, and heart failure. Review of Resident #65's impaired skin integrity skin plan of care initiated 10/13/23 revealed turning and repositioning as needed, elevate heels as tolerated, and pressure redistribution device in chair. There was no evidence the plan of care was revised to include turning every two hours, prevolon boots, roho cushion, limited sitting for one hour at a time, bed only, and Hoyer lift. Review of Resident #65's wound center note dated 12/18/23 revealed the intervention included bed only, Hoyer lift, prevolon boots, roho cushion, limited sitting one hour at a time, and turn every two hours. Review of Resident #65's wound note dated 01/09/24 revealed the resident had two Stage 4 pressure ulcers; one on the right gluteus and one on the left gluteus. Interview on 01/10/24 at 9:23 A.M., with Registered Nurse (RN) #143 confirmed Resident #65's skin integrity plan of care was not revised to include turning every two hours, prevolon boots, roho cushion, limited sitting for one hour at a time, bed only, and Hoyer lift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including encephalopathy, chronic obstructive pulmonary disease, schizophrenia, anxiety, seizures, hypertension, needs for assistance with personal care, difficult walking, gastro-esophageal reflux disease, hyperlipidemia, irritable bowel syndrome, Vitamin D deficiency, constipation, and moderate intellectual disabilities. Review of Resident #191's handwritten physician order dated 12/17/23 revealed house psych to see for schizophrenia and local gastric intestinal (GI) referral for history of ulcerative colitis. Laboratory testing (complete blood count (CBC), complete metabolic profile (CMP), iron profile, Vitamin B12, Thyroid, and Vitamin D) to be done on 12/18/23 for hypertension (HTN) anemia, fatigue, and Vitamin deficiency. Also, on 12/18/23 a Depakote level for epilepsy was to be drawn. Review of Resident #191's admission history and physical dated 12/17/23 revealed to have follow up blood work tomorrow and have psychology see her. The resident had been running up and down the hallways. She has currently fallen twice. She was on significant psychotropic medication and just needed to clarify, if they would like Depakote to be discontinued. She has a history of ulcerative colitis. Review of Resident #191's administration note dated 12/18/23 revealed the CBC, CMP, iron profile, B12, TSH, Vitamin D level for HTN, anemia, fatigue, vitamin D deficiency was not collected due to the resident refused. The physician was advised and would attempt to draw tomorrow morning. There was no mention of the Depakote level, house psych, or GI consult. Further review of the medical record (paper and electronic) revealed no evidence a second attempt was made to collect the laboratory test per orders or documented evidence the physician was notified the labs were not collected. There was no evidence the GI consult was made. Review of Resident #191's impaired cardiovascular care plan related to hypertension and high cholesterol initiated 12/18/23 revealed labs as ordered for testing. Review of Resident #191's at risk for fluid volume deficit related to cognitive impairment dated 12/18/23 revealed to do labs as ordered. Review of Resident #191's impaired gastrointestinal status related to history of constipation inflammatory bowel disease gastroesophageal reflux disease dated 12/17/23 revealed labs as ordered. Interview on 01/03/24 at 10:59 A.M. with the Director of Nursing (DON) confirmed Resident #191 had refused laboratory testing on 12/18/23, however there was no documented evidence a second attempt was tried or evidence the doctor was notified the labs were not obtained. The DON confirmed the GI consult was not made per the orders on 12/17/23. Review of the facility policy titled Laboratory and Diagnostic Guidelines (dated 10/30/20 and revised 10/26/23) revealed the facility set guidelines to track the timely completion, reporting, and monitoring of laboratory and diagnostic tests, results, and notifications which are used to monitor resident status and/or therapeutic medication levels. The physician should be notified of all refused lab test results orders and reason why. The physician should be notified if the labs test was unable to be completed, reason why, and request for a new order. All notification attempts at notification, and response should be noted in the resident medial record. Based on observations, medical record review, and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the care plan, and resident choice, in the areas of orthopedic follow up services, hospice services, and specialty physician consult services. This affected three residents (#26, #80, and #191) of 27 sampled residents. The facility census was 97. Findings include: 1. Review of the medical record for Resident #80 revealed an admission date of 09/27/23 with diagnoses including dementia and hypertension. The resident resided on the secured dementia unit. A Minimum Data Set assessment completed 10/01/23 documented a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. It indicated the resident had no functional limitation in range of motion and required only supervision or touching assistance for sit to stand, chair to bed, toilet transfer, and walking 10 feet. It indicated a fall history but no falls since admission. Observations on 01/08/24 at 7:50 A.M. revealed the resident to be seated in a wheelchair with a fracture boot on the right foot. Review of nurse's progress notes revealed on 12/07/23 at 11:27 A.M. the nurse was alerted by a state tested nursing assistant of Resident #80's fall. When entering the room it was noticeable the floor had just been mopped. Resident #80 was on the floor laying on her back complaining of pain in right ankle. Skin assessment completed with no physical injuries noted. The resident denied hitting her head. The resident was lifted off the floor via Hoyer lift and placed on bed. An ice pack was applied to the right ankle. The resident's physician was notified and 911 called for transport to emergency room. Review of an x-ray report for Resident #80 on 12/07/23 revealed an oblique fracture of the distal fibula which is mildly displaced and a mildly comminuted fracture of the medial malleolus noted. Review of the emergency room notes from 12/07/23 revealed an orthopedic glass splint was applied. The resident was to be non-weight bearing and follow up with orthopedics in one week. The resident returned to the facility on [DATE]. Physician's orders were obtained on 12/08/23 for vascular checks to the right foot every shift and as needed. On 12/10/23 there was an order for non-weight bearing to right leg every shift for fracture. A nurse practitioner note on 12/70/23 stated the resident slipped on the wet floor today and had fall related to that. The resident went to the emergency room and found to have a distal tibia fracture that was mildly displaced. The resident was put on splint and bedrest. Follow up with orthopedics. A nurse's progress note on 12/13/23 at 3:54 P.M. indicated an orthopedic appointment on 12/15/23. Review of the orthopedic consultation notes on 12/15/23 revealed Resident #80 was seen status post bimalleolar right ankle fracture. Patient should be non weight bearing. Please take boot off three times a day for skin checks. Follow up in office in one week. Review of the medical record revealed as of 01/08/24, there was no evidence Resident #80 had returned for orthopedic care for the fracture as recommended by orthopedics. Interview with the Director of Nursing (DON) on 01/09/24 at 7:55 A.M. confirmed Resident #80 had not been seen by orthopedics since 12/15/23 and was supposed to have a follow up appointment one week after that. The DON stated she does not know why the resident was not seen again as recommended. The DON stated an appointment was made for 01/09/24. Review of an orthopedic consultation note for 01/09/24 revealed patient was seen today status post right ankle fracture. She may be weight bearing as tolerated with boot. Ski boot for ambulation only, does not need to wear it for sleeping. Follow up in office in one month. 2. Review of the medical record for Resident #26 revealed an admission date of 07/31/18. The resident had diagnoses including chronic obstructive pulmonary disease, protein-calorie malnutrition, respiratory failure, pancreatitis, chronic kidney disease, fistula of intestines, malignant neoplasm of thyroid, chronic hepatitis B, and chronic pain. Review of the Minimum Data Set assessment completed 10/23/23 revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. The resident required moderate assist with transfers and toileting. The resident had a physician's order on 09/29/23 to admit to hospice services. Record review did not reveal any evidence of hospice visits or care provided. There was no evidence the hospice provider had provided a copy of their plan of care to the facility. Interview with Unit Manager (UM) #300 on 01/04/24 at 2:45 P.M. revealed the hospice nurse comes at least twice per week and the hospice aide once per week for Resident #26. UM #300 confirmed the hospice visit notes are typically kept in a binder at the nurse's station. She confirmed the facility did not have any evidence of any hospice services provided since 09/29/23. She stated she would have to call the hospice agency and get a copy of them. Review of hospice records, after obtained from the hospice provider, revealed care started on 09/28/23 for a terminal diagnosis of severe protein calorie malnutrition. Notes on 12/04/23 indicated the hospice staff would provide all core services/provision of care as outlined in the hospice plan of care including: wound care three times weekly, treatments as included in the plan of care, pain management, medication management, and instruction on catheter management. The resident was also receiving hospice chaplain services. On 12/06/23 notes stated a home health aide visits three times weekly starting 12/11/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to arrange an audiology consult per physician's orders for a resident who was hard of hearing. This affected one resident (#30) of two residents reviewed for communication. The facility census was 97. Findings include: Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, hyperlipidemia, congestive heart failure, and conductive hearing loss. Review of a care plan dated 08/16/23 revealed Resident #30 was at risk for impaired communication related to hard of hearing and interventions included audiology referral as needed. Review of orders revealed an order from 12/11/23 to please schedule audiology exam dx (diagnosis): hearing loss. Review of a progress note from 12/11/23 by Physician #303 revealed Resident #30 was seen regarding complaints of bilateral hearing loss with a plan of getting a consult for an audiology exam. Interview on 01/02/24 at 5:19 P.M. with Resident #30 revealed the resident was hard of hearing and denied the use of a hearing aid. During the interview, questions were repeated multiple times and above normal conversational tone for Resident #30 to hear. Interview on 01/04/24 at 2:20 P.M. with Resident #30 confirmed she does have a hard time hearing and she did ask someone about hearing aids but never heard back. Interview on 01/09/24 at 12:24 P.M. with Licensed Social Worker (LSW) #125 confirmed Physician #303 gave an order on 12/11/23 for Resident #30 to be referred to audiology for a consult. LSW #125 confirmed a referral for audiology had not been completed. LSW #125 stated she reviewed an audiology visit that occurred after Resident #30 admitted to the facility and she was not seen, and Resident #30 was also not on the list for the upcoming audiology visit. LSW #125 sent a referral on 01/09/24 for Resident #30 to be seen by the audiologist. Review of a policy titled Hearing and Vision Services (dated 10/30/23) revealed the facility is to ensure residents have access to and receive proper treatment and assistive devices to maintain vision and hearing abilities. Additionally, employees should refer any identified need for hearing or vision services/appliances to the social worker who is responsible for assisting residents in locating and utilizing any available resources for the provision of hearing services the resident needs then make an appointment and arrange transportation if needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy review the facility failed to ensure pressure ulcer treatments were administered as ordered. This affected one resident (#65) of two reviewed for pressure ulcers. The facility census was 97. Findings included: Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, Stage 4 pressure ulcers (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed) to left and right buttocks, paraplegia, and heart failure. Review of the wound center note dated 12/18/23 revealed the resident would return in three weeks (01/08/24). Review of Nurse Practitioner (NP) note dated 12/27/23 revealed the resident reported he would not be going to the wound center for three weeks due to the holidays fell on Monday, which was his scheduled day. The resident reported he would like his dressing changed to twice a day until he was able to go back to the wound center due to he was having a lot of soiling in his depends from the two wounds on his buttocks. The NP plan was to change the dressing change orders to twice a day for now until he can get back with the wound center as he was having a lot of drainage between dressing changes. Review of the written order dated 12/27/23 revealed to do dressing changes to the right ischium and left buttocks twice daily until appointment with wound center. Review of Resident #65's orders and treatment administration record (TAR) dated 12/27/23 to 01/03/24 revealed no evidence the 12/27/23 order to increase dressing changes to twice a day was implemented per the written order on 12/27/23. Review of Resident #65's December 2023 TAR revealed no evidence the pressure ulcer treatments to the left and right gluteal were administered on 12/13/23, 12/15/23, and 12/22/23. Review of the January 2024 TAR revealed no evidence the treatment was completed on day and night shift on 01/05/24, the day shift on 01/07/24, and the night shift on 01/08/24 to the left and right gluteal pressure ulcers. Review of Resident #65's wound note dated 01/09/24 revealed the resident had two Stage 4 pressure ulcers. One on the right gluteus and one on the left gluteus. Interview on 01/03/24 at 9:00 A.M., with Resident #65 revealed he had spoken to the doctor last week and staff were to change his two-pressure ulcer dressings twice daily, however they have only been changing it once daily. Interview on 01/03/24 at 9:00 A.M., with the Director of Nursing (DON) confirmed there was a new order written on 12/27/23 to change the two-pressure ulcer dressings twice daily, however it was never implemented for an unknown reason. Interview on 01/10/24 at 9:52 A.M., with Registered Nurse (RN) #143 confirmed Resident #65's treatments were not administered as ordered on 12/13/23, 12/15/23, 12/22/23, 01/05/24, 01/07/24, and 01/08/24. Review of the facility policy titled Pressure Ulcer/Skin Breakdown-Clinical Protocol dated 10/30/22 and revised on 01/02/23 revealed the provider would authorize pertinent orders related to wound treatments, including dressings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview, and policy review the facility failed to ensure suprapubic catheter treatments and antibiotics were administered per order. This affected one resident (#65) of one resident reviewed for urinary catheter/urinary tract infection. Findings include: Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of bladder, paraplegia, pressure ulcers, and heart failure. Review of Resident #65's pertinent charting for infections dated 12/31/23 and 01/01/24 revealed the resident had completed antibiotic (Clindamycin) regimen and was still having pain and redness around catheter site. New antibiotic being ordered. Review of Resident #65's current orders revealed on 12/21/23 a new order was written to wash suprapubic catheter site with soap and water, pat dry, apply split drain gauze and change daily. There was no evidence a new antibiotic order was written after the resident finished the Clindamycin on 12/31/23. Review of Resident #65's suprapubic catheter plan of care dated 12/21/23 revealed to report signs of peri-area redness, irritation, skin excoriation/breakdown and to administer medications as ordered. The plan of care did not include to wash suprapubic site with soap and water, pat dry, apply split drain gauze and change daily. Interview and observation on 01/02/24 at 9:48 A.M., with Resident #65 revealed he had recently had a suprapubic catheter surgically inserted, and it was infected. He had completed an antibiotic, and the doctor was supposed to start another antibiotic however, the staff has never started it. The resident pulled down the sheet to show the surveyor and the area around the suprapubic catheter was red, swollen, and there was serosanguinous drainage noted on his depends from the suprapubic catheter. Resident #65 also reported staff had not been applying a drain sponge around the suprapubic catheter per orders. Interview on 01/03/24 at 8:49 A.M., with Licensed Practical Nurse (LPN) #175 and the Director of Nursing (DON) revealed the physician had ordered Bactrim on 12/31/23 due to the suprapubic catheter still had drainage and redness after the resident completed the Clindamycin, however LPN #175 reported she forgot to put the order in and just realized it this morning. Observation on 01/03/24 at 9:00 A.M., of Resident #65 with the Director of Nursing (DON) revealed there was no drainage sponge noted around the suprapubic catheter and the area was still red, swollen, and there was serosanguinous drainage noted on the depends again. The resident confirmed staff did not put a drain sponge on yesterday or today. The resident reported to the DON he was supposed to be started on a new antibiotic, but the staff had not started it yet. The DON confirmed the resident did not have a drain sponge in place per the physician order. Review of the facility policy titled Catheter Care Procedure-Urinary (dated 10/30/20 and revised 12/28/23) revealed the facility would provide catheter care to all residents.

Based on observations, medical record review, policy review, and staff interview, the facility failed to evaluate a resident's decline in intake to ensure the resident maintained acceptable parameters of nutritional status, such as body weight. This affected one resident (#80) of four residents reviewed for nutritional status. The facility census was 97. Findings include: Review of the medical record for Resident #80 revealed an admission date of 09/27/23 with diagnoses including dementia and hypertension. The resident resided on the secured dementia unit. A Minimum Data Set (MDS) assessment completed 10/01/23 documented a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. It indicated the resident was independent with eating. It stated the resident was 64 inches tall, weighed 118 pounds, and had no weight changes. The resident was admitted on a regular diet. Review of the plan of care dated 09/28/23 revealed the resident was at risk for altered nutritional status related to age, variable intake, abnormal labs, history of significant weight fluctuations, and weight loss. The goal was for the resident to have adequate nutrition to meet nutritional needs for weight stability without significant change and have no signs/symptoms of malnutrition. Interventions included labs related to nutritional status as ordered, observe percentage of meal intake for changes in eating habits, and occupational/speech therapy screen as needed. The resident also had a plan of care for activities of daily living performance deficit which stated the resident required supervision and cueing with meals. A nutrition evaluation on 09/28/23 stated the resident's ideal body weight weight was 120 pounds plus or minus 10%. The resident had not had a change in weight and was not on a weight loss regimen. It stated she fed herself and had her own teeth. Meal intake averages 88%. Current diet order meets needs. Goal is for weight maintenance. The resident's weight was 118 pounds. Review of weight records revealed Resident #80 had the following weights: 9/27/23 and 9/28/23 118 pounds, 10/17/23 121.8 pounds, 10/24/23 121 pounds, 11/1/23 123 pounds, 11/21/23 116 pounds (This represents a 5.6% significant weight loss in one month). Review of nutrition progress notes by Dietary Director #186 on 11/21/23 revealed Resident #80 had a 5% weight loss and weighed 116 pounds. Meal intakes average 78% (down from 88% in September). Recommend continue with current nutrition plan. On 11/28/23 the resident continued to weigh 116 pounds. On 11/30/23 Dietary Director #186 noted the resident's intake had decreased to 52%. Fortified pudding was ordered twice daily. There was no evidence of any evaluation of why her meal intakes had decreased. On 12/01/23 the resident weighed 112.6 pounds (an additional 3.4 pound weight loss in 3 days). On 12/05/23 Dietary Director #186 noted the resident had decreased 3.4 pounds in one week. Intake averages at 56%. House supplement 60 milliliters twice daily was recommended and started. On 12/05/23 the resident weighed 111 pounds (an additional 1.6 pound weight loss in 4 days). A significant change Minimum Data Set assessment was completed on 12/12/23. The resident had a BIMS of 5, indicating severe cognitive impairment. It indicated the resident had weight loss and required set up help with eating. A nutrition evaluation on 12/13/23 indicated the resident weighed 111 pounds. However, a weight was documented on 12/13/23 of 110 pounds. The evaluation noted a weight loss of 9%. Goal was for weight maintenance. Meal intakes average 52%. There was no evidence of any evaluation of why her meal intakes had decreased. On 12/19/23 the resident weighed 114.6 pounds (gain of 4.6 pounds). However, meal intakes were noted to be an average of 46% on 12/20/23 dietary progress note. On 12/27/23 and 12/28/23 the resident weighed 112.6 (loss of 2 pounds). A nutrition progress note by Dietary Director #186 on 12/27/23 stated the resident's weight had decreased 2 pounds in one week and her average meal intakes were 38% (down from 88% on admission). The fortified pudding was discontinued and the house supplement was increased to five times daily. There was no evidence of any evaluation of why her meal intakes had decreased. On 01/02/24 the resident weighed 112.8 pounds, down from 123 pounds in November 2023. A dietary progress note on 01/03/24 indicated her average meal intake was 32%. Observations on 01/08/24 at 7:50 A.M. revealed Resident #80 to be sitting in a wheelchair in the secured unit dining room. She was seated at a table by herself. Her breakfast meal was sitting in front of her. She had two slices of french toast (not cut up and no syrup), bacon, a bowl of oatmeal, juice, and milk in a carton with no straw. A couple bites were taken out of one of the slices of french toast as if the resident picked it up and bit off bites. The resident was now just sitting and not eating. At 8:10 A.M. (20 minutes later) the resident was still sitting and had not eaten or drank anything. She had not received any cueing to eat from the two staff that were in the dining room but were at different tables feeding other residents. At 8:11 A.M. State Tested Nursing Assistant (STNA) #107 approached Resident #80 and asked her if she was finished eating. The resident stated no. STNA #107 asked the resident if she wanted syrup on her french toast. STNA #107 then added the syrup and cup up the french toast into small pieces. STNA #107 sat down beside Resident #80. The resident then began to eat (21 minutes after initially having her tray and not eating). At 8:14 A.M. the resident was then given a straw for her milk carton. At 8:17 A.M. the resident remained eating with STNA #107 sitting beside her. She had taken a few bites of her french toast. About two minutes after sitting down, STNA #107 then got up and left. Resident #80 then stopped eating again and did not take another bite or drink. At 8:22 A.M. another STNA asked Resident #80 if she was doing ok. Resident #80 shook her head yes and the staff kept on going. The resident was still not eating. At 8:23 A.M. she had not eaten anything else since STNA #107 had gotten up from beside her. At 8:26 A.M. another aide from across the room asked the resident if she was doing ok. The resident said yes, but was not eating or drinking. No cueing to eat was provided. At 8:32 A.M. STNA #218 picked up her tray. STNA #218 stated the resident ate 50% of her meal (the resident ate about 1 and half slice of the french toast, half of her juice, no bacon, no oatmeal, no milk). Interview with STNA #107 on 01/08/24 at 1:30 P.M. revealed she had worked on dayshift on the secured unit for about three months. She stated she was aware that Resident #80 was not eating well. She stated the resident could feed herself but does need staff to set her tray up such as cutting up foods and taking off lids. She stated the resident usually ate her meals in the dining room. She confirmed the resident's french toast had not been cut up or syrup added when her tray was delivered and a straw had not been provided. She confirmed the resident was eating when she was sitting with her. She stated she did not realize the resident stopped eating after she got up and left. She stated she did not know why the resident's intake had decreased over time but stated that maybe she does not like to eat alone and staff should sit her at a table where staff are nearby and can prompt her to eat. There was no evidence of any lab work being done to check the resident's nutritional status. Interview with Dietary Director #186 on 01/09/24 at 7:44 A.M. revealed Resident #80 could feed herself but needed cueing. She confirmed the resident was significantly cognitively impaired. She confirmed no lab work had been done to evaluate the resident's nutritional status. She stated she felt the resident's decreased meal intakes were related to the progression of her disease/behaviors but stated staff should provide the set up assistance and cueing the resident needs to ensure she eats as much as she will. Review of the facility policy titled weight monitoring (dated 10/30/20 and revised 10/26/23) revealed the facility would utilize a systemic approach to optimize a resident's nutritional status. This process includes: identifying and assessing each resident's nutritional status and risk factors; evaluating/analyzing the assessment information; developing and consistently implementing pertinent approaches, and monitoring the effectiveness of interventions and revising them as necessary.

Based on medical record review, resident interview, and staff interview, the facility failed to ensure a resident received timely respiratory care. This affected one resident (#73) of three residents reviewed for respiratory care. The facility census was 97. Findings include: Review of the medical record for Resident #73 revealed an admission date of 06/03/23 and diagnoses including chronic obstructive pulmonary disease (COPD) and alcoholic cirrhosis of the liver. Review of a Minimum Data Set assessment completed 12/15/23 revealed a Brief Interview for Mental Status score of 12, indicating moderately impaired cognition. Review of a nurse practitioner progress note dated 12/26/23 at 1:45 P.M. revealed the resident had recent heart catheterization. He was having some chest pain today with drop in oxygen saturation to 88%. He tells me that his pain is localized right to his left sided chest. He does have a moist cough. He does have some shortness of breath. He does not feel it is heart related. He has a history of heart failure as well as hypertension. Does not appear in any distress. Breathing even and unlabored. Did have a low-grade fever this morning of 99.3. The plan: does not want to be sent out to hospital today. He does have some abnormal lung sounds, sounds moist. The nurse practitioner identified she was going to get a chest x-ray for the resident and will continue to monitor him closely. Review of nurse's progress notes revealed on 12/26/23 at 2:31 P.M. a new order was received for a chest x-ray due to cough. Review of an x-ray report revealed a 2 view chest x-ray was completed on 12/27/23. The x-ray conclusion was patchy modest bilateral airspace disease. Pneumonia should be considered in the appropriate clinical setting. Recommend follow up examination to confirm resolution of findings. The report date was 12/27/23 at 1:19 P.M. However, there was no evidence the results were reported to the nurse practitioner until 12/28/23 (x-ray result signed and dated 12/28/23). Review of a nurse practitioner progress note on 12/28/23 at 12:20 P.M. stated resident (#73) had an episode of fever with some hypoxia, shortness of breath yesterday. He had a chest x-ray obtained which does show patchy modest bilateral airspace disease. Pneumonia should be considered. Today, the resident reports feeling fatigued. He has a cough. He is short of breath and just overall not feeling well. Temperature 98.2. Oxygen saturation 95%. He is alert and oriented and in no acute distress. His lungs are diminished bilaterally in the bases. Clear in the uppers. The nurse practitioner's assessment was pneumonia with cough and hypoxia. The nurse practitioner's plan was to start him on Levaquin 750 mg daily for 7 days (antibiotic). A nurse's progress note on 12/28/23 at 6:37 P.M. stated the nurse practitioner had been in to see resident. New orders received for Levaquin every day x 7 days for a diagnosis of pneumonia. Oxygen at 2 liters to maintain oxygen saturation 90% or greater, duoneb every 6 hours as needed for shortness of breath, Robitussin every 6 hours as needed for cough. Review of the medication administration record revealed that, although the Levaquin antibiotic was ordered on 12/28/23, it was not started until the morning of 12/29/23. Interview with Resident #73 on 01/04/24 at 10:40 A.M. revealed he was in bed in his room and felt his treatment for pneumonia went slowly after being seen by the nurse practitioner on 12/26/23 (x-ray 12/27/23, antibiotics ordered 12/28/23 but not started until 12/29/23). He stated he was feeling better now and had just finished his antibiotics. Interview with Nurse Practitioner #301 on 01/04/24 at 10:55 A.M. confirmed there was a delay in treatment of Resident #73's pneumonia. She stated the nurse practitioner should have been notified of x-ray results on 12/27/23 (not 12/28/23) and antibiotics should have been started the same day they were ordered (not wait until the next day). She stated the order could even be changed to something the facility had available in the facility emergency supply so that it could be started timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy review the facility failed to schedule a pain management appointment for a resident per physician orders. This affected one resident (#65) of one resident reviewed for pain. Findings include: Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, chronic pain, right hip pain, low back pain, radiculopathy, lumbar and cervical region, paraplegia, Stage 4 pressure ulcers, and heart failure. Review of Resident #65's pain plan of care dated 10/16/23 revealed the resident had low back, pain, pressure ulcers, right hip pain, myalgia, neuralgia, and polyneuropathy. The resident's intervention included pain management/physician referral. Review of Resident #65's pain assessment dated [DATE] revealed the resident had frequent pain in back and hips that was a constant ache. The pain occasionally affected his sleep and physical activities. Review of the Nurse Practitioner (NP) note dated 12/27/23 revealed the resident was complaining of severe right hip pain that he told her he had seen a pain doctor in the past for the SI joint. He would like to go ahead and follow up with a pain doctor for possible injections. The NP Plan was to go ahead and schedule the resident a follow up appointment with the pain doctor for his low back pain and right hip pain. Review of Resident #65's written order dated 12/27/23 revealed to schedule an appointment with the pain doctor of injections of the SI joint. Interview on 01/02/24 at 9:48 A.M., with Resident #65 revealed he was having increased pain his hip and back. The facility was supposed to make an appointment for him to see the pain specialist, but he has still not heard anything. Interview on 01/03/24 at 11:47 A.M., with Resident #65 and the Director of Nursing (DON) revealed the resident reported he was having increased pain. His pain has been from three to seven on a scale from zero to ten. He can tolerate pain five to six. The DON confirmed the facility was not aware of the order written on 12/27/23 and the appointment with the pain specialist had not been made. Review of the facility policy titled Pain Management (dated 10/20/20 and revised 10/26/23) revealed the facility would ensure that pain management was provided to residents who required such services. Based on assessment or evaluation, the facility in collaboration with the attending physician would develop, implement, monitor, and revise as necessary intervention to prevent or manage each resident's pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and resident interview, the facility failed to ensure a resident who required dialysis services received ordered care. This affected one resident (#197) of one resident reviewed for dialysis. The facility census was 97. Findings include: Review of the medical record for Resident #197 revealed an admission date of 12/19/23 and diagnoses including end stage renal disease, diabetes, and morbid obesity. A Minimum Data Set assessment completed 12/23/23 documented a Brief Interview for Mental Status score of 15, indicating intact cognition. It also documented the resident was on dialysis. Interview with Resident #197 on 01/03/24 at 3:25 P.M. revealed she goes out for dialysis three times weekly on Monday, Wednesday, and Friday. She stated, and it was observed, that she has a port in her chest used for the dialysis treatments. She stated she leaves around 6-6:30 A.M. and returns around 11-11:30 A.M. She confirmed she had went to dialysis on 01/03/24. Review of physician's orders revealed an order for dialysis on Monday, Wednesday, and Friday with chair time at 6:30 A.M. at a dialysis center. The name, address, and phone number of the dialysis center was listed. The surveyor asked the facility for the contract for that dialysis center and the Administrator confirmed on 01/04/24 at 2:30 P.M. that the dialysis center, address, and phone number listed in the physician's order was not the correct dialysis center that Resident #197 went to. Review of medication administration records revealed that on 12/22/23 (Friday), 12/27/23 (Wednesday), 12/29/23 (Friday), and 01/03/24 (Wednesday) Resident #197's morning medications were documented as administered at times when the resident would have been at dialysis. The morning medications were set up to be given between 7:00 A.M. and 10:00 A.M. Medications were documented as administered at the following times: 12/22/23: 8:59 A.M., 12/27/23 8:56 A.M., 12/29/23 7:53 A.M. and 01/03/24 7:49 A.M., even though the resident would have been at dialysis at those times. There was no documentation in the record to indicate that the resident did not go to dialysis on those days. Interview with the Director of Nursing (DON) on 01/04/24 at 8:15 A.M. confirmed the medications were documented as given at times when the resident would have been out of the facility for dialysis. She confirmed Resident #197 goes Monday, Wednesday, and Friday and leaves at 6:15 A.M. and gets back at lunch time. The DON stated she did not know if the resident went for dialysis on Christmas day or New Years day. Interview with Registered Nurse (RN) #143 on 01/04/24 at 11:15 A.M. revealed that Licensed Practical Nurse (LPN) #217 told her that she documented the medications as given on 12/27/23 at 8:56 A.M. but did not give them until the resident got back from dialysis (lunch time). She confirmed the medications should not be documented until they are actually given to the resident. Review of communication sheets from dialysis revealed the only communication sheet available was from 12/20/23. Resident #197 would have been scheduled to have dialysis on 12/22/23, 12/25/23, 12/27/23, 12/29/23, 01/01/24, and 01/03/24. Interview with LPN #217 on 01/04/24 at 9:03 A.M. confirmed the only communication sheet from dialysis was for 12/20/23. She stated the dialysis center is to send back a communication sheet to notify the facility regarding the dialysis session. She stated the facility was having trouble getting them from the dialysis center. On 01/04/24 at 11:10 A.M. LPN #217 stated she was unable to get any further communication sheets from dialysis as they were closed that day. Review of a nutrition assessment dated [DATE] revealed it was recommended to add a double entree to the diet order per Dietary Director #186. Review of physician's orders revealed an order for regular diet with double entree. Observation of the lunch meal on 01/04/24 at 12:10 P.M. revealed the lunch tray delivered to Resident #197's room. The resident received one pork chop, noodles, green beans, a roll, peaches, and cold tea. No double entree was noted. The tray card did not indicate to provide double entree. The resident stated, at that time, that she had never received a double entree. Interview with LPN #126 on 01/04/24 at 12:10 P.M. confirmed the resident had not received a double entree. Interview with Dietary Director #186 on 01/04/24 at 2:07 P.M. revealed she had recommended the double entree for Resident #197 for extra protein due to her dialysis. There was no evidence in the medical record of any laboratory testing for protein levels. There was no evidence that the Dietary Director had been in communication with the dialysis center to obtain the results of any laboratory testing that had been done at dialysis. Interview with Dietary Director #186 on 01/09/24 at 7:43 A.M. confirmed no laboratory testing had been completed at the facility to check protein levels. She stated she had called the dietician at the dialysis center last week but did not get to talk to him/her. She stated she did talk to the dietician at the dialysis center yesterday but had not documented it. She stated they do blood work monthly at dialysis but they had not provided the facility with any of the results. She stated that yesterday, the dietician at dialysis asked her to start the resident on protein supplements twice daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, resident record review, and facility policy review, the facility failed to ensure medication regimen review irregularities were reviewed by the physician and Director of Nursing (DON). This affected one resident (#47) of five residents reviewed for unnecessary medications. The facility census was 97. Findings include: Review of Resident #47's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure, type two diabetes mellitus, acute kidney failure, acute congestive heart failure, constipation, major depressive disorder, and generalized anxiety disorder. Review of Resident #47's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/04/23, revealed she was cognitively intact. Review of Resident #47's medication regimen review (MRR), dated for recommendations created between 06/01/23 and 06/23/23, revealed the pharmacy had noted Resident #47 was receiving an antipsychotic, Abilify, to treat anxiety, an inappropriate indication. A list of conditions and diagnoses for the use of the antipsychotic medication was provided by the pharmacy. The pharmacy requested the medical director and Director of Nursing (DON) to please check the appropriate diagnosis or consider discontinuation of the medication. Review of the MRR revealed no documentation by the medical director or the DON to confirm their review and response. Interview on 01/08/24 at 1:20 P.M. with the DON verified the Medication Regimen Review, dated 06/23/23, did not have any documentation to support the physician or the DON had reviewed and addressed the pharmacy irregularity. Review of the facility policy titled, Addressing Medication Regiment Review Irregularities, (reviewed/revised 01/01/22), revealed it was the policy of the facility to provide a Medication Regimen Review (MRR) for each resident in order to identify irregularities and response to those irregularities in a timely manner to prevent the occurrence of an adverse drug event.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to ensure resident medications were monitored per orders. This affected two residents (#65, #70) of five residents reviewed for medication review. Findings include: 1. Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including hyperlipidemia and heart failure. Review of Resident #65's medication orders dated 10/14/23 and 01/10/24 revealed the resident was receiving Lipitor 40 mg at bedtime for hyperlipidemia. Review of Resident #65's pharmacy review dated 11/27/23 revealed the pharmacist recommended laboratory monitoring for the resident's Lipitor therapy. The physician agreed on 11/29/23 to check lipid panel and liver function test (LFT) every six months. Review of Resident #65's laboratory orders revealed on 12/03/23 staff entered an order for lipid panel and LFT's every six months, however the start date wasn't until 12/04/24 (a year later). Review of Resident #65's laboratory results dated 10/2023 to 01/2024 revealed no evidence a lipid panel or LFT's were obtained. Review of Resident #65's plan of care for impaired cardiovascular status and hyperlipidemia dated 10/13/23 revealed labs/diagnostic testing as ordered. Interview on 01/10/24 at 11:10 A.M. and 11:18 A.M., with the Director of Nursing (DON) confirmed the order for the lipid panel and LFT was entered incorrectly, and the resident should have labs done when the order was obtained and then every six months after that. The DON confirmed she could not find any evidence the lipid panel or LFT was obtained. The DON reported she had spoken to the provider and the labs would be obtained tomorrow 01/11/24. 2. Medical record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses including hypertension, heart disease, and hyperlipidemia. Review of Resident #70's medication orders revealed the resident was on Lipitor 40 milligrams (mg) from 04/11/23 to 11/27/23. Review of Resident #70's laboratory orders dated 05/03/23 revealed to obtain a lipid panel and LFT every April and October. Review of Resident #70's laboratory results revealed no evidence the lipid panel or LFT's were obtained per orders. Review of Resident #70's impaired cardiovascular plan of care related to hyperlipidemia and hypertension dated 10/13/23 revealed to obtain labs and diagnostic testing as ordered. Interview on 01/08/24 at 4:00 P.M., with Registered Nurse (RN) #143 confirmed the resident did not have a lipid panel and LFT in October per order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of medication error report, review of drug administration information sheet, staff education sheet, interview, and policy reviews the facility failed to ensure residents were free of significant medication errors. This affected one resident (#191) of one resident reviewed for psychotropic medication review. Findings include: Record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including encephalopathy, chronic obstructive pulmonary disease, schizophrenia, anxiety, seizures, hypertension, needs for assistance with personal care, difficult walking, gastro-esophageal reflux disease, hyperlipidemia, irritable bowel syndrome, vitamin D deficiency, constipation, and moderate intellectual disabilities. Review of Resident #191's pertinent charting-change in condition progress note dated 12/29/23, 12/31/23, and 01/02/24 revealed on 12/28/23 the resident received a duplicate medication administered on night shift. No adverse reaction was noted at this time. Close monitoring for any adverse reaction for 72 hours. There was no documented evidence of which medication was given in error to ensure proper monitoring or evidence of monitoring on 12/30/23. Review of the facility medication error investigation, which was not part of the medical record, dated 12/28/23 at 9:00 P.M., revealed no evidence of which medications were given in error. Th incident description indicated the resident inadvertently received a duplicate dose of nighttime medication due to a miscommunication of the nurse with the medication tech. The medication tech had already administered the medication for G wing residents even before the scheduled shift and failed to notify the nurse and did not sign off on the medication administration record leading the nurse to believe that the medications had not been given yet. The immediate action was to check the Resident #191's vitals and neuro checks. The staff were re-educated regarding the importance of giving the medication at scheduled times, and accurately charting the time medication was given to avoid the risk of a similar error in the future. There was no evidence of which medication was given in error, resident assessment portion was blank, and there was no evidence of a statement from the medication tech. Review of the medication administration time (undated) that was provided to the survey team on entrance (01/02/24) revealed morning medications were administered from 7:00 A.M. to 10:00 A.M., afternoon medication was administered from 11:00 A.M. to 2:00 P.M., evening medications were administered form 4:00 P.M. to 7:00 P.M., and night medication were administered 8:00 P.M. to 11:00 P.M. Review of Resident #191's medication administration record dated 01/04/23 for 12/28/23 revealed a handwritten note on top of the record indicating the medication tech administered the medications around 7:00 P.M. The medications in question that were given in error were highlighted and included: Acetaminophen 325 milligrams (mg) two tablets for pain, Benzotropine 1 mg for decreased muscle control, Remeron 15 mg at bedtime for appetite, Miralax for constipation, Depakote delayed release 125 mg for seizures, Buspirone 15 mg for anxiety, Perphenazine 16 mg for schizophrenia, Zyprexa 10 mg for schizophrenia, and Lipitor 20 mg for hyperlipidemia. Staff had signed off the medication was administered at 7:54 P.M. and they were scheduled to be administered at 8:00 P.M. Review of the Depakote drug information sheet provided by the facility dated 08/2023 revealed Depakote should be administered at the same time each day. If someone has overdosed and has serious symptoms such as passing out or trouble breathing call 911 or otherwise call poison control center right away. Laboratory testing should be done while you are taking this medication. Review of the facility education sheet (undated) revealed the six rights of medication administration was the right patient, drug, dosage, route, time, and documentation. Review of the facility medication error policy (dated 01/01/22) revealed it was the facility's responsibility to provide protection for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication error. The facility shall ensure medication will be administered according to physician order. If a medication error occurs, the following procedure will be initiated: a nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible; monitor and document the residents' condition, including response to medical treatment or nursing interventions; document action taken in the medical record; once the resident was stable the nurse reports the incident to the appropriate supervisor and completes the incident or occurrence report. Review of the facility policy titled Medication Administration (dated 01/01/22) revealed medication was administered by licensed staff or authorized staff as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection; sign MAR after administered. Review of the facility policy titled Med Tech/Certified Medication Aide Playbook (dated 10/2022) revealed immediately after following administration of a medication, tech certified medication aide must document in the medical record the name of the medication and dose administered, date, time, route, and their name. The medication tech would report to the nurse at the beginning and end of the shift. Interview on 01/03/24 at 3:55 P.M., with Registered Nurse (RN) #143 revealed on 12/28/23 the medication tech gave the medication to Resident #191 around 7:00 P.M., and they were not due until 8:00 P.M. and the medication tech did not sign off the medication administration record when she administered the medications, then the night nurse administered the medication at 8:00 P.M., when they were due resulting in duplicate medications. Interview on 01/08/24 at 1:25 P.M., and 01/09/24 at 2:14 P.M., with the DON revealed she was off the day of the incident and did not obtain a statement from the medication tech. It was her understanding that the medication tech administered the medication too early (7:00 P.M.) and was not able to sign the medication off on the medication administration record because they were not due until 8:00 P.M. The resident receives Depakote, perphenazine, and buspirone three times a day, zyprexa, benzotropine, and miralax twice daily, and the other medications were just once daily. The resident was ordered labs on 12/18/23; however, they still have not be obtained yet including a Depakote level to ensure therapeutic level. The DON called the nurse and medication tech on 01/09/24 to obtain additional information and the medication tech indicated she started the medication pass at 6:30 P.M. The medication tech confirmed she gave the medication too early and that's why they were not signed off on the medication administration record. When the medication tech went to sign off the administration record, she noticed the nurse had signed the medication off already and when she inquired the nurse said she administered medication to the resident as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview, and policy review the facility failed to ensure laboratory tests were obtained per orders. This affected one resident (#191) of one resident reviewed for change of condition. Findings include: Record review revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including encephalopathy, chronic obstructive pulmonary disease, schizophrenia, anxiety, seizures, hypertension, needs for assistance with personal care, difficult walking, gastro-esophageal reflux disease, hyperlipidemia, irritable bowel syndrome, vitamin D deficiency, constipation, and moderate intellectual disabilities. Review of Resident #191's admission history and physical dated 12/17/23 revealed to have follow-up blood work tomorrow and have psychology see her. The resident had been running up and down the hallways. She had currently fallen twice. She was on significant psychotropic medication and just need to clarify, if Depakote to be discontinued. She has a history of ulcerative colitis. Review of Resident #191's handwritten physician order dated 12/17/23 revealed house psych to see for schizophrenia and local gastric intestinal (GI) referral for ulcerative colitis history. Laboratory testing (complete blood count (CBC), complete metabolic profile (CMP), iron profile, vitamin B12, thyroid, and vitamin D) to be done on 12/18/23 for hypertension (HTN) anemia, fatigue, and vitamin deficiency. Also on 12/18/23 a Depakote level for epilepsy was to be drawn. Review of Residents #191's paper and electronic medical record revealed no evidence the laboratory tests were completed on 12/18/23 per orders. Review of the Administration note dated 12/18/23 revealed the CBC, CMP, iron profile, B12, TSH, Vitamin D level for HTN, anemia, fatigue, vitamin D deficiency was not collected due to the resident refused. The physician was advised and would attempt to draw tomorrow morning. There was no mention of the Depakote level, house psych, or GI consult. Further review of the medical record review revealed no evidence a second attempt was made to collect the laboratory test or the physician was notified. There was no evidence the GI consult was made. The resident was seen by psych services on 12/21/23 and 12/28/23. Interview on 01/03/24 at 10:59 A.M. with the DON confirmed Resident #191 had refused laboratory testing on 12/18/23, however there was no second attempt to try again or that the doctor was notified the labs were not obtained, however he was notified on 12/18/23 of the refusal. Review of Resident #191's impaired cardiovascular care plan related to hypertension and high cholesterol imitated 12/18/23 revealed labs as ordered. Review of Resident #191's at risk for fluid volume deficit related to cognitive impairment dated 12/18/23 revealed to do labs as ordered. Review of Resident #191's impaired gastrointestinal status related to history of constipation inflammatory bowel disease, gastroesophageal reflux disease dated 12/17/23 revealed to complete labs as ordered. Review of the facility policy titled Laboratory and Diagnostic Guidelines (dated 10/30/20 and revised 10/26/23) revealed the facility set guidelines to track the timely completion, reporting, and monitoring of laboratory and diagnostic tests, results, and notifications which are used to monitor resident status and/or therapeutic medication levels. The physician should be notified of all refused lab test orders and reason why. The physician should be notified if the labs test was unable to be completed, reason why, and request for a new orders. All notification, attempts at notification, and response should be noted in the resident medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #47's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic respiratory failure, type two diabetes mellitus, acute kidney failure, acute congestive heart failure, constipation, major depressive disorder, and generalized anxiety disorder. Review of Resident #47's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/04/23, revealed she was cognitively intact. Review of Resident #47's physician order, dated 07/08/23, identified she was to receive Cefdinir oral capsule 300 milligram (mg) one capsule by mouth every 12 hours for a urinary tract infection (UTI) until 07/10/23. Review of Resident #47's medication administration record (MAR), dated 07/23, revealed she did receive the Cefdinir twice a day for three days as ordered on 07/08/23, 07/09/23, and 07/10/23. Review of Resident #47's facility antibiotic stewardship documentation, dated 07/04/23, revealed she did not meet the requirement for the use of an antibiotic for a UTI. Based on the documentation, Resident #47 needed to meet both criteria one and two. Resident #47 only had documentation to support criteria number two was met. Interview on 01/08/24 at 1:18 P.M. with the DON verified that based on the facility antibiotic stewardship documentation, Resident #47 did not meet the requirement for the Cefdinir for a UTI. Review of the facility policy titled, Antibiotic Stewardship Program, (reviewed/revised 10/24/22), revealed it was the policy of the facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Further review revealed the facility used the McGeer criteria to define infections and the Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics. Based on record review, review of the facility's infection control tracking logs, staff interview, and policy review, the facility failed to ensure a resident was not treated with an antibiotic, unless they met criteria for the treatment of an infection. They also failed to ensure a resident treated for a urinary tract infection caused by a multi-drug resistant organism received the appropriate antibiotic the identified organisms were sensitive to. This affected one resident (#21) of two residents reviewed for urinary tract infections (UTI) and one resident (#47) of five residents reviewed for unnecessary medications. Findings include: 1. A review of Resident #21's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included cerebral palsy, benign prostatic hyperplasia, and obstructive and reflux uropathy. A review of Resident #21's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was able to make himself understood and was able to understand others, but his cognition was severely impaired. He was indicated to have the use of an indwelling urinary catheter. A review of Resident #21's care plans revealed he had the need for an indwelling urinary catheter related to obstructive uropathy. His goal was to have reduced catheter-related complications through the next review. The interventions included observing for signs and symptoms of UTI and report to the physician, provide prophylactic interventions as ordered, and to administer medications as ordered. His care plans were updated on 01/02/24 to reflect he had an infection as evidenced by a UTI. That care plan included the need to administer medications and treatments to treat infection and/or symptoms as ordered. They were to obtain labs/ cultures/ diagnostic testing as ordered and report the results to the physician. A review of Resident #21's progress notes revealed a nurse's note dated 12/31/23 at 9:45 P.M. that revealed the resident had returned from emergency room at 9:17 P.M. He was given a dose of Rocephin intravenously (IV) for the treatment of a UTI. He was discharged back to the facility with an order to complete at 10-day course of Ciprofloxacin (Cipro) 500 milligrams (mg) twice a day for 10 days. The physician was made aware of above and was in agreement with the orders. A review of Resident #21's physician's orders confirmed the resident was ordered to receive Ciprofloxacin HCl 500 MG by mouth two times a day for 10 days for the treatment of a UTI. The order originated on 01/01/24. A review of Resident #21's urinalysis results for a urinalysis that had been collected at the hospital on [DATE] at 8:45 A.M. revealed the preliminary report showed the resident had the growth of two organisms (Pseudomonas Aeruginosa and Proteus Mirabilis) that were at a quantity greater than 100,000 colonies/ milliliter. The results indicated the sensitivity testing was to follow. There was a second preliminary urine culture report for a urinalysis that was done on 12/31/23 at 12:15 P.M. that showed Pseudomonas Aeruginosa and Proteus Mirabilis were again identified as the organisms growing in the resident's urine. The second urine culture report indicated for sensitivity information on that report refer to previous urine culture report specimen (No. B37921) received 12/31/23. Antibiotic susceptibility testing would not be routinely repeated on identical organisms isolated within 5 days of each other. Further review of Resident #21's electronic medical record (EMR) revealed it was absent for the sensitivity testing report that was to follow for the urinalysis that had been collected on 12/31/23 at 8:15 A.M. Findings were verified by Medical Records Employee #181. She was asked to contact the hospital to see if they had the sensitivity testing report that was absent report on 01/03/24 at 4:20 P.M. On 01/03/24 at 4:40 P.M., a copy of the sensitivity testing report from the urinalysis that was collected on 12/31/23 at 8:45 A.M. was provided for review. The final urine culture results showed Resident #21 had Pseudomonas Aeruginosa and Proteus Mirabilis- Extended Spectrum Beta Lactamases (ESBLs) an enzyme found in some strains of bacteria that can't be killed by many of the antibiotics that were typically used to treat infections that have been associated with poor outcomes). The sensitivity report revealed both organisms identified were susceptible to Meropenum and Gentamycin. They were not susceptible to Ciprofloxacin, which was the antibiotic the resident had been placed on and was to receive twice a day for 10 days to treat his UTI. On 01/04/24 at 10:20 A.M., an interview with the Director of Nursing (DON) confirmed Resident #21's urine cultures sensitivity testing report from the urinalysis that had been collected while the resident was in the hospital on [DATE] at 8:45 A.M. was not previously available in the resident's EMR until it was requested for review on 01/03/24 at 4:20 P.M. She further confirmed the resident's culture and sensitivity testing report that was obtained from the hospital showed the resident's organisms he had that was causing his UTI were not susceptible to the antibiotic he was receiving. She stated the facility's infection preventionist should be reviewing residents upon their return from the hospital to see if any antibiotics had been ordered and to follow up to ensure they had all testing results that had been obtained at the hospital to ensure the appropriate antibiotics were ordered. She indicated the physician had been made aware of the resident being on Ciprofloxacin upon his return to the facility and wanted the antibiotic continued. She acknowledged the infection preventionist should have followed up to get the sensitivity testing results to ensure the antibiotic that was ordered to treat his infection was effective. She acknowledged the resident continued to receive Cipro until it was brought to their attention that the Cipro was not effective in treating his type of UTI based on the organisms grown. The facility's policy on Antibiotic Stewardship Program (dated 10/24/22) revealed it was the policy of the facility to implement an antibiotic stewardship program as part of the facility's overall infection prevention and control program. The purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The infection preventionist, with oversight from the DON, served as the leader of the antibiotic stewardship program and received support from the Administrator and other governing officials of the facility. The infection preventionist coordinated all antibiotic stewardship activities, maintained documentation, and served as a resource for all clinical staff. The facility was to use the McGeer's criteria to define infections. Antibiotic orders obtained upon admission, whether a new admission or a readmission, to the facility should be reviewed for appropriateness. They were to monitor the response to antibiotics and laboratory results when available to determine if the antibiotic was still indicated or adjustments should be made.

Based on medical record review, policy review, and staff interview, the facility failed to ensure residents were offered a pneumococcal immunization as appropriate. This affected three of five residents reviewed for immunizations (Residents #80, #21, and #82). The facility census was 97. Findings include: 1. Review of the medical record for Resident #80 revealed an admission date of 09/27/23. There was no evidence the resident had received or been offered a pneumococcal immunization. Interview with the Director of Nursing (DON) on 01/03/24 at 2:23 P.M. confirmed the resident had not had and resident/responsible party had not been offered a pneumococcal immunization. She stated it was offered on 01/03/24 and the daughter wanted her to have one but it had not been provided yet. 2. Review of the medical record for Resident #21 revealed an admission date of 08/10/22. Record review revealed he had received a Prevnar 13 vaccine on 01/26/23. (He was less than 65 when getting this vaccine). There was no evidence he had received a follow up dose of PPSV23 as recommended. Interview with the Director of Nursing on 01/03/24 at 11:55 A.M. revealed the facility had gotten a consent signed for the resident to receive the follow up dose of PPSV23 on 11/29/23 but it had not yet been given. 3. Review of the medical record for Resident #82 revealed an admission date of 10/21/23. The resident had received Prevnar 13 on 10/29/19 and was older than 65. There was no evidence a follow up dose of PPSV23 had been offered or provided. This was confirmed by the Director of Nursing on 01/03/24 at 2:23 P.M. Review of the facility policy on Pneumococcal vaccine series (dated 03/01/22 and revised 10/30/23) revealed it was the policy to offer residents immunization against pneumococcal disease in accordance with current Center for Disease Control (CDC) guidelines and recommendations.

Based on medical record review, policy review, and staff interview, the facility failed to offer COVID-19 vaccines to residents. This affected two residents (#46 and #26) of five residents reviewed for immunizations. The facility census was 97. Findings include: 1. Review of the medical record for Resident #46 revealed an admission date of 02/07/19. Review of the immunization record revealed it simply stated the resident refused a COVID-19 vaccine. However, there was no documented evidence of education provided regarding the vaccine or a signed declination of the vaccine. Interview with the Director of Nursing on 01/03/24 at 2:23 P.M. confirmed no evidence for Resident #46 of education or signed declination of COVID-19 vaccine. 2. Review of the medical record for Resident #26 revealed an admission date of 07/17/23. Review of the immunization record revealed the resident had received COVID-19 vaccines on 01/18/21 and 06/10/22. There was no evidence the resident was provided with a booster or education regarding a booster vaccine. Interview with the Director of Nursing on 01/03/24 at 2:23 P.M. revealed boosters are to be provided annually and there was no evidence it was offered or declined for Resident #26. Review of the facility policy titled COVID-19 Vaccination (dated 05/01/22 and revised 10/20/23) revealed it is the policy of the facility to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 by educating and offering residents and staff the COVID-19 vaccine.

Based on observation, interview, and policy review the facility failed to ensure the noise levels were not too loud for Resident #82 and failed to ensure the walls were in good repair for Resident #46, #60, and #192. This affected four residents (Resident #82, #46, #60, #192) of five residents reviewed for environment. The facility census was 97. Findings include: Observation on 01/02/24 at 10:21 A.M. revealed the wall in Resident #46's room had a eight-inch area of wall which had been patched but not painted. Interview on 01/02/24 at 3:09 P.M. with Resident #82 revealed the facility is too loud because another resident keeps a television turned up and Resident #82 has sensitive hearing. Resident #82 stated she could not keep her door closed, and the other resident did not have to turn the television down and declined to wear hearing aids. Observation on 01/03/24 at 8:46 A.M. revealed a ceiling at the foot of Resident #192's bed by the window had a brown-stained tile and there were four quarter-sized holes in the wall in the middle of the room. During a tour with Maintenance Assistant (MA) #245 on 01/09/24 from 3:58 P.M. to 4:08 P.M., verified the hallway outside of Resident #82's room was observed to be loud while resident was trying to rest, two white patches above the first bed in Resident #46's room and three white patches on the opposite wall, a brown-stained ceiling tile at the foot of a bed, eight quarter-sized holes in the middle of the wall, and six inches of a baseboard was missing leaving a sharp edge, as well as two white patches on the wall in Resident #60's room. Review of a policy titled Safe and Homelike Environment (dated 01/01/22) revealed the facility should provide a comfortable and homelike environment including comfortable sound levels that do not interfere with residents' hearing. The policy stated maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility medication error investigation for Resident #191, which was not part of the medical record, dated 12/28/23 at 9:00 P.M., revealed the medication tech had administered the medication for G wing residents even before the scheduled shift and failed to notify the nurse and did not sign off on the medication administration record leading the nurse to believe that the medication had not been given yet. There was no evidence of the other resident affected by this incident or evidence they were monitored for side effects. Interview on 01/10/24 at 9:07 A.M., with the DON confirmed that giving medication prior to the scheduled administration time would be a medication error. The DON reported she didn't realize the medication tech had administered all night medications early to residents on G-wing until yesterday (01/09/24) when the surveyor had brought it to her attention. The facility had not started an investigation at this time to determine which residents were affected. Interview on 01/10/24 at 9:51 A.M., with the DON revealed there were nine other residents residing on G-wing the evening of 12/28/23 that received medication out of the scheduled time frame by the medication tech. The residents were Residents #60, #64, #63, #17, #12, #46, #70, #54, and #192. The DON had interviewed the medication tech yesterday (01/09/24) and she reported she had started her medication pass around 6:30 P.M. and had administered the nighttime medication, which was not due until 8:00 P.M., to residents on G-wing. Review of the facility medication error policy (dated 01/01/22) revealed it was the facility's responsibility to provide protection for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication error. The facility shall ensure medication will be administered according to physician order. If a medication error occurs, the following procedure will be initiated: a nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible; monitor and document the residents' condition, including response to medical treatment or nursing interventions; document action taken in the medical record; once the resident was stable the nurse reports the incident to the appropriate supervisor and completes the incident or occurrence report. Review of the facility education sheet (undated) revealed the six rights of medication administration was the right patient, drug, dosage, route, time, and documentation. Based on record review, review of medication error reports, review of staff education reports, resident interview, and staff interview, the facility failed to ensure residents only received medications ordered and intended for them, medications were administered in accordance with professional standards, and medications were administered within appropriate time frames set forth by the physician's orders. This affected 11 residents (#12, #17, #38, #46, #54, #60, #63, #64, #70, #191, and #192) who were identified from a review of one medication error report. Findings include: 1. A review of Resident #38's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included unspecified dementia, Parkinson's disease, schizophrenia, bipolar disorder, and hyperlipidemia. A review of Resident #38's physician's orders revealed the resident had an order to receive Atorvastatin 40 milligrams (mg) by mouth (po) at bedtime (hs) for hyperlipidemia. His orders included some psychotropic medications such as anti-anxiety medication and antipsychotic medication, but he did not have any orders to receive an anti-depressant. A review of an initial pertinent charting for a change in condition dated 12/28/23 at 9:15 P.M. revealed Resident #38 was involved in a medication error. No other information was included as to what medications were received in error. The change in condition form revealed the resident's vital signs were checked and the physician was notified. A review of a medication error report dated 12/28/23 at 9:30 P.M. that was completed by Registered Nurse (RN) #226 revealed Resident #38 was accidentally given the wrong medication. The nurse indicated the medication had been pulled, crushed, and mixed with pudding before it was given. The resident took a small bite, but had not finished consuming all of it before it was realized it was not the correct resident. The physician was notified, vital signs were obtained, and the resident was monitored for any immediate adverse reactions. He was to be monitored for the next 72 hours. The intervention implemented was to review medication administration protocols to prevent similar situations in the future. Again, the medication error report failed to identify exactly what medications the resident was given in error. A written statement by the facility's Director of Nursing (DON) that was part of their investigation into the medication error for Resident #38 revealed she had received a call from RN #226 on 12/28/23 at 9:51 P.M. The nurse had informed the DON of a medication error that had occurred for another resident (Resident #191). In giving her account to the DON pertaining to Resident #191's medication error, RN #226 told the DON she was so flustered after committing the medication error for Resident #191, that she gave another resident the wrong medications. The other resident was confirmed as being Resident #38. On 01/09/24 at 2:51 P.M., an interview with the DON revealed the investigation into Resident #38's medication error was not complete as the medication error (incident) report did not identify what medications were given in error. She had not spoken with the nurse involved to determine what medications were erroneously given to Resident #38 or who the medications he received were intended for. She was asked to obtain that information and to provide for review. On 01/09/24 at 4:00 P.M., the DON provided a copy of the December 2023 medication administration record (MAR) for Resident #84. An interview with the DON shortly after confirmed Resident #38 received the medications intended for Resident #84 that was to be given to that resident at bedtime on 12/28/23. The medications that were due at bedtime for Resident #84 (that was given to Resident #38) included Atorvastatin (medication ordered for the treatment of hyperlipidemia) 40 mg po every hs, Duloxetine Hydrochloride (an anti-depressant) 60 mg po hs, and Trazadone HCL (an anti-depressant) 25 mg po q hs. The Duloxetine HCL (Hydrochloride) and the Trazadone HCL were not ordered for Resident #38. On 01/10/24 at 9:50 A.M., further interview with the DON revealed she had talked with the nurse (RN #226) about the medication error for Resident #38. RN #226 reported she was pulling Resident #84's medications out of the medication administration cart for administration, but had her medication cart outside of Resident #38's room. When the medication tech (Medication Tech #119) asked whose medications they were, the nurse erroneously told her they were Resident #38's medications instead of Resident #84. The DON was asked why Medication Tech #119 would be passing medications that she had not prepared herself and had pulled out of the medication cart by RN #226, she replied she did not know. The DON acknowledged the nurse should not have pulled Resident #84's medications from the cart without being the one who administered the medications. The DON stated she provided education to the nursing staff regarding medication administration and the utilization of the medication techs/ aides as a result of the medication errors that occurred on 12/28/23. A review of the education provided to the facility's nurses and medication aides revealed the education was provided on 12/29/23. It included education on the proper utilization of the medication techs, medication administration, and signing off medications as you administered them. They reviewed the six rights of medication administration for nurses that included the right patient, right drug, right dosage, right route, right time, and right documentation. On 01/10/24 at 11:30 A.M., an interview with Resident #38 confirmed he was involved in a medication error occurring on 12/28/23 that included him receiving another resident's medications. He stated he only took about half of the medication given, as it was crushed and placed in pudding, before the nurse intervened. He denied he had any ill effects of receiving the wrong medications. On 01/10/24 at 11:45 A.M., an interview with Medication Aide #224 revealed she received her training/ medication tech classes in the facility on the 3rd floor. Her clinicals were completed in a sister facility in another town. She confirmed her training included only administering medications that were prepared by them. She denied she would ever pass medications to a resident that had been prepared by another staff member. A review of the facility's policy on Medication Errors revised 01/01/22 revealed it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by ensuring residents received necessary care and services safely in an environment free of significant medication errors. Medication errors were defined as the observed or identified preparation or administration of medications or biologicals which was not in accordance with the prescriber's order, manufacturer's specifications regarding the preparation and administration of the medications, or accepted professional standards and principles which apply to professionals providing services. The facility would ensure medications were administered according to physician's orders and in accordance with accepted standards and principles, which apply to professionals providing services. To prevent medication errors and ensure safe medication administration, nurses should verify the following information: right medication, dose, route, and time of administration, and the right resident and right documentation.

Based on facility documentation review, interview, and facility policy review, the facility failed to provide evidence all food was temperature checked prior to serving to confirm food had reached a safe cooking temperature. This had the potential to affect all 91 residents who received food from the facility kitchen. Six residents (#1, #23, #28, #29, #39, and #198) received nothing by mouth and did not receive food from the facility kitchen. The facility census was 97. Findings include: Review of the Service Line Checklists, dated 12/01/23 to 12/31/23, revealed there were no documented food temperatures on 12/15/23 for breakfast and lunch (prior to service to the residents) and no documented food temperatures on 12/19/23 for lunch. Interview on 01/03/24 at 9:50 A.M. with Dietary Manager #191 verified there was no evidence to support food temperatures were assessed for breakfast and lunch on 12/15/23 and for lunch on 12/19/23. He verified that without checking the temperatures of food, there would be no way to confirm it had reached or was maintained at a safe temperature for consumption. Review of the facility policy titled, Food Preparation and Service, (reviewed/revised 01/01/22), revealed food service employees shall prepare and serve food in a manner that complies with safe food handling practices. Further review revealed temperatures of foods held in a steam table will be monitored by food service staff.

Based on review of the facility's week at a glance menu, menus posted in the dining areas, review of the facility's daily newsletter, resident interview, and staff interview, the facility failed to ensure residents were informed of all alternate meals that were made available to them to allow them to make informed choices about the food they wanted to eat with each meal. This had the potential to affect all but six residents (Resident #1, #23, #28, #29, #39, and #198) who the facility identified as receiving nothing by mouth (NPO) and did not receive any food from the kitchen. Findings include: On 01/03/24 at 7:59 A.M., an interview with Resident #43 revealed he had food complaints when interviewed during the annual survey. He felt the food could be better and did not like what was always offered by the facility. He questioned whether the facility was required to offer an alternate meal, in addition to the main meal that was served for each of the three meals they received. He stated he often asked for an alternate to what was being served but there was only so many hot dogs you could eat before being tired of them. He was not aware of there being an alternate menu they could select a meal from other than the limited food items that were provided on their always offered menu. A review of the facility's menu for a week at a glance for week one of the cycle menu revealed alternates were included for each of the three meals. The alternate meal items were listed at the bottom of the main menu to include an alternate protein/ vegetable and starch. The week at a glance menu was not made available to the residents and was not the menu posted in the dining rooms or in the halls. A review of the menus posted in dining areas that were accessible to the residents who ate in the dining room revealed they only included the main menu food items that were available for breakfast, lunch, and dinner for a three day period. It did not include any of the food items that were known to be available on the alternate menu that was only kept in the kitchen. A review of the facility's daily newsletter that was passed out to the residents in the mornings revealed it included the same food items for each of the three meals that were were available on the main menu and the same food items that were posted in the dining rooms. The newsletter included the facility's always offered menu items that included a hot dog, grilled cheese, deli meat sandwich (bologna and cheese), peanut butter and jelly sandwich, side salad, and mashed potatoes. It did not include the food items that were known to be available as part of the alternate menu that was included on the week at a glance menus kept in the kitchen. On 01/03/24 at 4:30 P.M., State Tested Nursing Assistant (STNA) #112 was observed at the nurses station on the third floor passing out beverages to the residents prior to the evening meal. She was asked how residents were made aware of the meal options available to them for each of the three meals. She stated she thought the meals for the day were communicated to the residents in the facility's daily newsletter and were also posted in the halls and in the dining rooms. She reviewed the daily newsletter and confirmed it only included the main meals that were available that day and did not include the alternative meals that were available to the residents. She then went to check the menus that were posted in the hall and in the dining room on the third floor and confirmed they did not include the alternate meals either. She acknowledged that there was nothing posted or provided to the residents to let them know they had an alternate menu for each meal that they could choose. The facility's resident council president (Resident #57) was in the hall by the nurses' station and overheard the conversation taking place on how residents were informed of what meals were available to them. She entered into the conversation and re-iterated concerns with the residents not being informed of any alternate meals that were available to them. She stated they used to have the alternate meal posted in the daily newsletter and it also used to be included on the menus posted in the dining room, but they quit including it on those areas. Resident #57 said she was told someone from corporate or the State informed the facility that they did not have to do that any longer. On 01/03/24 at 4:33 P.M., an interview with STNA #229, who was also present in the area of the nurses' station and overheard the conversation with STNA #112 and Resident #57, revealed she felt the residents should be informed of what meal alternates were available to them for each meal. She agreed the residents may eat better, if the meal received was of their choosing and not just the meal served as part of the main menu. On 01/03/24 at 4:35 P.M., STNA #112 called the kitchen and spoke with the dietary manager to find out how residents were informed of the alternate meals that were made available to them. She was told by the dietary manager that the residents or the staff would have to call to see what the alternate meal was, if the resident did not like what had been served. The dietary manager verified the alternate meal was not communicated on any menu or in the daily newsletter that the residents had access to other than what was included on their always offered menu. On 01/03/24 at 4:45 P.M., an interview with Registered Nurse (RN) #143 was completed and she was informed the residents had voiced concerns with not being aware of what food items were available to them, other than the main meal on the week at a glance menus. She confirmed the daily newsletter and the menus posted that residents had access to only identified the main meal on the menu and an alternate menu was not made available to them. She stated in other facilities she worked in they had a select menu where an activity aide would go around and ask each resident what they wanted to eat for the following days' meals. She stated she would look to see if they could incorporate something like that or she would see if they could update the daily newsletter and menus posted throughout the facility to also include the alternate menu so residents could make an informed choice.

Based on observation, interview, and facility policy review, the facility failed to store food in a sanitary manner and failed to ensure food preparation equipment was clean. This had the potential to affect all 91 residents who received food from the facility kitchen. Six residents (#1, #23, #28, #29, #39, and #198) received nothing by mouth and did not receive food from the facility kitchen. The facility also failed to ensure two residents (#32 and #62)'s personal refrigerators were kept clean and at an appropriate temperature and failed to ensure four residents (#10, #33, #62, and #81)'s personal refrigerator temperatures were logged for safety. The facility census was 97. Findings included: 1. Observation on 01/02/24 at 8:09 A.M. revealed the onion powder and ground cinnamon containers were not closed properly. Observation on 01/03/24 at 9:15 A.M. revealed the onion powder, ground cinnamon, garlic powder, and lemon pepper seasoning salt containers were not closed properly. Interview on 01/03/24 at 10:10 A.M. with [NAME] #192 verified the spice container noted above were open, not closed properly and should have been closed for sanitation. 2. Observation on 01/02/24 at 8:09 A.M. of the can opener with a dried black substance on the puncture. There was also a white dried substance noted on the puncture. Interview on 01/02/24 at 8:20 A.M. with Dietary Manager #191 verified the can opener was dirty with dried substances. He reported the can opener was to be cleaned after each use and it was on the cleaning schedule for each evening to be cleaned and sanitized. He verified the can opener had not been used in preparing breakfast. Review of the facility document titled, CH2 End of Shift Checkout Sheet, undated, revealed the can opener was to be cleaned and sanitized at the end of the shift. Review of the policy titled, Environment, revised 09/2017, revealed all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. Further review revealed all food contact surfaces will be cleaned and sanitized after each use. 3. a. Observation on 01/08/24 at 8:03 A.M. of Resident #10's personal refrigerator revealed no temperature log on the refrigerator unit or in the room. Interview on 01/08/24 at 8:09 A.M. with Med Tech #225 verified there was no refrigerator temperature log on or around Resident #10's refrigerator. b. Observation on 01/08/24 at 8:03 A.M. of Resident #62's personal refrigerator revealed the thermometer inside read 48 degrees Fahrenheit and the mechanical unit was iced over. The refrigerator held the following perishable items: five cartons of milk, a container of sour cream, two containers of mayonnaise, and a bottle of ranch dressing. There was no temperature log noted on the refrigerator unit or in the room. An interview at the time with Resident #62 revealed the facility staff used to check the temperature of her refrigerator every day, but they hadn't for a while. Interview on 01/08/24 at 8:10 A.M. with Med Tech #255 verified the unit was not at an acceptable temperature of 41 degrees Fahrenheit or less, the mechanical unit was iced over and there was food in the unit that was perishable. She also verified there was no temperature log on or around Resident #62's refrigerator. c. Observation on 01/08/24 at 8:05 A.M. of Resident #33's personal refrigerator revealed no thermometer in the refrigerator and no temperature log on the refrigerator or in the room. Interview on 01/08/24 at 8:09 A.M. with STNA #103 revealed she did not know who was responsible for monitoring resident refrigerator temperatures. Interview on 01/08/24 at 8:10 A.M. with Med Tech #225 verified there was no thermometer in Resident #33's refrigerator and there should be. She also verified there was no temperature log on or around Resident #33's refrigerator. Med Tech #225 did not know who was responsible for monitoring resident refrigerator temperatures. She thought it may be housekeeping. d. Observation on 01/08/24 at 8:06 A.M. of Resident #81's personal refrigerator revealed no temperature log on the unit or in the room. Interview on 01/08/24 at 8:10 A.M. with Med Tech #225 verified there was no refrigerator temperature log on or around Resident #81's refrigerator. e. Observation on 01/08/24 at 8:11 A.M. of Resident #32's personal refrigerator revealed the thermometer inside read 50 degrees Fahrenheit, the mechanic unit was iced over, and the interior of the unit was dirty. The refrigerator held lunch meat sandwiches. Interview on 01/08/24 at 8:15 A.M. with State Tested Nursing Assistant (STNA) #111 verified the unit was not at an acceptable temperature of 41 degrees Fahrenheit or less, the mechanical unit was iced over, the refrigerator was dirty and there was food in the unit that was perishable. Interview on 01/08/24 at 8:40 A.M. with Licensed Practical Nurse (LPN) #211 revealed any staff can document a resident refrigerator temperature and the log should be on or near the refrigerator unit. Interview on 01/08/24 at 8:41 A.M. with the Director of Nursing (DON) revealed the resident refrigerator temperature logs should be in the unit narcotic books. Observation of the unit E and F narcotic books with the DON revealed no resident refrigerator temperature logs. Interview on 01/08/24 at 10:25 A.M. with the DON verified third floor residents' refrigerator temperatures should have been checked and logged daily but there was no documentation to support this was done. Review of the facility policy titled, Resident Refrigerators, (reviewed/revised 01/01/22), revealed the facility did not provide a refrigerator in a resident's room. However, it was the policy of the facility to ensure safe and sanitary use of any resident-owned refrigerators when approved by the administrator for use in the facility. Further review revealed housekeeping staff shall record refrigerator temperatures daily on a temperature log attached to the refrigerator. A thermometer shall remain in the refrigerator. Temperatures will be at or below 41 degrees. If temperatures are out of range, maintenance staff shall be notified and all foods that require refrigeration will be discarded immediately, and remedies will be put into place. Housekeeping staff shall clean the refrigerator daily and discard any foods that are out of compliance. Nursing staff shall clean up spills as needed or refer to housekeeping staff.

Based on observation, interview, and facility policy review, the facility failed to ensure garbage and refuse was disposed of properly. This had the potential to affect all 97 residents residing in the facility. Findings included: Observation on 01/02/24 at 9:20 A.M. of the facility dumpster/compactor revealed trash on the ground around the dumpster/compactor. The trash included milk cartons, straws, lids, rubber gloves and a used depends. Interview on 01/02/24 at 9:22 A.M. with State Tested Nursing Assistant (STNA) #131 verified the debris on the ground around the dumpster/compactor and that it should not be there. Review of the facility policy titled, Environment, (revised 09/2017), revealed all trash will be properly disposed of in external receptacles (dumpsters) and the surrounding area will be free of debris. Review of the facility policy titled, Disposal of Garbage and Refuse, (reviewed/revised 01/01/22), revealed refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #72's medical record revealed he was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the rectum, chronic obstructive pulmonary disease, viral hepatitis C, and other disorders of the lung. Review of Resident #72's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/12/23, revealed he was cognitively intact. Review of Resident #72's progress note, dated 12/28/23 at 1:09 P.M., revealed he had a positive COVID rapid test, and he was to be placed in transmission based precautions. Review of Resident #72's physician order, dated 12/28/23, identified he was to be in transmission based precautions. Observation on 01/02/24 at 12:15 P.M. of Resident #72's door revealed there was signage on the door directing anyone entering to stop and see the nurse. Additional signage directed anyone entering the room to don (put on) an isolation gown, gloves, N-95 mask and eye protection. Observation at this time revealed isolation carts outside of the room revealed all personal protective equipment (PPE) was present to be donned prior to entering the room. Observation on 01/02/24 at 12:20 P.M. of State Tested Nursing Assistant (STNA) #111 donning an isolation gown, gloves, and changing from a surgical mask to a N-95 mask prior to taking lunch into Resident #72. She did not don any eye protection. STNA #111 took Resident #72's tray into his room and set it up for him on his over bed table while he was lying in bed. She then doffed (removed) her isolation gown, gloves, and N-95 mask, entered Resident #72's rest room and washed her hands. Upon exiting the room, STNA #111 donned a new surgical mask. Interview on 01/02/24 at 12:24 P.M. with STNA #111 verified she did not wear any eye protection when she entered Resident #72's room who was on droplet isolation due to being COVID-19 positive. She verified she should have donned eye protection but forgot. She verified she had been trained to wear eye protection when caring for residents on droplet isolation. Review of the facility policy titled, Transmission-Based (Isolation) Precautions, (reviewed/revised 12/27/23), revealed it was the facility policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' mode of transmission. Further review revealed the facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. Additionally, the policy revealed the appropriate precaution for COVID-19 was airborne, droplet, and contact isolation and healthcare personnel should wear a facemask for close contact with an infectious resident. Based on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure a resident showing signs of Covid-19 was promptly identified, tested, and placed in transmission based precautions (TBP's) for Covid-19 when symptoms originated, failed to ensure staff wore appropriate personal protective equipment (PPE) when entering a room of another resident who was on TBP's for being positive for Covid-19, failed to timely identify and place a third resident in TBP's who had a multi-drug resistant organism in his urine, and failed to ensure sharps (syringes and vacutainers needles) were properly disposed of inside of sharps containers so the needles could not be easily retrieved. This affected three residents (#21, #72, and #82) of three residents reviewed for infections (two for Covid-19 and one for urinary tract infections) and had the potential to review all residents that resided in the facility. Findings include: 1. A review of Resident #21's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included cerebral palsy, benign prostatic hyperplasia, and obstructive and reflux uropathy. A review of Resident #21's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was able to make himself understood and was able to understand others, but his cognition was severely impaired. He was indicated to have the use of an indwelling urinary catheter. A review of Resident #21's care plans revealed he had the need for an indwelling urinary catheter related to obstructive uropathy. His goal was to have reduced catheter-related complications through the next review. The interventions included observing for signs and symptoms of UTI and report to the physician, provide prophylactic interventions as ordered, and to administer medications as ordered. His care plans were updated on 01/02/24 to reflect he had an infection as evidenced by a UTI. That care plan included the need to administer medications and treatments to treat infection and/or symptoms as ordered. They were to obtain labs/ cultures/ diagnostic testing as ordered and report the results to the physician. A review of Resident #21's progress notes revealed a nurse's note dated 12/31/23 at 9:45 P.M. that revealed the resident had returned from emergency room at 9:17 P.M. He was given a dose of Rocephin intravenously (IV) for the treatment of a UTI. He was discharged back to the facility with an order to complete at 10-day course of Ciprofloxacin (Cipro) 500 milligrams (mg) twice a day for 10 days. The physician was made aware of above and was in agreement with the orders. A review of Resident #21's physician's orders confirmed the resident was ordered to receive Ciprofloxacin HCl 500 MG by mouth two times a day for 10 days for the treatment of a UTI. The order originated on 01/01/24. A review of Resident #21's urinalysis results for a urinalysis that had been collected at the hospital on [DATE] at 8:45 A.M. revealed the preliminary report showed the resident had the growth of two organisms (Pseudomonas Aeruginosa and Proteus Mirabilis) that were at a quantity greater than 100,000 colonies/ milliliter. The culture report indicated the sensitivity testing was to follow. There was a second preliminary urine culture report for a urinalysis that was done on 12/31/23 at 12:15 P.M. that showed Pseudomonas Aeruginosa and Proteus Mirabilis were again identified as the organisms growing in the resident's urine. The second urine culture report indicated for sensitivity information on that report refer to the previous urine culture report specimen (No. B 37921) received 12/31/23. Antibiotic susceptibility testing would not be routinely repeated on identical organisms isolated within 5 days of each other. Further review of Resident #21's electronic medical record (EMR) revealed it was absent for the sensitivity testing report that was to follow for the urinalysis that had been collected on 12/31/23 at 8:15 A.M. Findings were verified by Medical Records Employee #181. She was asked to contact the hospital to see if they had the sensitivity testing report that was the absent report on 01/03/24 at 4:20 P.M. On 01/03/24 at 4:40 P.M., a copy of the sensitivity testing report from the urinalysis that was collected on 12/31/23 at 8:45 A.M. was provided for review. The final urine culture results showed Resident #21 had Pseudomonas Aeruginosa and Proteus Mirabilis- Extended Spectrum Beta Lactamases (ESBLs) (an enzyme found in some strains of bacteria that can't be killed by many of the antibiotics that were typically used to treat infections that have been associated with poor outcomes). The sensitivity report revealed both organisms identified were susceptible to Meropenum and Gentamycin. They were not susceptible to Ciprofloxacin, which was the antibiotic the resident had been placed on and was to receive twice a day for 10 days to treat his UTI. The sensitivity report did indicate Proteus Mirabilis- ESBL was multi-resistant and contact isolation protocol should be used with that organism. On 01/04/24 at 10:20 A.M., an interview with the Director of Nursing (DON) confirmed Resident #21's urine cultures sensitivity testing report from the urinalysis that had been collected while the resident was in the hospital on [DATE] at 8:45 A.M. was not previously available in the resident's EMR until it was requested for review on 01/03/24 at 4:20 P.M. She further acknowledged that the resident's culture and sensitivity report that was obtained from the hospital showed the resident had ESBL in his urine and the antibiotic (Cipro) that was ordered for him was not effective in treatment of the organisms identified in the urine's culture and sensitivity report. She was asked why the resident had not been placed in contact isolation for ESBL in his urine, after the final culture and sensitivity report was obtained upon request on 01/03/24 at 4:40 P.M. She verified the lab report showed the bacterial isolate on the resident was multi-resistant and contact isolation protocol should be used with the resident. On 01/04/24 at 10:40 A.M., an interview with State Tested Nursing Assistant (STNA) #134 revealed the aides were responsible for performing catheter care on Resident #21 and were also responsible for emptying of a resident's catheter bag. They typically emptied the resident's catheter bag at least three times a shift. She described the process in which the catheter bag was emptied and stated the staff would don gloves only when emptying the catheter, unless they had something in their urine. She was asked if the resident had anything in his urine and reported they just found out that he did. They were in the process of moving him down to the first floor, so he could be put in isolation. She took care of the resident yesterday and at that time she was only wearing gloves when emptying his catheter bag. A review of the facility's policy on Transmission Based (Isolation) Precautions (revised 05/22/23) revealed it was their policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens modes of transmission. Contact precautions referred to measures that were intended to prevent transmission of infectious agents which were spread by direct or indirect contact with the resident or the resident's environment. Facility staff would apply TBP's, in addition to standard precautions, to residents who were known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. Contact precautions were intended to prevent transmission of pathogens that were spread by direct or indirect contact with the resident or the resident's environment. Healthcare personnel caring for residents on contact precautions should wear a gown and gloves for interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning PPE upon room entry and discarding before exiting the room was done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. Contact precautions would be used for residents infected or colonized with MDRO's (multi-drug resistant organisms). 2. On 01/02/24 at 3:29 P.M., an interview with Resident #82 revealed she did not feel well. She was noted to have some nasal congestion and a dry cough. She requested her interview to be paused on a couple of occasions to get a drink of water and a cough drop. She complained of a headache and was sensitive to loud noises. She reported she had been tested for Covid-19 about a week ago and was negative. On 01/03/24 at 3:36 P.M., an ongoing observation of Resident #82 noted her to be sitting on the side of her bed coughing. Her cough was more moist than it had been the day prior to. She remained in a room by herself but was not under any type of TBP's. On 01/04/24 at 8:40 A.M., a follow up observation of Resident #82 noted her to be in her room sitting on the side of the bed. She had been placed in droplet isolation precautions and was identified by the facility as being positive for Covid-19. She continued with a moist cough, congestion, and complaints of a headache. A review of Resident #82's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, asthma, hypertension, and adult onset diabetes mellitus. A review of Resident #82's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to display any behaviors or reject care. A review of Resident #82's care plans revealed she had Covid-19/ symptoms of Covid-19/ and a positive Covid-19 test. The care plan was initiated on 01/04/24. The interventions included administering any treatments to treat infection and/ or symptoms. A review of Resident #82's nurses progress notes revealed a nurse's note dated 01/02/24 at 7:41 P.M. that indicated the resident was complaining of a headache more frequently over the past couple of days. She had been given Tylenol on an as needed basis with some effectiveness. The resident requested to see the physician the next time he was in the facility doing rounds. A nurse's progress note dated 01/03/24 at 8:06 P.M. revealed Resident #82 had complaints of a recent frequent headache that was not new to the resident or thought to be a new symptom of Covid-19. The resident had been known to frequently request Acetaminophen on an as needed (prn) basis related to a diagnosis of cervical degenerative disc disease with effectiveness documented. The progress notes did not document anything about the resident having nasal congestion or a cough despite observations of the resident on 01/02/24 and 01/03/24 noted her to have those symptoms. A nurse's progress note dated 01/03/24 at 8:35 P.M. revealed Resident #82 had been rapid tested for Covid-19 during routine testing and found to be positive for Covid-19. The floor staff asked the resident if she was experiencing any symptoms and the note indicated the resident only complained of a headache, which was noted to be a chronic issue related to cervical stenosis. The resident was placed in isolation precautions and the physician was notified. A nurse's progress note dated 01/04/24 at 3:39 P.M. revealed Resident #82 was ordered to receive Molnupiravir (an antiviral medication) 800 milligrams (mg) by mouth two times a day for 5 days for Covid-19. It was to continue until 01/10/2024. She was also given an order to receive Robitussin on an as needed basis every four hours for a cough. On 01/08/24 at 4:35 P.M., an interview with the DON confirmed Resident #82 was noted to be positive for Covid-19 through routine outbreak testing. She claimed the only symptom the resident was known to have was a headache, which was not out of the normal for the resident. She denied she was aware of the resident having any cough or nasal congestion prior to testing her for Covid-19. On 01/08/24 at 5:20 P.M., a follow up interview with the DON and Registered Nurse (RN) #143 was completed to review the timeline of Resident #82's symptoms and when she was tested for Covid-19. They acknowledged the resident was observed on 01/02/24 at 3:29 P.M. (while being interviewed) when she had complaints of not feeling well, a headache, and was noted to have nasal congestion and a cough. They further acknowledged another observation was made of the resident on 01/03/24 at 3:36 P.M. of her sitting on the side of her bed with a moist cough continuing. The resident was not in TBP's for suspected Covid-19, nor had she been tested for Covid-19 at that point in time when she was showing symptoms consistent with Covid-19. The DON and RN #143 verified Resident #82 was not tested for Covid-19 until 01/03/24 at 8:35 P.M. (greater than 24 hours after she was observed with congestion and a cough). They were questioned as to why there was a delay in identifying symptoms of Covid-19 and a delay in testing for Covid-19 when her symptoms had were noted on 01/02/24. They confirmed the facility already had one resident positive for Covid-19 and should have been vigilant to be observing other residents with symptoms of Covid-19. The DON stated that was the first they were hearing of the resident having any symptoms other than just a headache. They confirmed the resident should have been tested sooner for Covid-19, if she was displaying any of the symptoms consistent with Covid-19. A review of the facility's policy on Covid-19 Prevention, Response and Reporting (revised 05/26/23) revealed it was the policy of the facility to ensure that appropriate interventions were implemented to prevent the spread of Covid-19 and promptly respond to any suspected or confirmed Covid-19 infections. Staff would be alert to signs of Covid-19 and notify the resident's physician if the resident had a cough, congestion/ runny nose, or a headache among other symptoms. 3. On 01/02/24 at 4:15 P.M., an observation of the sharps container in Resident #38's room noted there to be syringes in the top of the sharps container that had not dropped down to the bottom of the container. There was a syringe that was vertical and stuck in the flapper of the insert that prevented the flapper from moving. Additional syringes used for vaccination were stuck at the top of the container and was retrievable. Findings were verified by RN #250. On 01/02/24 at 4:17 P.M., RN #250 removed the sharps container that was hanging on the bathroom wall and replaced it with a new one. She reported the syringe that was stuck in the top of the sharps container that was vertical prevented the flapper mechanism to work resulting in the other syringes that had been placed in the sharps container to not drop securely into the bottom of the container. She acknowledged the syringes that had not been dropped to the bottom of the container was retrievable and could pose a risk to any resident from a potential needle stick. On 01/02/24 at 5:11 P.M., an observation of Resident #30's bathroom revealed his sharps container had multiple syringes, vacutainer needles (used for blood draws), and straight razors resting at the top of the sharps container at the flapper area and had not been safely dropped into the bottom of the sharps container. All items were retrievable due to not dropping to the bottom of the container. Findings were verified by RN #250. She apologized for the sharps container being found that way and stated she would take care of it. On 01/04/24 at 10:40 A.M., an interview with the DON revealed the facility had recently changed the type of sharps containers they were using that went along with their on-site sharps disposal system. She reported the flapper in the insert was not allowing sharps to be dropped down into the container as easily as their prior sharps containers did. She stated she would have to remove one of the flappers in the insert to allow the sharps to more easily drop down into the container. There would still be a plastic piece that would go across the insert to prevent anyone from reaching down into the sharps container. A review of the facility's policy on Sharps Disposal (revised 10/30/23) revealed contaminated sharps would be discarded immediately or as seen as feasible into designated containers. Contaminated sharps would be discarded into containers that were closable. Designated individuals would be responsible for sealing and replacing containers when they were 75-80% full to protect employees from punctures and/ or needle sticks when attempting to push sharps into the containers. Whoever observed incorrect disposal or handling of contaminated sharps should report the information to the Infection Control Coordinator.

Based on interview, observation and review of the Maintenance Request log the facility failed to provide a resident with a pull cord for over the bed light, and place the telephone within reach of the resident. This affected one resident (#69) of five residents reviewed for physical environment. The facility census was 96. Findings include: An observation on 03/22/23 at 2:34 P.M. and on 03/23/23 at 8:34 A.M. revealed Resident #69's telephone was on the bedside table located between the resident's bed and room mate's bed and out of reach for the resident. In addition, observation revealed the pull cord for the over the bed light for Resident #69 bed was missing. There was no way for the resident to activate her light. An interview on 03/22/23 at 2:34 P.M. with Resident #69 revealed she would like to have the telephone in reach to speak to her family when they called. Resident #69 stated the phone had been out of reach for a couple of days and she had reported it to the Certified Nursing Assistants (CNA). Resident #69 stated the pull cord for the over the bed light had been missing for quite a while. Resident #69 stated she also reported that to the nurse several days ago. Resident #69 would like to be able to turn on the light in her room when she wanted. An interview on 03/23/23 at 11:21 A.M. with the Maintenance Staff #103 revealed the nurses and aids had the ability to put a maintenance request order online. The work orders present to the maintenance staff at the time the order was put in the system. The Maintenance Staff #103 stated an order (03/23/23) to fix the light pull cord for Resident #69 at 9:59 A.M. and was replaced at 11:00 A.M. An interview on 03/23/23 at 12:58 P.M. with the Director of Nursing (DON) revealed she had no knowledge of the pull cord missing. The DON stated the pull cord for the over the bed light was replaced this date. Review of the Maintenance Work Orders from 03/01/23 through 03/23/23 revealed there was not an order to repair the pull cord for the over the bed light until 03/23/23 at 9:59 A.M. This deficiency is cited as an incidental finding to Master Complaint Number OH00141282 and Complaint Number OH00141186.

Based on observation, record review, interview and facility policy review the facility failed to ensure a resident's nebulizer mask was stored in a sanitary manner to help prevent the risk of resident infection. This affected one resident (#69) reviewed for nebulizer or breathing treatments. The facility census was 96. Findings include: Observations made on 03/22/23 at 2:31 P.M. and on 03/23/23 at 8:34 A.M. revealed Resident #69's nebulizer machine was located on the bedside table. The tubing and mask were hanging over the side of the table and not properly stored in a protective device such as a plastic bag. The tubing was dated 03/19/23, the date it was changed. An interview on 03/23/23 at 8:34 A.M. with Resident #69 revealed she used the nebulizer machine often. Resident #69 stated the tubing and mask always hang over the side of the table and had not been placed in a plastic bag. Review of the Medication Administration Record (MAR) for March 2023 revealed Resident #69 received Albuterol Sulfate inhalation nebulization solution 1.25 milligrams (mg)/3 milliliters (ml), inhale orally every four hours as needed for airway patency. Resident #69 received the medication on 03/02/23, 03/08/23, 03/12/23, 03/13/23, 03/14/23, 03/16/23, 03/17/23 and 03/18/23 via nebulizer. An interview on 03/23/23 at 8:45 A.M. with Certified Nurse Assistant (CNA) #76 confirmed the nebulizer machine tubing and mask were hanging over the side of the bedside table and not properly stored. Review of the facility policy titled Nebulizer Therapy dated 01/01/20 revealed the facility should store the nebulizer cup and mouthpiece in a zip lock baggy after use. This deficiency is cited as an incidental finding to Master Complaint Number OH00141282 and Complaint Number OH00141186.

Based on observation, interview and record review, the facility failed to timely revise a resident's comprehensive care plan. This affected one (#19) of three residents reviewed for medication administration. The facility census was 97. Findings include: Review of the medical record for Resident #19 revealed an admission date of 08/31/21. Diagnoses included chronic respiratory failure, dependence on respirator, diabetes mellitus, phimosis, balanitis, chronic obstructive pulmonary disease, morbid obesity, cervical disk disorder, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #19, dated 12/06/22, revealed intact cognition. There was no psychosis. There was rejection of care indicated for one to three days. The assessment revealed the resident required supervision and one person assistance with bed mobility, toileting, and personal hygiene. Review of the Care Plan, initiated 06/17/22 identified the resident had a desire to self-administer medications to include apply peroxide to wash out his ears. The care plan was revised 02/09/23, to add the resident to apply cream to his penis. Review of a physician order (by Physician #200), dated 02/09/23, revealed the order for Clotrimazole-Betamethasone External Cream 1-0.05% to be applied to glans and phimotic band topically, two times a day for six weeks, for phimosis (the inability to retract the skin covering the glans of the uncircumcised penis). Review of nursing progress note (by RN #101), dated 02/08/23 at 3:39 P.M., revealed a new order was received from the urology certified nurse practitioner (CNP) #199 for Clotrimazole-Betamethasone 1-0.05% cream to apply to glans and phimotic band on foreskin twice daily for four to six weeks. The prescription also stated for the nurse to apply. Physician #200 was notified of the new order. Physician #200 was in agreement to change the order for the resident to apply the medication himself (due to the resident's history of being sexually inappropriate to female staff and his physical ability to apply medication himself as witnessed by this nurse). The resident stated that he could not apply the medication himself because he could not see past his stomach. Resident #19 was reminded of a prior occurrence when the resident requested nurse to return foreskin to original placement and resident was given lubrication to apply and while standing at the bedside, he returned the foreskin to the previous position without assistance. Resident stated, I'm going to call state and report you for not helping me out. Review of nursing progress note (by RN #101), dated 02/14/23 at 10:15 A.M., revealed nurse accompanied by State-Tested Nursing Assistant (STNA)#102 entered resident's room to give medication, for penis, to the resident. Resident #19 refused the cream stating, I haven't used the cream for two days. When asked why, the resident stated, because I can't get any help with it. The resident stated that he had to have another STNA hold the mirror for him the other day. The resident stated, take the cream and go. Physician (#200) and Unit Manager/Licensed Practical Nurse (LPN) #100 were notified. Review of nursing progress note (written by RN #101), dated 02/15/23 at 8:30 A.M., revealed nurse accompanied by STNA entered the resident's room to provide him with the medication to apply to his penis. Resident #19 refused again for the second time. When asked why the resident did not refuse cream from the night shift nurse, resident stated, because she holds the mirror for me. Resident #19 reminded that the mirror provided to him is adjustable and he didn't even use the mirror when the medication was brought before. The resident stated, I can't see, I need glasses. Unit Manager/LPN #100 was notified. Observation and interview on 02/28/23 at 10:05 A.M. revealed Resident #19 lying in his bed watching television. A mirror was attached to the footboard of the bed. The resident stated he has repeatedly asked staff to apply the medication to his penis, however, the staff insist that he is able to apply the medication himself. The resident stated due to his large belly, he can't see his penis to apply the medication, and his mobility is limited due to chronic left shoulder pain and previous shoulder injury. The resident further revealed the nursing staff brought a mirror for him to use, however, his vision is poor, and he has asked to be examined by an eye doctor. The resident expressed concern that he is not able to apply the medication properly and cannot exam the area and it is his belief that this is the responsibility of the nursing staff to apply the medication. Observation of Resident #19 during the interview, did reveal morbid obesity and a protruding abdomen. On 03/01/23 at 4:33 P.M. during interview with the Administrator, she was informed that after reviewing the additional documentation provided by the facility, Resident #19's care plan stated that he desired to apply the cream to his penis, however, surveyor interview with the resident and review of the documentation in the nursing progress notes revealed that he did not wish to apply the cream to his penis and the care plan was not accurate as it indicated the resident had the desire to apply the cream himself. The Administrator responded okay. This deficiency is cited as an incidental finding to Complaint Number OH00140244.

Based on observation, interview, record review, and policy review, the facility failed to administer medication to a dependent resident to treat a medical condition as ordered by the urology practitioner and staff failed to provide consistent, ongoing assessment of the affected area. This affected one (#19) of three residents reviewed for medication administration. Findings include: Review of the medical record for Resident #19 revealed an admission date of 08/31/21. Diagnoses included chronic respiratory failure, dependence on respirator, diabetes mellitus, phimosis, balanitis, chronic obstructive pulmonary disease, morbid obesity, cervical disk disorder, and muscle weakness. Review of the medical record revealed a social service note dated 02/21/23 that identified the resident had a vision appointment scheduled on 03/14/23. There was no documented evidence Resident #19 had a self- administration of medication assessment that identified the resident was safe to self-administer medications. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #19, dated 12/06/22, revealed intact cognition. There was no psychosis. There was rejection of care indicated for one to three days. The assessment revealed the resident required supervision and one person assistance with bed mobility, toileting, and personal hygiene. The MDS revealed the resident had adequate vision and no corrective lenses. Review of the Care Plan, dated 09/24/21, revealed the resident had inappropriate social behavior of being sexually inappropriate. Interventions included to document behavior occurrences on a tracking form and to re-direct during episodes of inappropriate behavior. Review of the Care Plan, dated 02/09/23, revealed the resident has phimosis. Interventions included to notify physician if skin becomes bloody or infected and to apply cream as ordered. Medical record review revealed a physician progress note (written by Physician #200) dated 02/02/23 that identified Resident #19 was seen by the physician on that date and there was some evidence of a yeast infection on the glans penis. The resident had been seen because of ongoing complaints about his penis. Review of Resident #19's nursing progress note dated 02/04/23 at 9:59 A.M., revealed the site of the infection was the penis. A new order was received for Nystatin to glans of penis related to signs and symptoms of yeast infection (fungal growth and yeast smell). Nystatin cream was ordered for 14 days, and Resident #19 was referred to urology for an appointment/consult. Review of Resident #19's nurse progress note dated 02/06/23 at 10:02 A.M. revealed the Nystatin cream to penis discontinued due to resident refusal. Review of a urology progress note by Certified Nurse Practitioner (CNP) #199, dated 02/08/23, revealed the resident was diagnosed with balanitis and phimosis with the treatment listed as Clotrimazole/Betamethasone cream to be applied to the affected area twice daily. The summary revealed a nurse (identified as Registered Nurse (RN) #101) from the skilled nursing facility contacted the office after the resident's appointment and said that nursing staff refused to apply medication to the resident's penis due to the patient being inappropriate. Per CNP #199, the resident is unable to retract foreskin and apply medicine at the same time due to body habitus as demonstrated on exam today. Medication will need to be applied by nursing at the skilled nursing facility. Alternative treatment would be circumcision, which would require bacitracin to sutures four to six times per day. Follow-up in six weeks. The resident weight was 328.37 pounds, and his height was 5 feet 10 inches. Review of nursing progress note (written by RN #101), dated 02/08/23 at 3:39 P.M., revealed a new order was received from the urology certified nurse practitioner (CNP) #199 for Clotrimazole-Betamethasone 1-0.05% cream to apply to glans and phimotic band on foreskin twice daily for four to six weeks. The prescription also stated for the nurse to apply. Physician #200 was notified of the new order. Physician #200 was in agreement to change the order for the resident to apply the medication himself (due to the resident's history of being sexually inappropriate to female staff and his physical ability to apply medication himself as witnessed by this nurse). Unit Manager/Licensed Practical Nurse (LPN) #100 present in the room when RN #101 updated Resident #19 on the new order. The resident stated that he could not apply the medication himself because he could not see past his stomach. Resident #19 was reminded of a prior occurrence when the resident requested nurse to return foreskin to original placement and resident was given lubrication to apply and while standing at the bedside, he returned the foreskin to the previous position without assistance. Resident stated, I'm going to call state and report you for not helping me out. Review of a physician order, dated 02/09/23, revealed the order for Clotrimazole-Betamethasone External Cream 1-0.05% to be applied to glans and phimotic band topically, two times a day for six weeks, for phimosis (the inability to retract the skin covering the glans of the uncircumcised penis). Review of Resident #19's medication administration record (MAR) for February 2023 revealed Clotrimazole-Betamethasone External Cream 1-0.05% two times a day. The MAR identified the nurses were applying the medication, even though that was not accurate and the resident was expected to apply the medication himself. Review of Resident #19's medical record did not reveal documentation of an ongoing, consistent assessment of Resident #19's affected balanitis and phimosis by the nursing staff. Review of nursing progress note (written by RN #101), dated 02/14/23 at 10:15 A.M., revealed nurse accompanied by State-Tested Nursing Assistant (STNA) entered resident's room to give medication, for penis, to the resident. The resident refused the cream stating, I haven't used the cream for two days. When asked why, the resident stated, because I can't get any help with it. The resident stated that he had to have another STNA hold the mirror for him the other day. The resident stated, take the cream and go. Physician and Unit Manager/Licensed Practical Nurse (LPN) #100 were notified. Review of nursing progress note (written by RN #101) dated 02/15/23 at 8:30 A.M., revealed nurse accompanied by STNA entered Resident #19's room to provide him with the medication to apply to his penis. Resident refused again for the second time. When asked why the resident did not refuse cream from the night shift nurse, resident stated, because she holds the mirror for me. Resident reminded that the mirror provided to him is adjustable and he didn't even use the mirror when the medication was brought before. The resident stated, I can't see, I need glasses. Unit Manager/LPN #100 was notified. Review of a nurse progress note dated 02/26/23 at 6:20 A.M. revealed Resident #19's glans penis continued to show improvement with no signs of irritation to the area noted. This was the first note regarding a documented assessment of the area and response to treatment. Observation and interview on 02/28/23 at 10:05 A.M. revealed Resident #19 lying in his bed watching television. A mirror was attached to the footboard of the bed. The resident stated has repeatedly asked staff to apply the medication to his penis, however, the staff insist that he is able to apply the medication himself. The resident stated due to his large belly, he can't see his penis to apply the medication, and his mobility is limited due to chronic left shoulder pain and previous shoulder injury. The resident further revealed the nursing staff brought a mirror for him to use, however, his vision is poor, and he has asked to be examined by an eye doctor. The resident expressed concern that he is not able to apply the medication properly and cannot exam the area and it is his belief that this is the responsibility of the nursing staff to apply the medication. Observation of Resident #19 during the interview, did reveal morbid obesity and a protruding abdomen. Interview on 02/28/23 at 11:25 A.M., Registered Nurse (RN) #101 stated that on 01/11/23 Resident #19 complained of having trouble urinating with burning and blood, so she notified the physician, and he ordered a urinalysis (UA). A clean catch urine sample was previously obtained, and it was grossly contaminated, so the physician ordered (on 01/17/23) a straight catheter to obtain another urine sample for a UA. RN #101 stated that she took two nursing assistants into the resident's room with her because the resident is known to be sexually inappropriate. RN #101 stated she had to pull the foreskin back to do the catheterization and once finished, with the urine cup in her hand, asked Resident #19 to return his foreskin to the proper position. The resident asked for lubrication and then stood at the bedside with the lubrication and stroked himself. RN #101 stated that she was mortified and notified the physician (Physician #200), who changed the order for the resident to apply the medication himself. Interview on 02/28/23 at 11:25 A.M., STNA #102 revealed she has witnessed the resident applying the medication himself with the use of a mirror. STNA #102 revealed the resident has never been sexually inappropriate with her and has always been a gentleman. Interview on 02/28/23 at 12:48 P.M., Licensed Practical Nurse (LPN) #103 stated the resident has been applying the medication to his penis himself with the use of a mirror. Interview on 02/28/23 at 12:55 P.M., LPN #104 stated Resident #19 applies the medication to his penis himself. LPN #104 stated she places the medication cream in a cup and the resident uses a Q-tip and mirror and while applying the medication. LPN #104 stated the resident does need some help holding and positioning the mirror and due to the resident's abdomen, it is difficult to observe the penis during the application of the medication. LPN #104 stated she does not assess the penis during the treatment. LPN #104 confirmed the only documentation is in the medication administration record (MAR) which indicates the medication has been administered. Interview on 02/28/23 at 5:00 P.M., the Regional Director of Nursing (DON), revealed licensed nurses administer medications in accordance with physician orders. The DON confirmed Resident #19 was applying the medication himself and there was not documentation of an ongoing nursing assessment of the affected area in order to determine if the area/condition was responding and improving with the treatment. Review of a policy titled, Medication Administration, dated 01/01/22, revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. This deficiency represents non-compliance investigated under Complaint Number OH00140244.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to ensure residents were treated with dignity and respect. This affected one Resident (#41) of three residents reviewed for dignity and respect. The facility census was 106. Findings included: Review of Resident #41's medical record revealed she was initially admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses including Alzheimer's disease with early onset, type two diabetes, essential hypertension, and bipolar disorder. Review of Resident #41's quarterly Minimum Data Set (MDS), dated [DATE], revealed she was minimally cognitively impaired and had minimal difficulty hearing. Observation on 02/06/23 at 2:23 P.M. revealed State Tested Nurse Assistant (STNA) #208 speaking loudly to Resident #41. STNA #208 and Resident #41 were standing at the second-floor nurses' station while this surveyor was at the end of Hall C and able to hear. This surveyor walked toward the nurses' station and noted STNA #208 was not only talking loudly but arguing with Resident #41. STNA #208 would interrupt Resident #41 when she was attempting to talk about her A.M. care. Unit Manager/Licensed Practical Nurse (LPN) #207 stepped up to speak with Resident #41 and offered her some coffee. STNAs #216 and #217 also stepped up to communicate appropriately with Resident #41. STNA #208 stepped away from the situation. Interview on 02/06/23 at 2:25 P.M. with STNA #208 revealed Resident #41 had hearing difficulty and staff must speak loudly to her. STNA #208 denied she had spoken rudely and disrespectfully to Resident #41. Interview on 02/06/23 at 2:30 P.M. with Unit Manager/LPN #207 verified STNA #208 should have spoken differently to Resident #41. Unit Manager/LPN#207 stated it was a fine line with Resident #41. Interview on 02/06/23 at 2:40 P.M. with Resident #41 revealed she didn't want this surveyor to address how STNA #208 spoke to her. Resident #41 reported she was spoken to rudely and without respect but must live in the facility and doesn't want to cause trouble for herself in the future. Resident #41 reported if anyone speaks to her again that way, she will address it. Resident #41 denied the encounter was abusive but acknowledged it to be disrespectful. Interview on 02/07/23 at 7:39 A.M. with Unit Manager/LPN #207 revealed her previous comment about fine line was about interventions used with Resident #41 may work one day and not the next. Review of the facility policy titled, Promoting/Maintaining Resident Dignity, revised 01/01/22 revealed it is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Further review of the policy revealed all staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights and staff are to speak respectfully to residents; avoid discussion about residents that may be overheard. This deficiency represents non-compliance investigated under Complaint Number OH00139597.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review the facility failed to ensure resident representatives were notified for a change in treatment plan. This affected one Resident (#107) of three residents reviewed for notification. The facility census was 106. Findings included: Review of Resident #107's medical record revealed an admission date of 01/09/23 with diagnoses including unspecified fracture of the right femur, type two diabetes, chronic obstructive pulmonary disease, chronic kidney disease, essential hypertension, major depressive disorder and generalized anxiety disorder. The resident was discharged from the facility on 01/20/23. Review of Resident #107's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 01/13/23, revealed the resident was cognitively independent. Review of Resident #107's nurse's progress notes dated 01/09/23 to 01/20/23 revealed the resident had Clostridium difficile and diarrhea upon admission and was treated for it. Review of Resident #107's progress note dated 01/16/23 by the facility Physician #215 revealed blood work had returned with a Sodium of 135, Blood [NAME] Nitrogen (BUN) of 34, and a creatinine of 1.88 which was roughly normal. Physician #215's plan for Resident #107 was no medication changes and follow up blood work. Review of Resident #107's progress note dated 01/17/23 by the facility Nurse Practitioner (NP) #214 revealed blood work had returned with a Potassium of 5.4, BUN of 41.5, and a creatinine of 2.33 all elevated from 01/16/23. NP #214 verified Resident #107 was on diuretics due to a history of cirrhosis. Physical therapy had reported to the NP that Resident #107 seemed more weak on 01/17/23. NP #214 noted signs of dehydration, and her plan was to hold Resident #107's diuretics for two days and then start back on the diuretics on day three at a lower dose. Staff were to encourage fluids to encourage fluids. Review of Resident #107's physician orders for January 2023, identified on 01/17/23, hold Lasix 40 mg daily due to sign and symptoms of dehydration and hold Spironolactone 100 mg daily due to signs and symptoms of dehydration. Review of the nurses' notes dated 01/15/23 to 01/20/23 revealed no notification of the family regarding the changes in Resident #107's results and the changes in the diuretic medication. Interview on 02/07/23 at 12:20 A.M. with Unit Manager/Licensed Practical Nurse (LPN) #207 verified there was no documentation to support the family was notified of laboratory results or changes in medication orders due to a change in lab values for Resident #107. Unit Manager/LPN #207 reported every time she spoke with the daughter the daughter wanted to focus on the Zyprexa. Review of facility policy titled, Notification of Changes, revised 01/01/22 revealed the purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification. Circumstances requiring notification include circumstances that require a need to alter treatment. This may include new treatment or discontinuation of current treatment due to adverse consequences, acute condition, or exacerbation of chronic condition. This deficiency represents non-compliance investigated under Master Complaint Number OH00139719.

Based on observation, interview, training record review, and policy review the facility failed to ensure staff wore N-95 masks appropriately. This had the potential to affect all 106 residents residing in the facility. Findings included: Interview on 02/06/23 at 8:00 A.M. with the Director of Nursing (DON), revealed the facility is in COVID-19 outbreak status due to a staff testing positive for COVID-19 on 02/04/23. The DON reported there were no residents with COVID-19 positive test results. 1. Observation on 02/06/23 at 10:00 A.M. revealed State Tested Nurse Aide (STNA) #201 was wearing her N-95 mask with both straps behind her neck. STNA #201's N-95 mask did not create a complete seal with her face. Observation on 02/06/23 at 12:17 P.M. revealed STNA #201 was wearing her N-95 mask the same way as observed earlier. An interview at this time with STNA #201 verified she was not wearing her N-95 mask correctly and the top strap should be over the crown of her head. 2. Observation on 02/06/23 at 11:26 A.M. revealed Licensed Practical Nurse (LPN) #202 wearing her N-95 mask with both straps behind her neck and below her ponytail. LPN #202's N-95 mask did not have a complete seal with her face. Observation on 02/06/23 at 12:08 P.M. revealed LPN #202 wearing her mask the same way as observed earlier. An interview at this time with LPN #202 revealed she had never been educated about the proper way to wear the straps of her N-95 mask with the upper strap over the crown of her head. 3. Observation on 02/06/23 at 11:26 A.M. revealed STNA #210 was wearing her N-95 mask with both straps behind her neck. STNA #210's N-95 mask did not create a complete seal with her face. Observation on 02/06/23 at 12:10 P.M. revealed STNA #210 was wearing her mask the same way as observed earlier. An interview at this time with STNA #210 verified she was not wearing her N-95 mask correctly and the top strap should be over the crown of her head. 4. Observation on 02/06/23 at 11:26 A.M. revealed STNA #211 was wearing her N-95 mask with both straps behind her neck. STNA #211's N-95 mask did not provide a complete seal with her face. Observation on 02/06/23 at 12:08 P.M. revealed STNA #211 wearing her mask the same way as observed earlier. An interview at this time with STNA #211 verified she was not wearing her N-95 mask correctly and the top strap should be over the crown of her head. 5. Observation on 02/06/23 at 11:30 A.M. revealed Dietary Aide #212 wearing her N-95 mask with the straps cut and tied. The straps did not go over the crown of her head or behind her head. The straps went behind each ear. Dietary Aide #212's N-95's mask did not provide a complete seal with her face. Observation on 02/06/23 at 12:12 P.M. revealed Dietary Aide #212 was wearing her mask the same way as observed earlier. An interview at this time with Dietary Aide #212 revealed she had never been told she could not alter her N-95 mask. 6. Observation on 02/06/23 at 11:47 A.M. revealed Activities Staff #213 was wearing her N-95 mask with both straps behind her neck. Activities Staff #213's N-95 mask did not provide a complete seal with her face. Observation on 02/06/23 at 12:13 P.M. revealed Activities Staff #213 was wearing her N-95 mask the same way as observed earlier. An interview at this time with Activities Staff #213 revealed she had forgotten how to wear a N-95 mask. Interview on 02/06/23 at 12:22 P.M. with the Director of Nursing (DON), revealed staff have been educated on the proper wearing of N-95 masks and to not alter the masks. Review of an in-service held on 01/08/23 to 01/12/23 revealed all facility staff were trained in proper Personal Protective Equipment (PPE) usage. Review of facility policy titled, Personal Protective Equipment, revised 01/01/22, revealed the facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. This deficiency represents non-compliance investigated under Complaint Number OH00139597.

Based on record review, review of a facility self-reported incident (SRI), facility investigation, employee personnel file review, facility policy review, and interview, the facility failed to ensure residents were free from misappropriation of medications. This affected one (Resident #4) of three residents reviewed for misappropriation. Findings include: Review of the medical record for the Resident #4 revealed an admission date of 12/17/22. Diagnoses included schizophrenia, dementia, anxiety disorder, alcoholic cirrhosis of the liver, chronic kidney disease, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/28/22, revealed the resident had intact cognition. The resident required extensive assistance of two staff for transfers, and extensive assistance of one staff for toileting and personal hygiene. Review of the resident's behaviors revealed no psychosis or rejection of care. Review of Resident #4's physician order, dated 12/21/22, revealed the order for Clindamycin HCL (antibiotic) capsule, give 450 milligrams (mg) three times per day, for seven days, for methicillin-resistant staphylococcus aureus (MRSA). Review of the Self-Reported Incident (SRI) #230910, dated 01/09/23 at 5:47 P.M., revealed on 01/09/23 at approximately 3:30 P.M., the Director of Nursing (DON) was notified by staff of a possible misappropriation of a discontinued medication belonging to Resident #4. The alleged nurse, Licensed Practical Nurse (LPN) #115, was immediately suspended pending the investigation. Review of the medical records revealed Resident #4 did receive the scheduled doses of medication. During interview with LPN #115, she revealed that she did take Resident #4's remaining clindamycin medication which was to be returned to the pharmacy. Review of the facility investigation, dated 01/09/23, revealed the DON and the Administrator interviewed LPN #115 regarding the allegation of misappropriation of Resident #4's clindamycin medication. The DON asked LPN #115 if she was aware of the incident involving the clindamycin and LPN #115 stated, I thought it would be thrown away, so I took them because I had a toothache. I never actually took the pills. I still have them with me, I can return them. LPN #115 was suspended immediately pending the investigation. The facility completed their investigation on 01/11/23 at 12:59 P.M. and substantiated the allegation of misappropriation. Review of State-Tested Nurse Aide (STNA) #114's witness statement, dated 01/09/23, revealed she was working on the first floor when she observed LPN #115 take some medications out of the medication room. According to the witness statement, LPN #115 sat at the desk and removed the medications from the packaging, placed them into a cup, and then placed the cup into her bag and went upstairs. LPN #115 placed the empty packaging into the garbage can. Review of LPN #116's witness statement, dated 01/09/23 at 4:10 P.M., revealed LPN #115 was observed taking Clindamycin 150 milligrams (mg) from the medication room and then popping them out of the card and into a cup, to reportedly take for a toothache. Review of LPN #115's personnel record revealed she was terminated from employment on 01/11/23 due to misappropriation of medication. During interview on 01/11/23 at 10:48 A.M., the Director of Nursing (DON) confirmed LPN #115 misappropriated Resident #4's remaining clindamycin medication. Reviewed facility policy, Abuse, Neglect, and Misappropriation, dated 07/28/20, revealed it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Investigation of Alleged Abuse: an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation. Written procedures for investigations include identifying staff responsible for the investigation; identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; providing complete and thorough documentation of the investigation. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to responding immediately to protect the alleged victim and integrity of the investigation; examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; increase supervision of the alleged victim and residents; room or staffing changes, if necessary, to protect the residents from the alleged perpetrator. This deficiency is cited as an incidental finding to Master Complaint Number OH00139296.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to adequately accommodate Resident #6's ability to call for assistance by providing a call signal device the resident could activate. This affected one resident (#6) of six residents reviewed for physical environment. Findings include: Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including diffuse traumatic brain injury without loss of consciousness, chronic respiratory failure, quadriplegia, cognitive communication deficit, and essential hypertension. Review of Resident #6's care plan, dated 10/13/22 revealed no focus regarding the resident not being able to use call system or related to the resident's needs in summoning staff assistance. Review of Resident #6's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/20/22 revealed the resident was severely cognitively impaired and required total dependence from two plus people to assist with bed mobility, transfers, dressing, toileting and personal hygiene. Review of the current physician's orders for Resident #6 revealed no order for frequent checks/increased monitoring due to the resident not being able to use a call light. On 10/31/22 at 3:56 P.M. observation revealed Resident #6 had been provided a thumb press call device. An interview at the time of the observation with Resident #6's family member revealed Resident #6 could not activate the call device. Resident #6's family member reported in the past, Resident #6 had a flat call device, but she was having trouble activating it. Resident #6's family member reported the facility had not provided a call signal device Resident #6 could easily use to call for assistance. On 11/02/22 at 9:17 A.M. interview with Respiratory Therapist (RT) #23 revealed he had seen different call devices for residents with brain injuries. Two examples of call devices for residents with brain injuries he provided were a flat one which a resident would hit with their hand and one the resident could activate by moving their head. On 11/02/22 at 9:18 A.M. interview with Licensed Practical Nurse (LPN) #94 verified Resident #6 did not have a call signal device she could use and there had not been an assessment completed to evaluate what call device would work or be most appropriate for the resident to summon assistance from staff. On 11/02/22 at 9:21 A.M. interview with Registered Nurse (RN) #56 revealed Resident #6 could move a couple of fingers on her right hand and move her head. On 11/02/22 at 9:41 A.M. LPN #94 was observed to provide Resident #6 with a flat call device that was activated by tapping it. Resident #6 was observed to be able to activate the call device when LPN #94 asked her to. On 11/02/22 at 9:43 A.M. interview with RN #56 verified there were no orders in Resident #6's medical record to check her more frequently than every two hours with turning and checking and nothing in the care plan regarding checks more frequently than every two hours with turning and repositioning. RN #56 verified with no call device to activate, Resident #6 could not notify staff of an emergent or non-emergent need for assistance. Review of the facility policy titled Call Lights: Accessibility and Timely Response, reviewed/revised 01/01/22 revealed each resident would be evaluated for unique needs and preferences to determine any special accommodations that might be needed in order for the resident to utilize the call system. Special accommodations would be identified on the resident's person-centered plan of care and provided accordingly. (Examples include touch pads, larger buttons, bright colors, etc.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #38's advance directives/code status was consistent between the paper (hard) chart and the electronic health record (EHR). This affected one resident (#38) of 32 residents reviewed for advanced directive. Findings include: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypercapnia, hereditary spastic paraplegia, dysphagia, moderate protein-calorie malnutrition and essential hypertension. Review of Resident #38's paper/hard chart revealed, effective [DATE] an advanced directive indicating the resident was a Full Code with cardiopulmonary resuscitation (CPR) desired. Review of Resident #38's admission Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident was cognitively intact. Review of Resident #38's electronic health record revealed an advanced directive, dated [DATE] for the resident to be a Do Not Resuscitate- Comfort Care Arrest (DNR-CCA). Review of Resident #38's physician's orders revealed an order related to advance directives, dated [DATE] which included the resident was a Do Not Resuscitate - Comfort Care Arrest (DNR-CCA) On [DATE] at 2:20 P.M. interview with Resident #38 revealed she did not wish to have CPR provided to her in the event of an emergency or situation requiring CPR (i.e. if her heart stopped). On [DATE] at 2:39 P.M. interview with State Tested Nursing Assistant (STNA) #52 revealed she knew what each resident's advanced directive was. She reported, if she wasn't sure, she could look at the hard/paper chart for confirmation of advanced directives. The STNA revealed Resident #38's was a DNR-CCA. On [DATE] at 2:54 P.M. interview with Licensed Practical Nurse (LPN) #108 revealed whatever advanced directive was signed and dated in the hard/paper chart was accurate for the resident's advanced directives. LP #108 verified the advanced directive in the hard/paper chart for Resident #38 was for CPR (signed [DATE]). On [DATE] at 3:00 P.M. interview with LPN #65 revealed if a resident did not have a pulse, she would first look in the electronic medical record (EHR) for the resident's advanced directive and then double check the advanced directive in the hard/paper chart. LPN #65 reported if the EHR revealed DNR-CCA and the advanced directive in the paper chart revealed CPR, and they were contradicting, she would start CPR. With this scenario, Resident #38 would receive CPR when her wishes and most recent signed advanced directive was for a DNR-CCA. Review of the facility policy titled Residents' Rights Regarding Treatment and Advanced Directives, reviewed/revised [DATE] revealed it was the policy of the facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advanced directive. Any decision making regarding the resident's choices would be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a beneficiary protection notification review form and interview the facility failed to ensure Resident #41 was provided an appropriate liability notice when discontinued/cut from Medicare Part-A services with days remaining. This affected one resident (#41) of two residents reviewed for liability notices who remained in the facility. Findings include: Record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including diffuse traumatic brain injury with loss of consciousness, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia, apraxia, lupus, pressure ulcer of right hip, peripheral vascular disease, pseudobulbar affect, Vitamin D and Vitamin B12 deficiency, depression, anemia, hyperlipidemia, history of malignant neoplasm of the testis, alcohol abuse, hypertension, atrial fibrillation, cognitive communication deficit, and insomnia. Review of Resident #41's undated Beneficiary Protection Notification Review form revealed the resident started Medicare Part A skilled services on 08/29/22 and his last covered day was 09/09/22. The facility/provider initiated the discharge for Medicare Part A Services when benefit days were not exhausted. The resident was not provided a Skilled Nursing Facility Advance Beneficiary Notice form (CMS-10055) or Notice of Medicare Non-Coverage Notice (CMS 10123) related to the termination of services as required. On 11/03/22 at 9:09 A.M. interview with the Director of Nursing (DON) confirmed the resident was to receive both forms CMS-10055 and CMS 10123, however there was some miscommunication between staff. The facility had been without a Licensed Social Worker (LSW) since July 2022 and another social service designee (SSD) from a sister facility, along with a Corporate LSW were helping the newly hired facility SSD. The new SSD thought the sister facility SSD had completed the liability notice forms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a facility self-reported incident, facility policy and procedure review and interview the facility failed to ensure Resident #50 was not forced to receive care against her wishes resulting in an allegation of rough care and the resident sustaining minor skin alterations. This affected one resident (#50) of three residents reviewed for physical abuse. Findings include: Record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including anxiety, major depression, bipolar, heart disease, and muscle weakness. Review of Resident #50's plan of care, dated 04/26/22 revealed the resident had potential to be physically aggressive or agitated related to anger, depression, history of harm to others, and poor impulse control. Interventions included to analyze times of days, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Monitor and document observed behavior and attempted interventions. Monitor/document/report as needed (PRN) any signs or symptoms of resident posing danger to self and/or others. Redirect emotional support food/fluids, activities, and remove from situation. Review of Resident #50's nursing progress note, dated 05/05/22 revealed the resident was combative with care. Hitting and kicking at staff while being changed due to the resident being incontinent of urine. Staff noticed two skin tears on resident. One skin tear noted to left hand third digit measuring 0.5 centimeters (cm) in length by 0.8 cm width with less than 0.1 cm depth. A second skin tear was noted to the top of the right-hand measuring two cm in length by 0.3 cm width with less than 0.1 cm depth. New orders were received to cleanse areas with wound wash, pat dry, apply triple antibiotic ointment and cover with border gauze. Change daily and as needed for soiling/dislodgement. Review of a facility self-reported incident and investigation, revealed on 05/08/22 at 8:30 P.M., staff reported Resident #50 voiced that staff (unidentified) were rough with care on 05/06/22 resulting in skin tears. A head-to-toe assessment was completed by the nurse with skin tears were noted on the resident's bilateral hands with bruising. Documentation supported the resident being combative with care on 05/05/22 resulting in the above injuries. Staff were educated on the abuse policy and resident's right to refuse care. The facility unsubstantiated an allegation of abuse as they determined there was no intent to harm the resident. Review of two undated staff witness statements revealed an incident occurred on 05/06/22 at 4:00 P.M., (not 05/05/22 per the above narrative summary and nursing progress note). State Tested Nursing Assistant (STNA) #68 reported STNA #47 and herself went into the residents room to change the resident because the resident and her bed were soaked. The statement revealed STNA #68 asked the resident if she could change her. The resident responded whatever and started screaming and fighting them. They then called STNA #122 for help and the resident started hitting and scratching STNA #122. The incident was reported to the nurse. STNA #122's statement indicated STNA #68 and STNA #47 went into change Resident #50 and the resident reported she was fine and then she started screaming and fighting when staff went to turn her. They asked if STNA #122 could come in and help. She went in and helped. The resident started hitting and kicking them and the bed rails. The incident was reported to the nurse. Review of a statement from Resident #48 (Resident #50's roommate at the time of incident), dated 05/09/22 revealed an incident had occurred on 05/05/22. The resident reported staff members had come in the room last week and were providing incontinence care Resident #50 and the resident started yelling, screaming, hitting, and kicking. Staff were trying to put the resident's (incontinence) brief on, and she heard them (staff) say watch her hands. The resident thought Resident #50 had kicked one of the girls. Record review revealed there was no statement obtained from STNA #48 or Resident #50 regarding the incident. Review of Resident #50's monthly behavior management nursing progress notes from 05/09/22 to 10/18/22 revealed the resident was [AGE] years old with a Brief Interview for Mental Status (BIMS) score of 13 (out of 15). The resident had behaviors of restlessness, agitation, refuses care, accusatory behaviors, physical aggression, tearfulness, and disrobing in public. Interventions included to redirect, emotional support, food, fluids, activity, and remove from area. Interventions were noted to be successful at times. On 10/31/22 at 1:49 P.M. an interview was attempted with Resident #50. However, the resident did not want to discuss the incident with the surveyor. On 11/03/22 at 3:40 P.M. and 11/07/22 at 12:15 P.M. interview with the Director of Nursing (DON) confirmed staff should have stopped providing care to Resident #50 when the resident started to become combative and should have not called additional staff into help (which likely escalated the situation). The staff should have walked away and tried to re-approach the resident later. The DON reported she had found dementia education she had provided to all staff on 11/06/22 after the incident, but prior to it being reported that was not included in the facility self reported incident. The DON verified there was no evidence statements were obtained from Resident #50 or STNA #48 as part of the investigation. Review of the facility Abuse, Neglect, and Exploitation policy and procedure, dated 07/28/20 and revised 10/24/22 revealed the policy was to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Staff should be trained on understanding behavioral symptoms of residents that may increase risk of abuse and neglect, aggressive/catastrophic reactions, resistance of care, and outburst or yelling. The investigation should include investigating different types of alleged violations. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrators, witness, or others who might have knowledge of the allegation. Provide complete and thorough documentation and investigation. The facility will make efforts to ensure the residents are safe during the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility Self-Reported Incidents (SRIs) and related investigation, review of controlled drug records/disposition forms, review of an employee personnel file, facility policy and procedure review and staff interview the facility failed to ensure residents were free from misappropriation of controlled (narcotic) medications. This affected two residents (#86 and #110) of three residents reviewed for misappropriation of medication. Findings include: 1. A review of Resident #86's closed medical record revealed the resident was originally admitted to the facility on [DATE] with a readmission date of 07/08/22. The resident had diagnoses including a left femoral neck fracture (hip fracture), low back pain, and the presence of bilateral artificial hip joints. Record review revealed the resident was discharged home on [DATE]. A review of Resident #86's admission Minimum Data Set 3.0 (MDS) assessment, dated 07/14/22 revealed the resident did not have any communication issues as he was able to make himself understood and was able to understand others. The assessment revealed the resident was cognitively intact and was not known to display any behaviors. A pain assessment revealed the resident did report having pain in the last five days and the pain was almost constantly. He rated the pain a 10 on a 1-10 scale at the worst during the last five days. The MDS assessment noted the pain did not affect his sleep at night but did limit his day-to-day activities. A review of Resident #86's care plans revealed a plan of care, initiated 10/01/22 related to the resident's risk for pain related to a left hip fracture, osteoarthritis, low back pain, and spinal stenosis. The goal was for the resident to have adequate pain control and for him to verbalize adequate relief of pain or the ability to cope with incompletely relieved pain. The interventions included administering his pain medications as ordered. A review of Resident #86's physician's orders revealed the resident had an order in place to receive Percocet (a controlled narcotic pain medication used in the treatment of moderate to severe pain) 5- 325 milligrams (mg) with directions to give one tablet by mouth every six hours as needed (PRN) for pain rated a three to six on a 1-10 scale. The instructions indicated two tablets could be given for pain levels between a seven and 10 on a 1-10 scale. A review of Resident #86's medication administration record (MAR) for October 2022 revealed RN #125 documented administering the resident his PRN Percocet twice during her night shift going from the evening of 10/11/22 into the morning of 10/12/22 and again the evening of 10/12/22 going into the morning of 10/13/22. During all four administrations of the PRN Percocet, RN #125 documented she gave the resident two of the 5-325 mg tablets with each dose given. The two tablets of Percocet that were documented as having been given to the resident on 10/11/22 at 10:20 P.M. did not follow the parameters set forth by the physician on when to administer the PRN Percocet. The resident's pain level was recorded as only being a 2 on a 1-10 scale at the time of the administration. The physician's orders did not permit the PRN Percocet to be given unless the resident's pain level was a 3 or higher. The resident was only to receive two tablets of the PRN Percocet when his pain level was 7 or higher. RN #125 did not follow the parameters specified with the physician's orders again on 10/13/22 at 6:07 A.M. when she documented she gave two Percocet 5- 325 mg tablets for a pain level of a 6 on a 1-10 scale. Documentation on the MAR and Controlled Drug Record/ Disposition form indicated RN #125 administered a total of four Percocet tablets the night of 10/13/22. A review of facility self-reported incident (SRI), tracking number 228015 revealed an allegation of misappropriation of resident property was made on 10/13/22. The initial source of the allegation was from Resident #86, who was identified to be the resident victim. Resident #86 was noted to have been able to provide meaningful information when interviewed and the effect the incident had on the resident was reports of diarrhea. The alleged/ suspected perpetrator was a staff member not identified in the initial report. The final report for SRI tracking number 228015 revealed the date/ time/ location of the occurrence was on 10/13/22 at 5:40 A.M. in the resident's room. The narrative summary of the incident revealed the facility Administrator was made aware Resident #86 was concerned he was given the wrong medication in place of his prescribed pain medication by RN #125. As a result, the resident did not take the medication and sat it to the side, so the oncoming day shift nurse could see what he had been given. Shortly after 7:00 A.M., Resident #86 called for Licensed Practical Nurse (LPN) #112 to come to his room. He showed the nurse the pills that had been given to him that night by RN #125 as his PRN pain (Percocet) medication. Upon further investigation, it was confirmed the pills Resident #86 received were actual stool softener, Colace 100 mg capsules and not his PRN Percocet ordered for pain. The information was brought to the Administrator's attention and an investigation began with RN #125 being suspended pending the outcome of the investigation. Resident #86's physician's orders were reviewed as part of the facility's investigation, and it was determined the resident did not have a physician's order to receive Colace 100 mg capsules on a scheduled or a PRN basis. Statements were obtained from Resident #86 and LPN #112 as part of the facility's investigation. The local police department were also informed of the alleged misappropriation of controlled narcotic pain medication. The facility unsubstantiated the allegation of misappropriation at the conclusion of their investigation indicating the evidence was inconclusive, although misappropriation was suspected. RN #125 was terminated from employment but was terminated due to nursing policies in regard to medication and documentation being violated. A review of the facility's investigation revealed a witness statement from Resident #86 was obtained. The resident reported in his statement the night before (10/11/22- 10/12/22) the nurse (RN #125) gave him pills for pain and he did not get any relief from his pain after taking the pills nor did they make him sleep. He informed another nurse about it (LPN #112) and she encouraged him to check his pills the next time they were given to him and told him what to look for. The resident alleged he had received four pills that were not the same pain pills he was familiar with receiving. The evening of 10/12/22 going into the morning of 10/13/22, the resident indicated he informed the nurse (RN #125) the pills she was giving him did not look right. The nurse took them back, looked at them, and handed them back to him while telling him they had come from a new box. He had to put them in his mouth under his tongue until she left and then he took them out of his mouth. A witness statement from LPN #112 revealed Resident #86 had reported to her the morning of 10/12/22 he did not know what the night shift nurse (RN #125) had given him, but that it was not his pain pills. Resident #86 informed LPN #112 he was in pain all night (10/11/22- 10/12/22) and could not sleep. He also reported to her that he was using the bathroom all night to defecate. She offered for him to file a complaint then, but the resident declined. The resident remained adamant he did not receive the proper pain medication. LPN #112 stated she told the resident to look at his pills the next time and if they did not have the identifying numbers on them as his PRN Percocet did then they were not his pills. The nurse hoped that would clear things up and prove he was getting the proper medication. She stated, however, it did not. The resident kept the pills he was given the next night (10/12/22) as his PRN pain medication and showed LPN #112 the morning of 10/13/22. The nurse indicated in her witness statement that what was given to the resident were stool softeners. At that time, the resident requested to file a complaint. A review of an email from RN #125 to the facility's Administrator, sent 10/20/22 at 10:36 A.M. revealed, on her shift from the evening of 10/12/22 to the morning of 10/13/22, she woke Resident #86 that morning to give him his pain medication. She also gave the resident stool softeners as he had told her earlier he had not gone to the bathroom, so she gave him two stool softeners after his pain medication. A review of RN #125's employee file revealed a Performance Improvement Form dated 10/20/22. The form indicated the RN had a hire date of 02/28/20. The reason for counseling/ corrective action was for violating company policy related to medications given without a physician's order, which was verified by RN #125 during an interview on 10/20/22. Documentation was also not taking place at the time medication was being administered. There was also the improper wasting of a narcotic pain medication of another resident found by the DON during the course of Resident #86's investigation. The facility's investigation file also included a complaint form to the State of Ohio Board of Nursing, dated 10/27/22 that revealed the facility's Director of Nursing (DON) filed a complaint with the Board of Nursing about RN #125. A description of the complaint or violation revealed RN #125 had been suspended for misappropriation. Their investigation revealed violations of three company policies that resulted in her termination from employment. The involved resident was mentioned in the complaint and the resident was indicated to have had pain management issues related to the practice breakdown. The resident was indicated to have received the wrong medication and reported he did not receive the pain medication that was signed off as having been administered to him. The DON indicated no harm occurred to the resident despite him having unrelieved pain that kept him up all night. The involved nurse was also indicated to have administered a medication (Colace) without a physician's order to do so. The DON added the resident reported he was given the wrong medication when he asked for his PRN pain medication. Their investigation revealed the nurse gave Colace to the resident without an order, inappropriate documentation related to signing the medication administration record (MAR's) at the correct times, and improper waste of a narcotic medication. A review of a Controlled Drug Receipt/ Record/ Disposition form for Resident #86's Percocet that was included in the facility's investigation file revealed RN #125 documented she gave the resident his PRN Percocet twice on the evening of 10/11/22 going into the morning hours of 10/12/22 and again the evening of 10/12/22 going into the morning hours of 10/13/22. Both times she signed to reflect she gave the resident two tablets of Percocet (Oxycodone/ Acetaminophen) 5-325 milligrams (mg) at each administration totaling four tablets each of the two shifts. On 11/02/22 at 8:27 A.M. interview with LPN #112 revealed the incident involving Resident #86 happened about three weeks ago. The resident told her the morning of 10/12/22 (the day before the incident was reported to administration) he did not get his pain medication from the night shift nurse (RN #125) as he requested and the resident suspected the nurse gave him something else instead. The LPN stated she showed the resident what his PRN Percocet looked like after he questioned whether he was being given the correct medication. The next morning (10/13/22) when she came to work, the resident asked to see her. The resident had four stool softeners to show her that he stated had been given to him by RN #125 after he had requested his Percocet pain medication. LPN #112 verified what the resident was given was Colace and not his PRN Percocet. She denied the resident had an order to receive Colace. The LPN revealed the night before (10/11/22- 10/12/22), the resident reported he was up all night with pain and had to go to the bathroom to defecate. She stated the PRN Percocet was ordered on a PRN basis and the resident would have to ask for it before it being administered. The LPN revealed the resident was given two Colace capsules each time he asked for his PRN Percocet. The second time the resident was supposedly given his PRN Percocet (the morning of 10/13/22), LPN #112 revealed the resident got two more Colace in place of his PRN Percocet when he did not even ask for it. The resident was reportedly told (by RN #125) they looked different because they came out of a different box when the resident questioned why they looked different from his usual PRN pain medication. The resident recognized the PRN Percocet given to him by RN #125 were not the same that he had received previously. On 11/02/22 at 5:38 P.M. interview with the facility's Administrator and Director of Nursing (DON) revealed they both were involved in the investigation of SRI tracking number 228015 and RN #125's alleged misappropriation of Resident #86's PRN Percocet. Resident #86 thought things did not seem right with his medications. LPN #112 was the first to hear about the resident's concerns (on 10/11/22), but stated she did not have immediate concerns when it was first brought to her attention. The Administrator and DON were aware LPN #112 showed the resident what his Percocet looked like so in the event he thought something was wrong, he would know. On the evening of 10/12/22 going into 10/13/22, the resident reported he requested pain mediation and RN #125 brought medication into him that didn't look right. He placed the medication to the side after not taking them. Later that morning, RN #125 came in again with his PRN pain medication and he informed her they did not look right. RN #125 looked at them then gave them back to him telling him they came in a new box. The resident placed the medication under his tongue and removed them after she left the room. LPN #112 came in around 7:00 A.M. that morning as the day shift nurse. He showed LPN #112 the medication that was given to him by RN #125 as his PRN pain medication. LPN #112 verified the PRN pain medication was not his Percocet but was Colace instead. The Administrator confirmed four capsules of Colace were shown to LPN #112 that morning. It was after this second night that LPN #112 reported the incident to the Administrator. Witness statements were obtained and a SRI was initiated. The facility suspended RN #125 pending an investigation. The Administrator revealed although the suspected RN #125 took the PRN Percocet, they did not feel they could prove it. The Administrator revealed as part of the facility investigation the they looked at other resident's narcotic documentation to see if a pattern was seen with PRN pain medications. The Administrator revealed it seemed odd to him Resident #86 may have used his PRN pain medications here and there for other nurses but when RN #125 worked she seemed to administer it to the resident more frequently. They calculated about 46% of Resident #86's pain medication ordered on a PRN basis was given by RN #125. They suspected concerns with other residents controlled narcotic pain medications during their facility wide investigation as well. The Administrator indicated, because of their investigation into Resident #86's misappropriation, the facility unsubstantiated as their evidence was inconclusive. They suspected RN #125 took the PRN Percocet, but did not feel they could prove it. Their policy on medication diversion did not permit them to drug test staff suspected of medication diversion without evidence of the employee showing signs of being under the influence. He believed the local police investigation hit a dead end as well due to RN #125 refusing to take a polygraph test. He denied Resident #86 was reimbursed for the PRN Percocet that was signed out for him, but not administered. He acknowledged the four doses could not be accounted for, since they were signed out and it was proven what was given to the resident for those documented doses were not the PRN Percocet he should have been given. The DON confirmed there was no order for the resident to receive Colace on a scheduled or PRN basis. She stated that was what they used to be able to terminate the nurse, since she administered it without an order. The DON acknowledged RN #125 did not follow the physician's orders regarding the provided parameters in which the PRN Percocet could be given or at what dose. A review of the facility policy on Abuse, Neglect, and Exploitation revised 01/01/22 revealed it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The definition of misappropriation of resident property meant the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Possible indicators of abuse included resident reports of theft of property. 2. A review of Resident #110's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including the presence of a left artificial knee joint and aftercare following joint replacement surgery. A review of Resident #110's Minimum Data Set (MDS) 3.0 assessment, dated 10/13/22 revealed the resident did not have any communication issues as she was able to make herself understood and was able to understand others. The assessment revealed the resident was also noted to be cognitively intact and was not known to have displayed any behaviors. The resident was assessed to have complaints of frequent pain that she rated a 7 on a 1-10 scale at it's worst. The assessment revealed the pain did not affect her sleep or day to day activities. A review of Resident #110's care plans revealed a care plan, dated 10/05/22 related to being at risk for pain related to a recent left knee replacement. The goal was for the resident to verbalize adequate relief of pain or the ability to cope with incompletely relieved pain. Interventions included administering pain medication as ordered. A review of Resident #110's physician's orders revealed she had an order in place to receive Hydrocodone- Acetaminophen (Norco) 5- 325 mg by mouth every four hours as needed (PRN) for a pain level between 6-10 on a 1-10 scale. A review of Resident #110's Controlled Drug Receipt/ Record/ Disposition Form for her Norco (a narcotic pain medication used to treat moderate to severe pain) 5- 325 mg tablets revealed RN #125 documented she pulled a dose of Norco from the controlled medication supply on 10/12/22 at 1:44 A.M. and again at 5:52 A.M. A review of Resident #110's MAR for October 2022 revealed RN #125 only documented the resident was given a dose of Norco on 10/12/22 at 1:44 A.M. There was no documented evidence of the resident being given a dose of her PRN Norco on 10/12/22 at 5:52 A.M. as signed out on the Controlled Drug Receipt/ Record/ Disposition Form. A review of the facility's investigation pertaining to SRI tracking number 228015 revealed Resident #110 was reviewed as a like resident related to another resident's allegation of misappropriation of medications. The facility reviewed other residents narcotic pain medication count sheets as part of their investigation to include Resident #110's. The resident's Controlled Drug Receipt/ Record/ Disposition Form for her Norco (Hydrocodone- Acetaminophen) 5-325 mg tablets revealed a dose was noted to have been given to the resident on 10/12/22 at 5:52 A.M. by RN #125. The dose signed out on the Controlled Drug Receipt/ Record/ Disposition Form by RN #125 was not recorded on Resident #110's October 2022 MAR to show documented evidence the Norco had been actually administered to the resident. The facility's investigation included a written statement from the facility's Administrator revealing he had a conversation with LPN #112 who indicated she had spoken with Resident #110 about her PRN pain medication prior to the resident's discharge from the facility. LPN #112 reported Resident #110 told her there were many times she did not receive her PRN pain medication when reviewing what was documented as having been given on the Controlled Drug Receipt/ Record/ Disposition Form. The Administrator indicated in the same written statement he reached out to Resident #110 on two occasions but was unable to reach her as he did not receive a return call. Resident #110 was discharged from the facility on 10/13/22. A review of a Performance Improvement Form for RN #125, dated 10/20/22 revealed she received corrective action on that date for the improper wasting of a narcotic. It was found by the DON during the course of a facility investigation into another resident's allegation of misappropriation of medication and was confirmed by RN #125 during her interview on 10/20/22 at 9:00 A.M. On 11/02/22 at 8:27 A.M., an interview with LPN #112 revealed she recalled one morning when Resident #110 had asked her for a PRN narcotic pain pill. She checked the MAR and it showed RN #125 had given the resident her last dose of Norco around 1:00 A.M. When she looked at the Controlled Drug Receipt/ Record/ Disposition Form it showed a dose of the medication had been signed out around 1:00 A.M. and again around 5:00 A.M. She informed the resident the records showed she received a Norco tablet around 5:00 A.M. that morning based on what was documented by RN #125, however the resident denied that she had been given that dose. On 11/02/22 at 2:50 P.M., an interview with the DON revealed Resident #110's narcotic pain medication (Norco) was improperly wasted by RN #125 on 10/12/22 at 5:52 P.M. The DON stated the Norco had been signed out on the Controlled Drug Receipt/ Record/ Disposition Form but was struck out on the MAR. RN #125 reported she did not administer the Norco and wasted it instead. The destruction or wasting of that controlled medication was not witnessed by another nurse. On 11/02/22 at 5:38 P.M., an interview with the DON revealed the dose of Norco that was signed out on the Controlled Drug Receipt/ Record/ Disposition Form for 10/12/22 at 5:52 A.M. by RN #125 could not be accounted for, since it was not signed off on the MAR for October 2022 as having been given. She confirmed her investigation determined the Norco was signed out and marked on the MAR but had been struck out. It was no longer recorded to show it had been received. She stated their interview with RN #125 revealed she had wasted the Norco when it was not given to the resident. The nurse did not have another nurse witness the destruction of that medication as was required when disposing of a controlled medication. She acknowledged, since the narcotic pain medication had been signed out on the Controlled Drug Record and was not documented as having been given on the MAR, the medication was misappropriated as it could not be shown it was given to the resident as intended for. They could not show evidence of the controlled medication being wasted as it was not documented as having been wasted nor was there a witness account by another nurse to prove that it was. She confirmed RN #125 was associated with the suspected misappropriation of another resident's PRN narcotic pain medication. This deficiency represents non-compliance investigated under Complaint Number OH00136857, Control Number OH00136889 and Control Number OH00136939.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure residents and/or their representatives were provided with a transfer notice as required and failed to ensure the State Ombudsman was notified of facility initiated transfers/discharges. This affected three resident (#75, #52 and #109) of four residents reviewed for hospitalization and discharge. Findings include: 1. Medical record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease stage 4, and urinary tract infection (UTI). The resident was hospitalized from [DATE] to 10/10/22 for diagnoses of small bowel obstruction, UTI, abscess of chest wall, and high troponin level. Further review of the resident's electronic medical record and paper/hard chart revealed no evidence a transfer/discharge form was completed and given or sent to the resident/resident representative. There was no evidence of the Ombudsman being notified of the facility initiated hospital transfer. During interview on 11/09/22 at 10:33 A.M., the Director of Nursing (DON) confirmed there was no evidence a transfer form was completed and was given to the resident/resident representative in writing when the resident was transferred to the hospital on [DATE] or that the State Ombudsman had been notified of the transfer. Review of the facility policy titled Transfer and Discharge, dated 10/28/20 revealed during emergency transfer/discharges initiated by the facility for medical reasons, the resident/resident representative would be notified, the facility would complete and send with the resident a Transfer Form, and the Social Services Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list. 3. Record review revealed Resident #109 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Resident #109 had diagnoses including acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, absence of part of a lung, sacrolitis, paraplegia, pneumonia, Parkinson's disease, pressure ulcers, cognitive communication deficit, depression, restless leg syndrome, overactive bladder, muscle weakness, anxiety, hyperlipidemia, and lumbago with sciatica. Review of Resident #109's nursing note, dated 09/25/22 revealed the resident's oxygen saturation reading was 70 percent. No other signs of hypoxia, respirations even and unlabored. The resident was alert and oriented times four (person, place, time and circumstance), denied pain or shortness of breath and refused to go the hospital. The husband was very persistent he did not want the resident sent to the hospital. At approximately 4:00 P.M., the nursing assistant was changing the resident's brief and noted the resident was more lethargic but still awakened to voice and able to answer questions appropriately. The resident's son arrived at this time and stated to call the squad. Based upon her own nursing judgement and the family's request she sent the resident to the emergency room for evaluation at this time. Further review revealed no evidence a transfer form was completed or documented in the paper or electronic medical record as to what was communicated to the receiving provider. In addition, there was no evidence the State Ombudsman was notified of the transfer. On 11/08/22 at 8:32 A.M. interview with the Director of Nursing (DON) revealed she was not able to find the transfer form or evidence what was communicated to the receiving provider at the time of transfer. The DON was also unable to provide evidence the State Ombudsman was notified of the resident's transfer to the hospital. Review of the facility Transfer and Discharge policy and procedure, dated 10/18/20 and revised 01/01/22 revealed it was the facility policy to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents were endangered. The emergency transfer/discharge was initiated by the facility for medical reason, or for the immediate safety and welfare of the resident. The resident/representative should be notified. Complete and send with the resident a transfer form with the resident and obtain a copy for the medical record. Provide a notice of the resident's bed hold policy to the resident and representative at the time of the transfer if possible, but not later than 24 hours of the transfer. Provide the transfer notice as soon as practicable to the resident and representative. Social service director or designee shall provide a notice of the transfer to a representative of the state long term, care ombudsman via monthly list. In case of discharge, notice requirements and procedures for facility initiated discharges would be followed. 2. A review of Resident #52's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, non-Hodgkin lymphoma, adult onset diabetes mellitus, and chronic kidney disease. The resident was hospitalized on [DATE] and was readmitted to the facility on [DATE]. A review of Resident #52's Situation Background Assessment Request (SBAR) note under the assessment tab of the electronic health record (EHR) revealed the resident was having shortness of breath, rapid respirations, emesis, decreased oxygen saturation, and shaking with complaints of terrible leg pain. Symptom onset was 10/20/22 and the symptoms had gotten worse since their onset. The resident's blood pressure was low at 98/55 and his oxygen saturation was low at 86% (92% or above was normal) but the rest of his vital signs were stable. The Registered Nurse (RN) indicated under her assessment she thought the problem may have been related to a shunt adjustment at an appointment he had earlier that day. A review of Resident #52's hospital records for his hospitalization from 10/20/22 to 10/25/22 revealed the resident was sent to the hospital for a low blood pressure. The resident reported feeling unwell with an onset of nausea and vomiting. He was transferred to a hospital in Columbus, Ohio where he was noted to have an elevated temperature of 102.6 degrees Fahrenheit and a low blood pressure of 94/33. The resident was diagnosed with septic shock due to gram negative bacteremia and an acute complicated UTI due to chronic supra pubic catheter use. The facility denied they had any documented evidence of the resident and/or his representative being provided a copy of a transfer notice when the resident was sent out to the hospital on [DATE]. They also were not able to provide any evidence of the State Ombudsman being notified of Resident #52's transfer to the hospital as necessary with the transfer/ discharge requirement. Findings were verified by the Director of Nursing (DON). On 11/08/22 at 10:05 A.M. interview with the DON revealed she was not able to find evidence of a transfer notice being provided to Resident #52 or his resident representative. She also stated she did not have any evidence of the local Ombudsman being notified of the resident's transfer to the hospital as required. A review of the facility policy on Transfer and Discharge, revised 01/01/22 revealed for emergency transfers/ discharges the facility was to notify the resident and/or resident representative of the transfer. They were to provide the transfer notice as soon as practicable to the resident and representative. The Social Service Director, or designee, should provide notice of the transfer to a representative of the State Long-Term Care Ombudsman via a monthly list.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #109 was provided a bed hold notice upon transfer to the hospital. This affected one resident (#109) of three residents reviewed for hospitalization. Findings include: Record review revealed Resident #109 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Resident #109 had diagnoses including acute and chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, absence of part of a lung, sacrolitis, paraplegia, pneumonia, Parkinson's disease, pressure ulcers, cognitive communication deficit, depression, restless leg syndrome, overactive bladder, muscle weakness, anxiety, hyperlipidemia, and lumbago with sciatica. Review of Resident #109's nursing note, dated 09/25/22 revealed the resident's oxygen saturation reading was 70 percent. No other signs of hypoxia, respirations even and unlabored. The resident was alert and oriented times four (person, place, time and circumstance), denied pain or shortness of breath and refused to go the hospital. The husband was very persistent he did not want the resident sent to the hospital. At approximately 4:00 P.M., the nursing assistant was changing the resident's brief and noted the resident was more lethargic but still awakened to voice and able to answer questions appropriately. The resident's son arrived at this time and stated to call the squad. Based upon her own nursing judgement and the family's request she sent the resident to the emergency room for evaluation at this time. Further review revealed no evidence the resident or the resident representative received a copy of the facility bed hold notice. On 11/08/22 at 8:32 A.M. interview with the Director of Nursing (DON) verified the facility was unable to provide evidence the resident and/or responsible party were provided a bed hold notice at the time of the resident's transfer to the hospital. Review of the facility Transfer and Discharge policy and procedure, dated 10/18/20 and revised 01/01/22 revealed it was the facility policy to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents were endangered. The emergency transfer/discharge was initiated by the facility for medical reason, or for the immediate safety and welfare of the resident. The resident/representative should be notified. Complete and send with the resident a transfer form with the resident and obtain a copy for the medical record. Provide a notice of the resident's bed hold policy to the resident and representative at the time of the transfer if possible, but not later than 24 hours of the transfer. Provide the transfer notice as soon as practicable to the resident and representative. Social service director or designee shall provide a notice of the transfer to a representative of the state long term, care ombudsman via monthly list. In case of discharge, notice requirements and procedures for facility initiated discharges would be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure Pre-admission Screening and Resident Review (PASARR) documentation was accurate to reflect the resident's cumulative diagnoses and updated following a change in mental health diagnoses. This affected one resident (#77) of two residents reviewed for PASARR. Findings include: Review of Resident #77's medical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses including bipolar disorder, major depressive disorder, anxiety disorder, essential hypertension, chronic obstructive pulmonary disease, and tremors. Review of Resident #77's PASARR, dated 08/02/22 revealed under Section E, subsection 1.: Indications of Serious Mental Illness the boxes beside panic or other severe anxiety disorder and personality disorder were marked with an X. The box beside of mood disorder was not marked with an X even though Resident #77 had a depression and bipolar disorder diagnosis. Review of Resident #77's admission Minimum Data Set (MDS) 3.0 assessment, dated 08/31/22 revealed the resident was cognitively impaired and had active diagnoses of anxiety disorder, depression, and bipolar disorder. Record review revealed the diagnoses of panic disorder and obsessive-compulsive disorder were added to the resident's diagnosis list on 09/20/22. On 11/01/22 at 3:31 P.M. interview with Social Service Designee (SSD) #84 verified the most recent PASARR for Resident #77 was the one dated 08/02/22 (prior to the resident's admission). SSD #84 verified the facility failed to update the PASARR upon admission related to the diagnoses of bipolar disorder and depression or on 09/20/22 following the addition to the diagnoses of panic disorder and obsessive-compulsive disorder to reflect the resident's indicators of serious mental illness and to ensure the resident was properly assessed for potential Level II services. Review of the facility policy titled PASARR - Pre-admission Screen and Resident Review, reviewed/revised 01/01/22 revealed if a resident was admitted with a level diagnosis as indicated a review was required upon change in the resident's condition. For example, there had been a significant change in the resident's physical or mental condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed for Resident #39 prior to admission. This affected one resident (#39) of two residents reviewed for PASARR. Findings include: Record review revealed Resident #39 was admitted to the facility originally on 06/23/22 and re-admitted on [DATE] with diagnoses including dementia with moderate behavioral disturbance, major depression, anxiety, psychosis, and insomnia. Review of Resident #39's progress notes revealed the resident was admitted on [DATE] and transferred back out to the psychiatric hospital a few hours later. Review of Resident #39's paper/hard chart and electronic medical record revealed no evidence a PASARR was completed for the 06/23/22 admission or the 07/11/22 re-admission. Review of Resident #39's admission Minimum Data Set (MDS) 3.0 assessment, dated 07/19/22 revealed the resident was not considered for Level II services through the PASARR review. On 11/08/22 at 9:16 A.M. interview with admission Coordinator (AC) #114 verified a PASARR was not completed for Resident #39 upon admission or re-admission. AC #114 revealed she completed the PASARR today. The admission coordinator indicated there had been some confusion related to who in the facility was responsible for completing the PASARR's. AC #114 revealed the facility had completed an audit, but stated they must have missed this one. After reviewing the PASARR AC #114 completed on 11/08/22 it was noted the PASARR was inaccurate and did not reflect the resident's psychiatric hospitalizations. On 11/08/22 at 1:08 P.M. interview with the Director of Nursing (DON) verified the resident was admitted on [DATE] from a psychiatric hospital and was transferred back to the hospital after a few hours after admission to the facility. The DON confirmed the PASARR that was completed today (11/08/22) by AC #114 indicated unknown to psychiatric services in the last two year which was inaccurate and did not reflect the resident's recent two psychiatric hospital stays. On 11/08/22 at 1:46 P.M. interview with AC #114 revealed she called the Area of Aging and was able to fix the PASARR to include the two psychiatric hospital visits and a referral was made to have the resident evaluated for Level II services. On 11/08/22 at 2:34 P.M. interview with Licensed Practical Nurse (LPN) #67 revealed social services staff were responsible for completing Section A1500 of the MDS assessment related to PASARR. The LPN confirmed the section was coded inaccurately due to there being no PASARR completed for the resident at the time of the MDS assessment. Review of facility Pre-admission Screen and Resident Review policy and procedure, dated 10/18/20 and revised 01/01/22 revealed the facility must coordinate assessments with the pre-admission screening and resident review program under Medicaid in part 483, subpart C to the maximum extent practicable to avoid duplicative testing and efforts. All residents were required to have a Level I PASARR screen prior to or upon admission to the facility. When indicated on the Level I screen that a Level II screen was required, the facility would complete notification to the States' PASARR program notice for the Level II.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure comprehensive and individualized care plans were developed and implemented for all residents. This affected three residents (#38, #54, and #77) of 36 sampled residents reviewed for care planning. Findings include: 1. Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypercapnia, hereditary spastic paraplegia, moderate protein-calorie malnutrition, and essential hypertension. Review of admission Minimum Data Set (MDS) 3.0 assessment, dated 08/25/22 revealed Resident #38 was cognitively intact, had no broken or loosely fitting full or partial denture and had no natural teeth or tooth fragments. Review of Resident #38's care plan, dated 08/19/22 revealed a focus area related to the resident's dentures not fitting appropriately. An intervention included to coordinate arrangements for dental care, transportation as needed and as ordered. On 10/31/22 at 11:26 A.M. interview with Resident #38 revealed her dentures did not fit properly and the facility was supposed to get them fixed but didn't. An observation at the time of the interview revealed Resident #38 was edentulous (without teeth). On 11/06/22 at 11:39 A.M. interview with Licensed Practical Nurse (LPN) #94 revealed she stated she dropped the ball regarding obtaining a referral for dental from Resident #38's physician. On 11/09/22 at 3:01 P.M. interview with the Director of Nursing verified the care plan for Resident #38 regarding her dentures not fitting appropriately had not been implemented as it should have been. 2. Review of the medical record for Resident #54 revealed the resident was admitted to the facility 08/31/21 with diagnoses of chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, morbid obesity, and type two diabetes. Review of Resident #54's annual Minimum Data Set (MDS) 3.0 assessment, dated 09/06/22 revealed the resident was cognitively intact, had no abnormal mouth tissue, no obvious or likely cavity or broken teeth, no inflamed or bleeding gums or loose natural teeth and no mouth or facial pain, discomfort or difficulty with chewing. On 10/31/22 at 5:27 P.M. interview with Resident #54 revealed he had had been seen by an in-house dentist who couldn't help him in October, 2022. Resident #54 reported he was to be referred to a different dentist outside the facility. Resident #54 reported he had not seen a different dentist or been told when that appointment would be and that he needed to see someone related to dental issues he was having. Review of Resident #54's current care plan revealed the facility failed to develop any type of plan of care related to the resident's dental needs or concerns. On 11/06/22 at 8:46 A.M. interview with the DON verified there was no care plan developed for Resident #54's dental needs and verified a care plan should have been developed since the resident was having dental concerns requiring dental consult. 3. Review of Resident #77's medical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses including bipolar disorder, major depressive disorder, anxiety disorder, essential hypertension, chronic obstructive pulmonary disease and tremors. Review of Resident #77's admission Minimum Data Set (MDS) 2.0 assessment, dated 08/31/22 revealed the resident was cognitively impaired and had active diagnoses of anxiety disorder, depression, and bipolar disorder. On 09/20/22 the resident's diagnosis list was updated to include diagnoses of panic disorder and obsessive-compulsive disorder. Review of Resident #77's care plan, dated 10/13/22 revealed Resident #77 had a care plan for anti-anxiety medication, anti-depressant medication and anti-psychotic medication use. Record review revealed no evidence a plan of care had been developed to address the resident's needs related to the diagnosis of bipolar disorder. On 11/09/22 at 3:10 P.M. interview with the DON verified there was no care plan developed for Resident #77's diagnosis of bipolar disorder needs. The DON verified a care plan should have been developed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure comprehensive, person-centered care plans were accurate to reflect the resident's current status and/or revised to include current interventions for Resident #28 related to pressure ulcers and for Resident #41 related to falls/accident hazards. This affected two residents (#28 and #41) of 36 sampled residents whose care plans were reviewed. Findings include: 1. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including unspecified fracture of shaft of left humerus, hypertension, atrial fibrillation, and muscle weakness. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/06/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 (out of 15), which indicated intact cognition. There assessment revealed the resident had no behaviors or rejection of care. The MDS 3.0 assessment further revealed Resident #28 required extensive, two-person assistance with personal hygiene, bed mobility, and transfers. The resident was continent of bowel and bladder. Review of the care plan, dated 09/03/22 revealed the resident had pressure wound development with interventions including to administer treatments as ordered. The care plan was not individualized to reflect the resident's specific wound treatment order for the suspected deep tissue injury (SDTI) the resident had located on the right heel. Review of the physician's orders revealed an order, dated 09/29/22 to cleanse right heel with soap and water, pat dry, and apply skin prep. Cover wound with border foam dressing and change every three days and as needed. This intervention was not added to the resident's care plan. During interview on 11/02/22 at 10:25 A.M., the Director of Nursing (DON) confirmed Resident #28's care plan was not individualized to reflect the specific wound treatment order or extent of the wound the resident had. 2. Record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including diffuse traumatic brain injury with loss of consciousness, hemiplegia and hemiparesis, lupus, cognitive communication deficit, and muscle weakness. Review of Resident #41's fall plan of care related to history of falls and traumatic brain injury dated 08/17/20 revealed an intervention (dated 07/21/22 and revised 10/10/22) to ensure chair and bed alarms were functioning and in place and an intervention (dated 09/08/22) to ensure mattress was securely fastened to bed frame. Review of Resident #41's Treatment Administration Records (TAR) revealed staff had been documenting the mattress was secured to the bed frame from 04/25/22 to 11/03/22 and the chair and bed alarm from 07/25/22 to 10/11/22. On 11/01/22 at 2:40 P.M. observation of Resident #41 with an unidentified State Tested Nursing Assistant revealed the resident had interventions in place except for the chair and bed alarms. The resident was in bed at the time of the observation and the surveyor was unable to check mattress to ensure it was secure. On 11/02/22 at 8:20 A.M. observation of Resident #41 with STNA #46 verified the resident had no bed or chair alarm at that time. The STNA reported all alarms had been discontinued on all residents, including Resident #41 recently. On 11/03/22 at 11:11 A.M. observation of Resident #41 with STNA #16 and Unit Manager (UN) #65 revealed the resident's mattress was not strapped/secured to the bed. Staff reported it was a new mattress and the intervention to secure the mattress to the bed frame should have probably been removed from the resident's plan of care. On 11/02/22 10:31 A.M. interview with the Director of Nursing (DON) confirmed Resident #41's fall care plan was not revised when the alarms were discontinued. On 11/02/22 at 3:08 P.M. interview with UM #65 revealed Resident #41's fall care plan was not revised to reflect discontinuing the bed and chair alarms or securing the mattress to the bed frame when the new mattress was applied. Review of facility Accidents and Supervision policy, dated 10/30/20 and revised 08/11/22 revealed each resident would assessed for fall risk and would receive care and services in accordance with their individual level of risk to minimize the likelihood of falls. Review of the Fall Prevention Program policy, dated 10/20/20 and revised 01/01/22 revealed each resident would be assessed for the risk of falling and would receive care and services in accordance with the level of risk to minimize the likelihood of falls. Each residents risk factors, and environmental hazards would be evaluated when developing the residents comprehensive plan of care. Interventions would be monitored for effectiveness and the plan of care would be revised as needed. When any resident experienced a fall, the facility would assess the resident, complete a post-fall assessment, complete and incident report, notify physician and family, review the resident's plan of care, and update as indicted, document all assessments and actions, obtain witness statements in the case of injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #39 received the necessary care and weight monitoring as ordered related to a diagnosis of congestive heart failure and failed to ensure Resident #2 had appropriate indication of use of an anti-fungal medication and monitoring. This affected one resident (#2) of one resident reviewed for non-pressure related skin impairment and one resident (#39) of five residents reviewed for unnecessary medication use. Findings include: 1. Record review revealed Resident #39 was admitted to the facility on [DATE] with diagnosis including hypertensive heart disease with heart failure. Review of Resident #39's congestive heart failure plan of care, dated 07/12/22 revealed to monitor vital signs and monitor, document, report to the nurse and physician as needed for any signs and symptoms of congestive heart failure (CHF) such as weight gain and weight monitoring as ordered. Review of Resident #39's physician's orders revealed an order, dated 07/15/22 to obtain the resident's weight every Monday, Wednesday, and Friday. There was no evidence of parameters to report to the physician. Review of Medication Administration Records (MAR), weights, and progress notes dated 09/01/22 to 11/08/22 revealed no evidence the resident was weighed or refused to be weighed on 09/09/22, 09/14/22, 09/23/22, 09/26/22, 10/07/22, 10/12/22, 10/26/22, 10/28/22 or 11/04/22. There was no evidence the resident was weighed from 10/21/11 to 11/02/22 or evidence the physician was notified of weights not being obtained as ordered. There was only one refused weight from 10/21/22 to 11/02/22, on 10/31/22. On 11/09/22 at 7:59 A.M. interview with the Director of Nursing (DON) confirmed the resident was not weighed per order and care plan to monitor the resident's diagnosis of CHF. The DON confirmed there was no evidence the resident was weighed on 09/09/22, 09/14/22, 09/23/22, 09/26/22, 10/07/22, 10/12/22, 10/26/22, 10/28/22 or 11/04/22. The DON reported staff should notify the physician of two to three pound weight gain in a day or two or five pounds in one week. The facility did not have a policy for obtaining weights for CHF residents or parameters for physician notification of weight changes. 2. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including diabetes and yeast infections. Record review revealed Resident had a plan of care, dated 08/15/22 related to the presence of yeast to abdominal folds. Interventions included to monitor skin for redness and increased spread or signs of infection and apply treatments as ordered. Review of Resident #2's Medication and Treatment Administration records, dated 08/2022 to 11/2022 revealed the resident had received Nystatin powder topically to abdomen folds twice daily since 08/19/22. Review of Resident #2's hard/paper chart and electronic medical record revealed no evidence of any type of skin assessment for the resident's breast or abdominal fold area. On 11/03/22 at 11:25 A.M. observation with State Tested Nursing Assistant (STNA) #16 and Unit Manager (UM) #65 revealed there was no evidence Resident #2 had any type of yeast infection or any type of skin alterations under the breast or abdomen fold areas. Findings confirmed with UM during observation. On 11/07/22 at 1:06 P.M. interview with the Director of Nursing (DON) confirmed the resident had been receiving Nystatin to the abdomen folds since 08/19/22 without documented monitoring of the area. The DON reported the Nystatin order should have been written for 14 days initially and then the resident re-assessed to see if the medication needed to be continued. The DON reported the UM called the physician to have the Nystatin discontinued since the resident had no active yeast infection or skin alterations under the abdomen folds following the observation on 11/03/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including diabetes, macular degeneration bilaterally, hypertensive retinopathy, cataract bilateral, and presbyopia. Review of Resident #50's plan of care, dated 08/07/18 revealed the resident had impaired vision related to cataracts and macular degeneration. Interventions included to ensure appropriate visual aid glasses were available to support resident's participation in activities. Record review revealed Resident #50 had an optometry note, dated 01/31/22 indicating the resident needed new glasses ordered. Review of Resident #50's annual Minimum Data Set (MDS) 3.0 assessment, dated 09/01/22 revealed the resident had impaired vision without glasses. On 10/31/22 at 1:49 P.M. interview with Resident #50 revealed she was having difficulty seeing and needed to see an eye doctor. On 11/03/22 at 2:35 P.M. interview with the Resident #50 revealed she was also having trouble with her vision and had not seen an eye doctor recently. At the time of the interview, observation revealed Resident #50 was not wearing any glasses. On 11/03/22 at 3:01 P.M. a follow up interview with Resident #50 revealed she did not recall receiving new glasses in January 2022 after being seen. On 11/03/22 at 3:13 P.M. interview with Licensed Practical Nurse (LPN) #45 revealed she recalled Resident #50 did wear glasses in the past. On 11/07/22 at an unrecalled time, interview with the Administrator revealed Resident #50's glasses had been located under her bed. However, one of the lens were missing and social services was working on getting them replaced. Review of Resident #50's social service progress note, dated 11/07/22 revealed the resident's glasses were located but were missing a left lens. The optometrist was contacted and new lenses were ordered on this date. A review of the facility policy titled Hearing and Vision Services, revised 01/01/22 revealed it was the policy of the facility to ensure residents had access to and received proper treatment and assistive devices to maintain vision and hearing abilities. The facility would utilize the comprehensive assessment process for identifying and assessing a resident's vision and hearing ability in order to provide person-centered care. That process included ongoing monitoring of any sensory problems, care plan development and implementation, and evaluation. Employees should refer any identified need for vision services/ appliances to the social worker or social service designee. The social worker/ social service designee was responsible for assisting residents, and their families, in locating and utilizing any available resources for the provision of the vision services the resident needs. Once vision services had been identified, the social worker/ social service designee would assist the resident by making appointments and arranging for transportation if needed. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure residents received optometry services timely when needed. This affected two residents (#50 and #92) of four residents reviewed for vision/hearing. Findings include: 1. A review of Resident #92's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including a history of a stroke with hemiplegia/ hemiparesis affecting the left non-dominant side, pseudobulbar affect, major depressive disorder, and generalized anxiety disorder. A review of Resident #92's ancillary service consent form revealed the resident consented to receive optometry services from the facility's contracted optometrist while residing in the facility. A review of Resident #92's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/01/22 revealed the resident did not have any communication issues and her cognition was moderately impaired. The assessment revealed the resident's vision was adequate with the use of corrective lenses. The resident was not assessed to have any behaviors nor was she known to reject care. A review of Resident #92's active care plans revealed the resident did not have a care plan in place to address any vision problems or the use of corrective lenses. Resident #92's medical record was absent for any documented evidence she had been seen by an optometrist since her admission into the facility on [DATE]. On 10/31/22 at 6:01 P.M. interview with Resident #92 revealed she needed new glasses as hers were dropped on the floor and the right lens was scratched. The resident stated she had informed staff a while ago, but had not been seen by an optometrist nor had she heard anything about an optometry appointment being made. On 11/07/22 at 10:30 A.M. interview with Registered Nurse (RN) #90 revealed Resident #92 had requested to see an eye doctor about four to six months ago. She recalled the resident told her a couple of times she needed to see the eye doctor. The resident reported she could not see out of her glasses and needed a new pair. RN #90 revealed she passed the resident's request to be seen by an optometrist to her unit manager by writing a note on paper. RN #90 revealed the facility had had some issues with their previous social worker. A referral for the resident to be seen by the visiting optometrist was supposed to be set up by the facility prior social worker but RN #90 revealed she was not sure what happened to that referral. On 11/07/22 at 10:51 A.M. interview with Social Service Designee (SSD) #84 revealed Resident #92 had spoken to the facility's prior social worker about needing optometry services. SSD #84 revealed she took over as the facility social worker in July 2022. SSD #84 denied a referral was made for the resident to be seen by the visiting optometrist. She reported the facility's contracted optometry company had last visited the facility on 08/08/22. She denied Resident #92 was one of the residents seen during that visit and they could not find any optometry consults to show evidence the resident had been since her admission on [DATE]. The facility had the resident sign paperwork on 11/07/22, after it had been brought to their attention, the resident was in need of being seen, and would be setting up an appointment for the resident to be seen by the optometrist. SSD #84 revealed she was still waiting to here back when that visit might be. A review of the facility policy titled Hearing and Vision Services, revised 01/01/22 revealed it was the policy of the facility to ensure residents had access to and received proper treatment and assistive devices to maintain vision and hearing abilities. The facility would utilize the comprehensive assessment process for identifying and assessing a resident's vision and hearing ability in order to provide person-centered care. That process included ongoing monitoring of any sensory problems, care plan development and implementation, and evaluation. Employees should refer any identified need for vision services/ appliances to the social worker or social service designee. The social worker/ social service designee was responsible for assisting residents, and their families, in locating and utilizing any available resources for the provision of the vision services the resident needs. Once vision services had been identified, the social worker/ social service designee would assist the resident by making appointments and arranging for transportation if needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure a thorough and complete pressure ulcer assessment was completed for Resident #28 following a re-admission to the facility and failed to ensure wound treatments were provided as ordered by the physician. This affected one resident (#28) of three residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. Findings include: Medical record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including unspecified fracture of shaft of left humerus, hypertension, atrial fibrillation, and muscle weakness. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/06/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 (out of 15), which indicated intact cognition. The assessment revealed the resident had no behaviors or rejection of care. The MDS 3.0 assessment further revealed Resident #28 required extensive, two-person assistance for personal hygiene, bed mobility, and transfers. The resident was continent of bowel and bladder. Review of Resident #28's Braden Skin Assessment, dated 08/12/22 revealed a score of 15, which indicated the resident was at a moderate risk for the development of a pressure ulcer. Review of the care plan, dated 09/03/22 revealed the resident had pressure wound development with interventions including to administer treatments as ordered and evaluate for effectiveness, to encourage/assist to float heels when in bed as tolerated, to inspect skin during care and showers/baths, and to apply bilateral Prevalon boots as tolerated. Review of Resident #28's nursing re-admission assessment, dated 09/23/22 revealed the resident had a suspected deep tissue injury (SDTI) located to the right heel. There were no wound measurements noted on the form or in the nursing progress notes. Review of Resident #28's Skin and Wound Evaluation, dated 09/29/22, revealed a suspected deep tissue injury (SDTI) located on the right heel. The onset date noted the area was present upon re-admission from hospital. The wound measured 0.7 centimeters (cm) length by 0.6 cm width. There was no exudate, odor, or signs of infection. The surrounding tissue was intact. The wound note revealed the resident was re-admitted to the facility on [DATE] with a SDTI located on the right heel. The treatment order was to cleanse area with soap and water. Pat dry and apply skin prep to area. Cover with border and foam dressing and change dressing every three days and as needed. The physician was notified. Review of the physician's orders revealed an order, dated 09/29/22 revealed an order to cleanse with soap and water, pat dry, and apply skin prep. Cover the wound with border foam dressing and change every three days and as needed for soiling or dislodgement. On 11/02/22 at 8:36 A.M. observation revealed there was no dressing on Resident #28's right heel SDTI as ordered by the physician. During interview on 11/02/22 at 8:45 A.M., Unit Manager/Licensed Practical Nurse (LPN) #78 confirmed there was no foam dressing applied to Resident #28's SDTI, located on the right heel. The facility staff indicated this was due to the resident's refusal of a dressing change the night before on 11/01/22. LPN #78 confirmed the physician was not notified of the resident's dressing change refusal. During interview on 11/02/22 at 11:00 A.M. interview with the Director of Nursing (DON) confirmed Resident #28's pressure ulcer located on the right heel should have been covered with a foam dressing as ordered by the physician and the physician should have been notified of the resident's refusal of treatment. The DON verified Resident #28's Nursing re-admission Assessment, dated 09/23/22, revealed a SDTI located on the right heel, without wound measurements noted on the form or in the nursing progress notes. Review of the facility policy titled Wound Treatment Management, dated 10/30/22 revealed the wound treatments would be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Characteristics of the wound: pressure injury stage, size, volume and characteristics of exudate, presence of pain, presence of infection, condition of the tissue in the wound bed, condition of peri-wound. The effectiveness of treatments would be monitored through ongoing assessment of wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypercapnia, hereditary spastic paraplegia, essential hypertension and generalized muscle weakness. Review of admission MDS 3.0 assessment, dated 08/25/22 revealed Resident #38 was cognitively intact and required extensive assistance from two staff for bed mobility, dressing and toileting and total dependence from two staff to assist for transfers and locomotion on and off the unit. The MDS also revealed Resident #38 was receiving speech therapy, occupational therapy and physical therapy and not receiving any restorative nursing. Review of Resident #38's physician's orders revealed an order, dated 09/26/22 for restorative therapy by nursing. Review of Resident #38's care plan, dated 10/12/22 revealed the resident was to have active (motion at a joint when the resident moves the joint voluntarily) range of motion (ROM). The care plan revealed Resident #38 would benefit from a restorative active ROM for impaired physical mobility of upper extremities (arms) and lower extremities (legs) of both sides (bilateral). Review of the documentation for restorative nursing revealed Resident #38 was to receive level two restorative nursing for active ROM. Resident #38 was to tolerate 15 minutes of active ROM to bilateral upper and lower extremities daily to maintain joint motion. This documentation also revealed Resident #38 received restorative active ROM on 10/24/22, 10/25/22, 10/29/22, 10/30/22, 11/05/22 and 11/06/22. Based on the date of the order, Resident #38 received restorative active ROM only six days out of 41 potential days. On 10/31/22 at 11:39 A.M. interview with Resident #38 revealed staff were not doing anything for her limited ROM. She reported she had only been guided with active ROM a few times. The resident felt she had experienced some decrease in her ROM. On 11/03/22 at 8:15 A.M. during a follow up interview Resident #38 revealed no staff had worked with her to assist with ROM exercises. On 11/07/22 at 8:23 A.M. interview with Registered Nurse (RN) #90 revealed she did not know if Resident #38 received restorative nursing services. After RN #90 reviewed Resident #38's orders, RN #90 verbalized Resident #38 was to receive therapy, but wasn't sure about restorative nursing services. On 11/07/22 at 8:24 A.M. interview with RN #41 revealed Resident #38 was to receive active ROM to her upper and lower extremities. RN #41 reported Resident #38 had been receiving restorative nursing services since 09/30/22 and RN #41 was not sure why it took four days to initiate the restorative nursing order. She reported according to the order, the restorative therapy should have been started earlier. RN #41 reported there was only one restorative aide (RA), and when RA #111 wasn't working, the floor aides did not pick up the restorative nursing duties. On 11/07/22 at 8:35 A.M. interview with the DON revealed RA #111 had been off since 10/05/22 and there were no other staff performing the restorative services for residents, including Resident #38. Review of the facility policy titled, Restorative Nursing Programs, dated 01/01/22 revealed the goal(s) of restorative nursing included improving and/or maintaining independence in activities of daily living and mobility. The policy defined Level Two Restorative Nursing as a reasonable expectation that improvement would continue to occur with resident participation and goal setting. This deficiency represents non-compliance investigated under Complaint Number OH00137086. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #28 received appropriate services to maintain range of motion/mobility and failed to ensure Resident #38 received restorative services. This affected two residents (#28 and #38) of five residents reviewed for position/range of motion and mobility. Findings include: 1. Medical record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including unspecified fracture of shaft of left humerus, hypertension, atrial fibrillation, and muscle weakness. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/06/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 (out of 15), which indicated intact cognition. The assessment revealed the resident had no behaviors or rejection of care. The MDS further revealed Resident #28 required extensive, two-person assistance with personal hygiene, bed mobility, and transfers. The MDS assessment revealed the resident did not receive restorative nursing services or splinting. Review of the care plan, dated 10/19/22 revealed Resident #28 would be able to improve functionality to arm with an intervention for an elastic wrist brace, to right wrist, as tolerated. Review of the physician's orders revealed an order, dated 10/18/22 for an elastic wrist brace to the right wrist for stabilization of the wrist, every shift. On 10/31/22 at 2:26 P.M., Resident #28 was observed without the elastic wrist brace in place. During observation on 11/01/22 at 2:54 P.M., Resident #28 was lying in bed and not wearing an elastic wrist brace as ordered. During interview on 11/01/22 at 2:57 P.M., State Tested Nursing Assistant (STNA) #51 confirmed Resident #28 was not wearing his right wrist elastic brace. STNA #51 stated she did not know there was an order for a wrist brace. During interview on 11/01/22 at 2:58 P.M., Licensed Practical Nurse (LPN) #112 revealed she was unaware of Resident #28 having the order for a wrist brace and she had not observed him to be wearing one during the past week or so. During interview on 11/01/22 at 3:00 P.M., Occupational Therapist (OT) #144 stated the wrist brace arrived last week and she personally gave the brace to Resident #28's nurse to apply to the resident's wrist. During interview on 11/01/22 at 3:30 P.M., the Director of Nursing (DON) confirmed Resident #28 was not wearing the right wrist brace as ordered. The DON verified the wrist brace had been found in the resident's room and applied per physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #41 was admitted to the facility on [DATE] with diagnosis including diffuse traumatic brain injury with loss of consciousness, hemiplegia and hemiparesis, aphasia, apraxia, lupus anticoagulant, and cognitive communication deficit. Record review revealed a plan of care, (initiated 08/17/20) related to the resident's history of falls and traumatic brain injury. Interventions included (on 07/21/22 and revised 10/10/22) to ensure chair and bed alarms were functioning and in place and (09/08/22) ensure mattress was securely fastened to bed frame. Record review revealed a fall investigation, dated 07/20/22 indicating Resident #41 was found on the floor by an STNA. The resident appeared to have slid out of bed onto his buttocks. The investigation revealed the resident's bed alarm was not in place and was found underneath the resident's Dycem in the chair. Returned alarm to bed and placed a new alarm on electric chair. There was no evidence the facility determined a root cause of the fall. Staff were educated on the placement of alarms and function. Review of Resident #41's fall risk evaluations revealed there was no evidence a new fall risk evaluation was completed after the fall that occurred on 07/20/22. Review of Resident #41's Minimum Date Set (MDS) 3.0 assessment, dated 09/02/22 revealed the resident required extensive assistance from two for dressing and bed mobility and was totally dependent on staff for transfers. Review of Resident #41's fall investigation, dated 09/19/22 revealed the resident was lying on the mat next to his bed. The resident had turned himself around in the bed so that his head was at the bottom. There was no evidence the facility investigation determined a root cause of the fall. Review of Resident #41's fall risk evaluations revealed there was no evidence a new fall risk evaluation was completed after the fall that occurred on 09/19/22. Review of Resident #41's fall investigation, dated 10/04/22 revealed the resident was found crawling on the floor from his room out into the hallway. There was no evidence the facility determined a root cause of the fall. Further review revealed on 10/04/22 the resident was noted to be high risk for falls because he had three or more falls in the last 90 days. The resident displayed no behaviors, required assistance with elimination, was confined to chair, and not able to attempt to balance without physical assistance. Under health conditions and risk staff did not check neuromuscular/functional for loss of arms or leg movement. On 11/01/22 at 2:40 P.M. observation of Resident #41 with an unidentified STNA revealed interventions were in place except for chair and bed alarms. The resident was in bed at the time of the observation and the surveyor was unable to check the mattress to ensure it was secure. On 11/02/22 at 8:20 A.M. observation with STNA #46 verified the resident had no bed or chair alarm. The STNA reported all alarms had been discontinued recently for all residents, including Resident #41. On 11/03/22 at 11:11 A.M. observation of Resident #41 with STNA #16 and Unit Manager (UN) #65 revealed the resident's mattress was not strapped/secured to the bed. Staff reported it was a new mattress and that the intervention to secure the mattress to the bed frame should probably have been removed from the plan of care. The staff members revealed the resident was not able to physically roll by himself, however he could scoot his body. On 11/01/22 at 3:03 P.M. interview with Resident #41's mother revealed she had concerns that her son had fallen out of bed four times even though he was unable to move much. The resident's mother felt there was no reason the resident should be falling out of bed. On 11/08/22 at 9:32 A.M. and 10:05 A.M. interview with the Director of Nursing (DON) verified Resident #41's falls on 07/20/22, 09/19/22 and 10/04/22 were not thoroughly investigated to determine the root cause nor were fall risk assessments completed after the falls that occurred on 07/20/22 and 09/19/22. The DON reported a new fall risk assessment were supposed to be completed after each fall. The DON confirmed the resident's plan of care had not been revised on 10/11/22 when the alarms were discontinued or when the mattress was replaced with a new one and no longer required to be secured to the bed frame. Review of facility Accidents and Supervision policy, dated 10/30/20 and revised 08/11/22 revealed each resident would be reassessed for fall risk and would receive care and services in accordance with their individual level of risk to minimize the likelihood of falls. Review of the Fall Prevention Program policy, dated 10/20/20 and revised 01/01/22 revealed each resident would be assessed for the risk of falling and would receive care and services in accordance with the level of risk to minimize the likelihood of falls. Each residents risk factors, and environmental hazards would be evaluated when developing the residents comprehensive plan of care. Interventions would be monitored for effectiveness and the plan of care would be revised as needed. When any residents experienced a fall, the facility would assess the resident, complete a post-fall assessment, complete and incident report, notify physician and family, review the resident's plan of care, and update as indicted, document all assessments and actions, obtain witness statements in the case of injury. This deficiency represents non-compliance investigated under Complaint Number OH00133600. Based on observation, record review, review of facility fall investigations, facility policy and procedure review and interview the facility failed to ensure Resident #92 received the appropriate level of assistance during a transfer and had proper footwear on at the time of the transfer to prevent an avoidable fall. The facility also failed to develop a comprehensive and individualized fall prevention program for Resident #41 and failed to ensure comprehensive fall investigations were completed to identify the root cause of falls so appropriate interventions could be initiated to prevent additional falls from occurring for the resident. This affected two residents (#41 and #92) of four residents reviewed for falls and/or accident hazards. Findings include: 1. A review of Resident #92's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a stroke affecting the left non-dominant side, unsteadiness on her feet, abnormalities of gait and mobility, muscle weakness, and difficulty walking. A review of Resident #92's active care plans revealed a plan of care initiated on 02/11/22 reflecting the resident was at risk for falls related to decreased safety awareness. The resident denied having had a stroke and having the inability to ambulate. Interventions included anticipating/ meeting the resident's needs based on nursing assessments. A review of Resident #92's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/06/22 revealed the resident did not have any communication issues and her cognition was moderately impaired. The assessment revealed the resident's vision was adequate with the use of corrective lenses. She was not known to have any behaviors and was not known to reject care. The assessment revealed the resident required extensive assistance from two staff for transfers and toilet use and ambulation did not occur. Balance issues were noted when going from a seated to a standing position and with surface to surface transfers requiring physical help from staff to stabilize. The resident exhibited functional limitation in her range of motion to the upper and lower extremity on one side. The resident was not indicated to have had any falls since her entry into the facility or since the prior assessment. A review of Resident #92's progress notes revealed an incident note for 05/08/22 that indicated the resident was assisted to the floor by staff. The note indicated a State Tested Nursing Assistant (STNA) was helping the resident transfer into bed when the resident started sliding. The STNA assisted the resident to the floor. The resident was wearing regular socks and was not wearing proper footwear when she was being transferred. The intervention added was to ensure the resident was wearing proper footwear when transferring to her bed and chair. A review of a fall investigation for Resident #92's fall on 05/08/22 revealed the fall was as indicated in the progress note. The resident was indicated to have been assisted to the floor by staff. Mitigating factors was the resident was not wearing proper footwear and the intervention added was to ensure the resident was wearing proper footwear when transferring to the bed or chair. The fall occurred at 10:15 P.M. and occurred in the resident's room. STNA #500 was identified as the staff member who transferred the resident at the time of her fall. A subsequent quarterly MDS 3.0 assessment, dated 07/01/22 revealed the resident remained an extensive assist of two staff for transfers. The assessment noted the resident had one fall with injury that was not major injury. On 11/03/22 at 1:31 P.M., an interview with STNA #500 revealed she worked the night of 05/08/22 when Resident #92 had to be lowered to the floor during a transfer. She confirmed she was the STNA who was assisting the resident with during the transfer. She was able to recall the incident as she stated she pulled her hamstring as a result of that incident. She reported she was transferring the resident from her wheelchair to her bed. She denied she had another STNA or staff member assisting with the transfer. The STNA revealed when she stood the resident up, the resident's feet started to slide so she lowered the resident to the floor. She was questioned on the assistance level the resident required for transfers at the time the incident occurred. The STNA stated as far as she knew, the resident only required a one person assist. She was not sure how it was communicated to the STNA staff the assistance level a particular resident needed with transfers. She went by what she was told by the nurse and a nurse had told her the resident was to be a one person assist with transfers. She could not recall which nurse told her that. She denied the resident had proper footwear on at the time of the transfer, as she was wearing regular socks. The STNA failed to ensure the resident had proper footwear on when transferring her from the wheelchair into bed. She confirmed she was the only STNA on the floor at the time as her coworker was on break. A nurse was available on the unit that she could have asked for assistance if needed. She denied she asked the nurse to assist with the resident's transfer as the nurse was busy. On 11/03/22 at 1:49 P.M., an interview with Director of Nursing (DON) revealed Resident #92 did have a fall on 05/08/22 that was a result of her not having proper footwear on at the time of the fall. She confirmed the resident's transfer on 05/08/22 was performed by one STNA, when the resident's prior MDS assessment identified her as requiring a two person assist with transfers. The DON acknowledged the fall on 05/08/22 could not be considered an unavoidable fall due to her not having proper footwear on while being transferred by staff and not having the appropriate assistance level when being transferred from her chair to bed. A review of the facility policy on Fall Prevention Program, revised 01/01/22 revealed each resident would be assessed for the risk of falling and would receive care and services in accordance with the level of risk to minimize the likelihood of falls. The policy included the definition of a fall to include a near miss which was also considered a fall. A near miss was when a resident would have fallen if someone else had not caught the resident from doing so. The facility would use a standardized risk assessment for determining a resident's fall risk. Each resident's risk factors and environmental hazards would be evaluated when developing the resident's comprehensive plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #79 received adequate and proper care during incontinence care to decrease the resident's risk of developing a urinary tract infection. In addition, the facility failed to timely obtain a urinalysis with reflex culture for Resident #28, who had symptoms of a urinary tract infection, as ordered by the physician. This affected two residents (#28 and #79) of nine residents reviewed for unnecessary medication use or urinary tract infection. Findings include: Review of Resident #79's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses including type two diabetes, morbid obesity, systemic lupus and chronic obstructive pulmonary disease. Review of Resident #79's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/24/22 revealed the resident was cognitively intact and always incontinent. On 11/02/22 at 2:10 P.M. State Tested Nursing Assistant (STNA) #15 and STNA #38 were observed providing incontinence care to Resident #79. The STNAs gathered items and applied appropriate personal protective equipment (PPE) as the resident was in contact isolation. STNA #15 and STNA # 38 failed to wash their hands prior to applying gloves to provide care. During the process, STNA #38 removed her gloves and with the help of STNA #15, who did not remove her gloves, pulled Resident #79 up in bed. STNA #15, who kept her gloves on, touched Resident #79's sheets, blankets, pillows and reacher to pick a box of tissues up off floor with the dirty gloves following incontinence care. When all care was provided in the room, STNA #38 removed her isolation gown and washed her hands. STNA #15 also removed her gloves and isolation gown and washed her hands. On 11/02/22 at 2:30 P.M. interview with STNA #38 and STNA #15 verified neither one of them washed their hands prior to providing incontinence care for Resident #79. STNA #15 verified she touched multiple items in the room with the same gloved hands she wore while providing incontinence care. Review of the facility policy titled Hand Hygiene, reviewed/revised 01/01/22 revealed all staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. In the section titled Policy Explanation and Compliance Guidelines, section six additional considerations included the use of gloves does not replace hand hygiene. If your task required gloves, perform hand hygiene prior to applying (donning) gloves and immediately after removing gloves. Review of the undated Hand Hygiene Table revealed staff should perform hand hygiene before performing resident care procedures and after handling contaminated objects. 2. Medical record review revealed Resident #28 had diagnoses including unspecified fracture of shaft of humerus, left arm, hypertension, atrial fibrillation, pressure induced deep tissue damage of right heel, and muscle weakness. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 08/06/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 (out of 15), which indicated intact cognition. The MDS further revealed Resident #38 required extensive, two-person assistance with personal hygiene, bed mobility and transfers. The assessment revealed the resident was continent of bladder. Review of Resident #28's care plan, initiated on 08/24/22 revealed an intervention to monitor/document signs/symptoms of urinary tract infection. Review of physician's progress note, dated 10/05/22, revealed the plan to obtain a urinalysis with reflex culture (UA) due to recurrent urinary tract infections (UTI) and progression of confusion. Review of the physician's orders revealed an order, dated 10/05/22 at 11:50 A.M. to obtain a urinalysis with reflex culture. During interview on 11/02/22 at 11:10 A.M., the Director of Nursing (DON) confirmed there was not a urinalysis with reflex culture obtained as ordered by the physician order. During interview on 11/02/22 at 3:42 P.M., Licensed Practical Nurse (LPN) #112 revealed the urinalysis with reflex culture was not obtained on 10/05/22 and the physician was not notified of the inability to obtain the urinalysis until 10/07/22.

Based on observation, record review, facility policy and procedure review and interview the facility failed to accurately document Resident #78's enteral (tube) feeding intake to ensure the resident's overall nutritional status was monitored. This affected one resident (#78) of two residents reviewed for nutrition. Findings include: Review of Resident #78's medical record revealed an initial admission date of 07/07/22 with a readmission date of 10/28/22. Resident #78 had diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, dysphagia, and type two diabetes. Review of Resident #78's admission Minimum Data Set (MDS) 3.0 assessment, dated 09/28/22 revealed the resident was cognitively intake and received enteral feeding via a gastrostomy (feeding) tube for nutritional intake. Review of Resident #78's physician's orders revealed an order, dated 10/26/22 for dietary to evaluate calorie intake/tube feedings. Review of Resident #78's physician's order revealed an order, dated 11/03/22 for Resident #78 to receive the enteral (tube) feeding product, Glucerna 1.5 calorie at 50 milliliters/hour. The Glucerna running at 50 milliliters/hour should have a milliliter intake in an eight-hour shift of 400 milliliters. Review of Resident #78's November 2022 medication administration record (MAR) revealed Glucerna 1.5 calorie running at 50 milliliters/hour. On 11/04/22 the MAR noted 100 milliliters on day shift, 100 milliliters on evening shift, 100 milliliters on night shift, on 11/05/22 100 milliliters on day shift, 100 milliliters on evening shift, 100 milliliters on night shift, on 11/06/22 150 milliliters on day shift, 150 milliliters on evening shift and 150 milliliters on night shift, and an intake on 11/07/22 of 100 milliliters on day shift. On 11/07/22 at 9:45 A.M. Resident #78's Glucerna 1.5 calorie tube feeding was observed running at 50 milliliters/hour via pump. On 11/07/22 at 10:31 A.M. interview with the Director of Nursing (DON) verified Resident #78's tube feed intake documentation on the November 2022 MAR was not accurate and if the tube feeding intake was not documented accurately, then the dietitian would not have accurate information to potentially adjust the tube feed rate for intake for weight loss. Review of the facility policy titled Nutritional Assessment, reviewed/revised 01/01/22 revealed the nutritional assessment would be a systematic, interdisciplinary process that included gathering and interpreting data to define meaningful interventions for the resident at risk for or with impaired nutrition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure oxygen was delivered at the flow rate ordered by the physician for Resident #38. This affected one resident (#38) of four residents reviewed for respiratory therapy. Findings include: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypercapnia, hereditary spastic paraplegia, moderate protein-calorie malnutrition, and essential hypertension. Review of Resident #38's physician's orders revealed an order, dated 08/20/22 for oxygen at three liters/minute via a nasal cannula continuously. Review of admission Minimum Data Set (MDS) 3.0 assessment, dated 08/25/22 revealed Resident #38 was cognitively intact, had an active diagnosis of respiratory failure and was receiving oxygen prior to admission and while a resident. Review of Resident #38's October and November 2022 Treatment Administration Records (TAR) revealed staff documented Resident #38 had received oxygen as ordered at three liters/minute via nasal cannula. On 10/31/22 at 11:45 A.M. Resident #38 was observed with oxygen being administered at four liters/minute via a nasal cannula. On 11/01/22 at 2:20 P.M. Resident #38 was observed with oxygen being administered at four liters/minute via a nasal cannula. On 11/02/22 at 7:40 A.M. Resident #38 was observed with oxygen being administered at four liters/minute via a nasal cannula. On 11/03/22 at 10:40 A.M. Resident #38 was observed with oxygen being administered between 3.5 and four liters/minute via a nasal cannula. This was verified at the time of the observation by Licensed Practical Nurse (LPN) #9. LPN #9 also verified Resident #38's oxygen was not running at the appropriate flow rate and should be running at a flow rate of three liters/minute per her physician order. Review of the facility policy titled Oxygen Administration, reviewed/revised 01/01/22 revealed oxygen was administered under orders of a physician, except in the case of any emergency. Review of the facility policy titled Medication Administration, reviewed/revised 10/30/20 revealed medications were administered by licensed nurses, or other staff who were legally authorized to do so in the State, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Based on record review and interview, the facility failed to ensure Resident #78 had an appropriate diagnosis for the use of the anti-psychotic medication, Seroquel. This affected one resident (#78) of five residents reviewed for unnecessary medication use. Findings include: Review of the medical record for Resident #78 revealed an admission date of 09/22/22 with diagnoses including dementia without behavioral disturbance, major depressive disorder, anxiety, diabetes mellitus, muscle weakness, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/28/22 revealed Resident #78's Brief Interview for Mental Status (BIMS) score was 14 (out of 15), which indicated intact cognition. The assessment revealed the resident did not have any hallucinations, delusions, physical or verbal behaviors, or rejection of care. The resident required total, two-person physical assistance with bed mobility, transfers, toileting, and dressing. Review of the resident's plan of care reflected the use of anti-psychotic medication. Review of a physician's order revealed an order, dated 11/06/22, for Quetiapine Fumarate (Seroquel) 50 milligrams (mg) via gastrostomy tube, two times per day, for depression. Review of the Medication Administration Record (MAR), for November 2022 revealed the resident received the Seroquel 50 mg via gastrostomy tube on 11/07/22, 11/08/22, and 11/09/22. During interview on 11/09/22 at 1:10 P.M., the Director of Nursing (DON) verified the resident was receiving Seroquel, which was an anti-psychotic medication without evidence of an appropriate diagnosis to justify the medication administration. The DON confirmed the physician order, dated 11/06/22 indicated the medication was ordered for depression (which was not an appropriate diagnosis).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to maintain a medication error rate of less than five (5) percent (%). The medication error rate was calculated to be 6.25% and included two medication errors of 32 medication administration opportunities. This affected one resident (#98) of three residents observed for medication administration. Findings include: A review of Resident #98's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic congestive heart failure, hypertensive heart disease, history of a myocardial infarction (heart attack), and arthropathy (any disease of the joints such as arthritis). On 11/02/22 at 8:27 A.M., a medication administration observation was made for Resident #98's morning medication administration. The resident's medications were administered by Registered Nurse (RN) #90. During the observation, the resident was administered a Coreg (a beta blocker used in the treatment of hypertension) 3.125 milligram (mg) tablet. The resident's medication came in a blister card (card that had bubble packs containing an individual tablet of the medication to be punched out through the paper backing) and the nurse was observed to punch the Coreg tablet into a medicine cup. Prior to the nurse replacing the blister card back into the medication administration cart before going into the resident's room to administer his scheduled medication, the blister pack was observed and was noted to still have a quarter of the tablet stuck in the packaging. The nurse was not aware that the entire tablet had not been removed from the blister pack until she was asked to pull the blister card back out of the medication administration cart before going into the resident's room. She then verified the entire tablet had not been removed, which would have resulted in the resident not receiving the full dose of Coreg that had been ordered. Continued observation during the administration revealed RN #90 was also noted to administer a Lidocaine 5% patch topically to the resident. The label on the packaging the Lidocaine patches came in included the physician's orders which specified the Lidocaine patch was to be removed in the morning and applied at night. RN #90 applied the Lidocaine 5% patch to the left side of Resident #98's abdomen. A review of Resident #98's physician's orders revealed the resident had an order to receive Coreg 3.125 mg by mouth twice a day for hypertension. The resident's orders also included the use of Lidocaine patch 5% with directions to apply it to the affected area topically at bedtime for pain and to remove per schedule. A review of Resident #98's medication administration record (MAR) for October 2022 revealed the administration times of the Lidocaine patch 5% had changed as it used to be ordered to be applied every 12 hours between 10/04/22 through 10/20/22. As of 10/20/22, the Lidocaine patch 5% was to be applied only at bedtime with directions to remove the Lidocaine patch 5% every morning by 7:59 A.M. Findings were verified by RN #90 on 11/02/22 at 10:46 A.M. On 11/02/22 at 10:46 A.M., an interview with RN #90 revealed she did not note that a portion of the Coreg 3.125 mg tablet was not removed from the blister card it was packaged in when she popped the tablet out of the blister pack. She acknowledged, by not receiving the entire tablet, Resident #98 did not receive the proper dose as ordered by the physician. She also acknowledged she applied a Lidocaine 5% patch to the resident's left side of his abdomen when the current physician's orders were to remove the patch in the morning and to only apply it every night at bedtime. A review of the facility Medication Administration policy, revised 01/01/22 revealed it was the policy of the facility for medications to be administered as ordered by the physician in accordance with professional standards of practice. The nurse was to review the MAR to identify medications to be administered. The nurse was to compare the medication source with the MAR to verify the resident's name, medication name, form, dose, route, and time of administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #38 received timely diagnostic services. This affected one resident (#38) of two residents reviewed for nutrition. Findings include: Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypercapnia, hereditary spastic paraplegia, dysphagia, moderate protein-calorie malnutrition, and essential hypertension. Review of Resident #38's care plan, dated 08/19/22 revealed a focus related to the resident having a potential for nutritional deficits related to therapeutic and mechanically altered diet, abnormal labs, and potential for weight fluctuations related to fluid, variable intake. The goal was for Resident #38 to maintain an adequate nutritional status as evidenced by diet tolerance and adequate intakes for weight stability without significant change. An interventions to meet this goals was to obtain and monitor labs and diagnostic work as ordered. Review of admission Minimum Data Set (MDS) 3.0 assessment, dated 08/25/22 revealed Resident #38 was cognitively intact, had no broken or loosely fitting full or partial denture and had no natural teeth or tooth fragments. Review of Resident #38's weights revealed the following: 09/02/2022 14:34- 108.6 pounds 09/06/2022 12:40- 109.1 pounds 09/20/2022 18:15- 110.2 pounds 10/01/2022 13:57- 98.8 pounds 10/07/2022 08:23- 98.6 pounds 10/09/2022 15:50- 98.8 pounds 10/17/2022 16:54- 95.8 pounds 10/25/2022 15:34- 96.2 pounds 11/03/2022 08:48- 96.6 pounds Review of Resident #38's physician orders revealed the following dietary/nutritional/diagnostic orders: An order on 10/07/22 for weekly weights, an order on 10/08/22 for fortified pudding, an order on 10/20/22 for fortified potatoes with dinner and an order on 10/03/22 for a barium esophageal x-ray. Review of the physician's progress note, dated 10/03/22 revealed noted weight loss and difficulty swallowing pills due to dysphagia. The plan was to get a barium x-ray to evaluate for esophageal narrowing. Review of a nurse's note, dated 10/03/22 at 5:47 P.M. revealed activities were aware of the order for a barium esophageal x-ray and need to schedule at the local acute care facility. Review of a fax, dated 10/04/22 revealed Resident #38's order for a barium esophageal x-ray due to dysphagia was faxed to central scheduling at the local acute care facility. On 11/06/22 at 1:36 P.M. an interview with Activities Director (AD) #106 revealed she faxed Resident #38's order for the barium esophageal x-ray to central scheduling at the local acute care facility on 10/04/22 but has not heard back from them regarding a date for the test. AD #106 reported she does not follow-up with central scheduling regarding pending tests. She reported she just waits for them to contact her with the testing date. AD #106 reported residents had waited two months for tests. On 11/06/22 at 1:40 P.M. an interview with the Director of Nursing (DON) revealed she does not consider Resident #38 waiting for over a month for her barium esophageal x-ray good and timely care since Resident #38 had a diagnosis of dysphagia and had been losing weight. The DON reported AD #106 should have followed up with central scheduling for a date for the barium esophageal x-ray. On 11/09/22 at 3:06 P.M. an interview with AD #106 revealed she did not have a tracking system to make sure diagnostic testing was scheduled and completed. Review of the facility policy titled, Laboratory and Diagnostic Guidelines, reviewed/revised 01/01/22 revealed the guideline was set up to track the timely completion, reporting and monitoring of laboratory and diagnostic tests, results, and notifications which were used to monitor resident status and or therapeutic medication levels.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to implement an effective infection control program including the timely implementation of contact isolation for Resident #92 who was diagnosed with a urinary tract infection that was positive for Methicillin Resistant Staphylococcus Aureus to prevent the spread of infection. This affected one resident (#92) of nine residents reviewed for unnecessary medication use or urinary tract infections. Findings include: A review of Resident #92's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including a history of a stroke with hemiplegia and hemiparesis affecting the left non-dominant side, neuromuscular dysfunction of the bladder, urinary tract infection (UTI), and Methicillin Resistant Staphylococcus Aureus (MRSA) infection. A review of Resident #92's nursing progress notes revealed a nurse's note, dated 10/27/22 that revealed the resident was complaining of a burning sensation at site of her indwelling urinary catheter. The physician was notified and a new order was received to obtain a urine sample via straight catheterization for a urinalysis (U/A) and culture and sensitivity (C&S). A nurse's progress note, dated 10/30/22 at 8:15 P.M. revealed Resident #92's U/A and C&S results were received and showed the resident tested positive for a UTI. An order had been received to start the resident on Fosfomycin every 72 hrs for three doses. A nurse's progress note, dated 11/01/22 at 9:45 A.M. revealed Resident #92's urine culture was noted to be positive for MRSA in her urine. Contact isolation precautions were initiated at that time. The unit manager, physician and the resident representative were made aware and in agreement with the plan of care. A review of a laboratory report for a U/A with a C&S revealed Resident #92 had her urine tested on [DATE]. The urine was received in the laboratory on 10/28/22 at 5:53 A.M. The results of that U/A was reported to the facility on [DATE] at 8:46 A.M. A urine culture had been set up and the results were pending. The final culture results were received on 10/30/22 at 7:59 A.M. and showed the resident's urine was positive for a UTI. The bacterial isolate noted on the U/A and C&S revealed the resident had MRSA in her urine. A review of Resident #92's physician's orders revealed the resident was started on Fosfomycin Tromethamine (a broad spectrum antibiotic used in the treatment of bladder infections) three grams by mouth every 72 hours times three doses for the treatment of a UTI. The order was given on 10/30/22. The physician's orders revealed the resident was not placed in contact isolation precautions until 11/01/22 despite her being known to have MRSA in her urine as of 10/30/22. A review of Resident #92's active care plans revealed a care plan for the resident having a UTI was added on 10/30/22. The care plan did not identify her as having MRSA in her urine. The interventions included giving antibiotic therapy as ordered. The interventions did not include the need to place the resident in contact isolation precautions as ordered on 11/01/22. A review of Resident #92's medication administration record (MAR) for October 2022 revealed the resident was given her first dose of Fosfomycin Tromethamine three grams on 10/31/22. She continued to receive the medication until her last dose of three was given on 11/06/22. Review of the treatment administration record (TAR) for November 2022 confirmed the resident was not placed into contact isolation precautions until 11/01/22 (two days after she was known to have MRSA in her urine). On 11/07/22 at 3:55 P.M., an interview with the DON revealed the facility did receive Resident #92's final culture results showing she had MRSA in her urine on 10/30/22. She verified the resident was not placed in contact isolation for having MRSA in her urine until 11/01/22. She stated it was the facility's infection preventionist who caught that the resident had MRSA and initiated the implementation of contact isolation on 11/01/22 when she became aware of it. A review of the facility policy on Multi Drug Resistant Organisms (MDRO's), revised 10/24/22 revealed it was the policy of the facility to implement facility wide strategies for preventing the spread of infections with MDRO's. MDRO's were defined as bacteria and other microorganisms that had developed resistance to one or more classes of antimicrobial drugs. Infections with MDRO's were difficult to treat and were associated with increased mortality rates. Common MDRO's found in nursing facilities included MRSA. Staff were to use contact isolation precautions in addition to standard precautions when caring for a resident with a MDRO infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to develop and implement an effective antibiotic stewardship program as part of their infection control program to ensure the appropriate use of antibiotic treatment for infections. This affected three residents (#2, #79 and #77) of nine residents reviewed for unnecessary antibiotic use or urinary tract infections. Findings include: 1. Record review for Resident #77 revealed the resident had diagnoses including acute infections, bipolar disorder, major depressive disorder, anxiety disorder, essential hypertension, chronic obstructive pulmonary disease, and tremors. Review of acute care documentation, dated 08/16/22 revealed Resident #77 had a urine culture positive for pseudomonas, E. coli, candida with susceptibility pending. The acute care facility recommended to change the antibiotic, Rocephin to Cefepime and add Diflucan for seven days with renal dose adjustment following the first dose. Record review revealed no urine culture and sensitivity (testing that verifies an antibiotic will kill the bacteria in the urine) results in the documentation. Record review revealed the resident had an order for and received an intravenous antibiotic, Meropenem from 08/25/22 to 09/03/22. Review of Resident #77's admission Minimum Data Set (MDS) 3.0 assessment, dated 08/31/22 revealed the resident was cognitively impaired and had active diagnoses of extended spectrum beta lactamase (ESBL) resistance, neurogenic bladder, renal insufficiency, renal failure, urinary tract infection with multi-drug-resistant organism. Review of acute care documentation, dated 09/20/22 revealed Resident #77 had recurrent urinary tract infections (UTIs) with multi-drug resistant (MDR) organisms in the urine culture. Resident #77 was on the antibiotic, Zosyn for renal function and pseudomonas dosing for a duration of 14 days. Directions were to start Piperacillin-Tazobactam. Record review revealed there was no urine culture and sensitivity (testing that verifies an antibiotic will kill the bacteria in the urine) results in the documentation. Record review revealed the resident had an order for and received an intravenous antibiotic, Piperacillin from 09/21/22 to 10/03/22. Review of acute care documentation, dated 10/21/22 revealed Resident #77's urinalysis showed white blood cell clumping diffuse signs of infection. A urine culture, dated 10/15/22 revealed extended spectrum beta-lactamase Escherichia and Pseudomonas with no sensitivity to show if the antibiotic would kill the organisms. Record review revealed the resident had an order for and received an intravenous antibiotic, Ertapenem from 10/22/22 to 10/30/22. On 11/02/22 at 4:38 P.M. an interview with the Director of Nursing (DON) verified the three different intravenous antibiotics Resident #77 received as noted above. On 11/02/22 at 5:10 P.M. an interview with Registered Nurse (RN) #60 revealed she did not have documentation of Resident #77's urine culture and sensitivity testing from the acute care facilities. She reported she did not contact the acute care facilities for the documentation and therefore could not confirm the antibiotics were appropriate to treat the bacterial organisms noted above. Review of the facility policy titled, Antibiotic Stewardship Program, reviewed/revised 10/24/22 revealed the program included antibiotic use protocols and a system to monitor antibiotic usage which included antibiotic orders obtained from consulting, specialty, or emergency providers which shall be reviewed for appropriateness. 2. Review of Resident #79's medical record revealed the resident was re-admitted to the facility on [DATE] with diagnoses including type two diabetes, morbid obesity, systemic lupus, chronic kidney disease and chronic obstructive pulmonary disease. Review of a urine culture and sensitivity, dated 08/28/22 revealed the final culture result showed the resident was positive for Escherichia Coli. However, there was no sensitivity result to guide for the appropriate antibiotic to kill the bacteria in the urine. Record review revealed there was no McGeer Criteria for Infection Surveillance Checklist for Resident #79 provided for the urinary infection of 08/28/22. Review of Resident #79's physician's orders revealed an order (09/2022) for the antibiotic, Cephalexin 500 milligrams by mouth three times a day for a urinary tract infection for seven days. Review of the Medication Administration Record from 09/2022 revealed the medication was administered as ordered. The facility did provide a McGeer Criteria for Infection Surveillance Checklists for Resident #79 dated 09/01/22 which revealed the resident did not have at least one of the signs or symptoms documented in table two, section one to meet the requirements for antibiotic use. Table two of the McGeer Criteria for Infection Surveillance Checklist for urinary tract infections revealed a resident with a urinary tract infection without an indwelling catheter must fulfill both one and two of the requirements for antibiotic usage. Review of Resident #79's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/24/22 revealed the resident was cognitively intact, had an active diagnosis of renal failure and was assessed to be always incontinent. On 11/07/22 at 2:58 PM an interview with the DON revealed the urine culture and sensitivity dated 08/28/22 did not contain the sensitivity part. Therefore, the nursing staff would not know if the antibiotic ordered would have been effective to treat the resident. On 11/07/22 at 4:45 PM an interview with Registered Nurse (RN) #60 revealed she was not checking the medication ordered with the urine sensitivity results. She reported she was new to the position (related to antibiotic stewardship) and still learning the process. She assumed the physicians were checking for antibiotic correctness. During the interview, the 09/01/22 McGeer Criteria for Infection Surveillance Checklist for Resident #79 was reviewed with the RN #60. She revealed she charted c/o problems with urine from a physician's note. RN #60 verified she did not check with the resident and based on not marking anything in table two section one, Resident #79 did not meet the requirements for antibiotics and should not have been put on an antibiotic at that time. On 11/07/22 at 5:42 PM an interview with RN #60 verified Resident #79 did not meet the McGeer Criteria for antibiotics used in 09/2022. She reported she should have called the physician and made them aware of the resident not meeting the criteria for antibiotic use. Review of the facility policy titled, Antibiotic Stewardship Program, reviewed/revised 10/24/22 revealed the program included antibiotic use protocols and a system to monitor antibiotic usage which included antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness. 3. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including heart failure and allergic rhinitis. Review of Resident #2's Medication Administration Records (MAR) and orders revealed form 08/19/22 to 11/03/22 the resident received Nystatin, an anti-fungal powder twice daily to abdominal fold for a yeast infection and from 10/06/22 to 10/20/22 the antibiotic, Doxycycline (antibiotic). Review of the infection control/antibiotic stewardship log, dated 08/2022 to 10/2022 revealed no evidence the yeast infection which required an anti-fungal treatment or the Doxycycline treatment for an infection was documented on the log. Interview on 11/02/22 at 1:13 P.M., with Infection Preventionist (IP) RN #60 verified the yeast infection that was treated with Nystatin and the Doxycycline for an infection were not documented on the infection control log.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #52's call signal device was in proper working order. This affected one resident (#52) of six residents reviewed for physical environment. Findings include: Review of Resident #52's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, benign prostatic hyperplasia, and generalized muscle weakness. Review of Resident #52's annual Minimum Data Set (MDS) 3.0 assessment, dated 09/02/22 revealed the resident was cognitively impaired and required supervision with (staff) set up assistance only for eating. On 10/31/22 at 2:30 P.M. observation of Resident #52's call signal device revealed the device did not activate when the button was pushed. On 11/02/22 at 8:50 A.M. observation revealed Resident #52's call signal device did activate when the button was pushed. The resident was observed to attempt to activate the call light twice. Interview with Maintenance Director (MD) #116, who was present at the time of the observation revealed staff from the maintenance department check three resident call lights every morning and by the end of the month all call lights would have been assessed. MD #116 verified Resident #52's call signal device was not properly functioning and the resident could not use the call device for seek assistance from staff due to it not working. On 11/03/22 at 10:58 A.M. an interview with Licensed Practical Nurse (LPN) #9 revealed Resident #52 was lucid at times and would be able to use his call light if assistance was needed. On 11/03/22 at 10:59 A.M. an interview with State Tested Nursing Assistant (STNA) #69 revealed Resident #52 could use his call light and had used it in the past to get staff assistance. Review of the facility policy titled, Call Lights: Accessibility and Timely Response, reviewed/revised 01/01/22 revealed the purpose of the policy was to ensure the facility was adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the Resident #54's medical record revealed the resident had diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, morbid obesity and type two diabetes. Review of Resident #54's annual Minimum Data Set (MDS) 3.0 assessment, dated 09/06/22 revealed the resident was cognitively intact. Review of Resident #54's medical record revealed a care conference, dated 08/07/22. Review of the form titled, Care Plan Conference Summary, dated 08/07/22, revealed there were no signatures in the Attendee/Participant Signatures section to identify the resident, resident representative or any staff actually present for the conference. On 10/31/22 at 5:10 P.M. during an interview with Resident #54, the resident denied participation in any care conferences. On 11/06/22 at 8:29 A.M. interview with the DON revealed on 08/08/22 the facility noticed an issue with the care conference process and that they were not being completed correctly. The DON reported the facility then initiated a process where social services was now overseen by the DON and the Administrator to correct the identified problem with care conferences. The facility was unable to provide additional evidence of this oversight and monitoring to ensure all residents and/or their responsible parties were notified timely and afforded the opportunity to participate in care planning associated with comprehensive assessments being completed for each resident. Review of the facility policy titled, Patient/Family Initial Care Conference, reviewed/revised 01/01/22 revealed each resident and his/her family members were encouraged to participate in the development of the resident's comprehensive assessment and care plan. 2. Medical record review revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including encounter for orthopedic aftercare, type 2 diabetes mellitus, morbid obesity, atrial fibrillation, anxiety, colostomy, bipolar disease, schizoaffective disorder, muscle weakness, and spinal stenosis. Review of care planning documentation revealed there was no evidence of any care conferences being held for the resident. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/30/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. There were no behaviors or rejection of care. The MDS further revealed Resident #81 required extensive, one-person assistance for personal hygiene, bed mobility, and toileting. On 11/08/22 at 3:37 P.M. interview with Resident #81 revealed she had concerns about her teeth being sensitive to hold and cold foods. During the interview the resident reported she had not participated in any type of care conference or discussion about her care. During interview on 11/08/22 at 3:40 P.M. SSD #84 revealed the facility had been behind on care planning conferences and verified there had been none held for Resident #81 since she was admitted in December 2021. Based on record review, facility policy and procedure review and interview the facility failed to ensure care planning conferences were conducted in the required timeframe, failed to ensure resident(s) and/or their representative(s) were invited to attend the meetings and /or failed to ensure all necessary staff members were involved in the care planning process. This affected three residents (#54, #81, and #92) of sixteen residents interviewed and one resident (#41) of three residents whose families were interviewed related to care planning participation. Findings include: 1. Record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including diffuse traumatic brain injury with loss of consciousness, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia, apraxia, lupus, pressure ulcer of right hip, peripheral vascular disease, pseudobulbar affect, Vitamin D and Vitamin B12 deficiency, depression, anemia, hyperlipidemia, history of malignant neoplasm of the testis, alcohol abuse, hypertension, atrial fibrillation, cognitive communication deficit, and insomnia. Review of a care conference note, dated 04/13/22 revealed neither family nor the resident representative (RR) attended the meeting. The note documented family/RR was invited to participate via phone or to change date/time to accommodate them. A note indicated all of the family's concerns were answered to satisfaction even though the note prior indicated the RR did not attend. There was only one person who attended the meeting according to the sign in sheet, and it was the facility licensed social worker (LSW). An additional note was made to include the family declined a copy of the care plan. Review of Resident #41's last care conference note, dated 08/08/22 revealed neither the family nor the resident representative (RR) attended the meeting. The note documented family/RR was invited to participate via phone or to change date/time to accommodate them. Additional comments indicated the care conference included the RR and interdisciplinary team (IDT) had met and agreed to continue the current plan of care after all topics were discussed, even though it was noted the RR did not attend. The section for signatures for those who attended and participated i the care planning meeting was blank. The note revealed the family declined a copy of the care plan. Further review of Resident #41's paper and electronic medical record revealed no evidence the resident/family or RR was invited to the next quarterly care planning meeting due around 11/08/22. On 11/01/22 at 3:30 P.M. interview with Resident #41's mother revealed a concern she was not involved in or invited to attend care planning meetings. The resident's mother revealed she had concerns with her son's care and treatment including issues with falls and pressure ulcers. On 11/02/22 at 3:34 P.M. interview with Social Services Designee (SSD) #84 revealed the facility currently didn't have a Licensed Social Worker (LSW). SSD #84 reported she was new to the designee position and would have to review Resident #41's care conference notes to see if she could find any additional information she could provide regarding the 08/08/22 care conference meeting due to the one in the chart indicated the RR did not attend and the sign in sheet was blank to reflect who attended the meeting. On 11/07/22 at 3:04 P.M. interview with the Director of Nursing (DON) revealed the facility was aware care conferences were not being held at least quarterly as required in August 2022 and started a Quality Assurance and Performance Improvement plan (QAPI) was initiated on 08/08/22. Based on the plan, the facility had a goal to be back in substantial compliance by 08/31/22. The DON revealed the previous LSW had been let go the end of July 2022. The DON reported all resident care conference were completed by 08/31/22 and she was responsible for monthly audits to ensure the care conference were completed monthly. The DON confirmed she had not completed the October 2022 audits as of this time. The DON reported care conferences did not correlate with the Minimum Data Set (MDS) assessment reviews, however, were correlated with the last time a care conference meeting was completed. The DON confirmed Resident #41's care conference indicated the RR did not attend and there was no evidence of who attended the meeting due to the sign in sheet being left blank. The DON reported her audits were to ensure care conference were completed and not to ensure the accuracy of the documentation including ensuring the sign in sheets were completed and reflected who attended. The DON confirmed Resident #41's next care conference was due tomorrow and there was no evidence one had been scheduled or that the resident's family/RR had been invited to attend. On 11/07/22 at 3:17 P.M. interview with SSD #84 revealed she had not invited Resident #41 or his family/RR to attend the next care planning conference which was due tomorrow because she was still behind on October 2022 care conferences. The SSD reported she still had 20 out of the 22 care conference to complete from October, only had four of the 20 scheduled and still needed to schedule the other 16 before she even started the list for November 2022. During the interview, the SSD reported she had not been completely trained for her job position. She was supposed to have three days of training and only received one half day. She had just met the regional corporate LSW a couple of weeks ago and went over care plan meeting because she had a question and needed assistance. Review of Care Conference audits revealed the audits were completed on 08/31/22 and 10/03/22 (for September 2022). The September 2022 audits was a census sheet with check marks next to the resident's name. There were no evidence October 2022 audits had been completed. Review of care conferences scheduled that were due in October 2022 revealed only two had been completed, four scheduled (however not completed) and sixteen had not been scheduled as of this time. The previous care conferences for these 22 residents were done in 07/2022. Review of the care conference policy and procedure, dated 09/03/20 and revised 01/01/22 revealed each resident and his/her family members were encouraged to participate in the development of the resident's comprehensive assessment and care plan. The resident and his/her family and or legal representative were invited to attend and participate in the resident's assessment and care planning conference. A seven-day advance notice of the care planning conferences to the resident and interested family members for all concerns would be provided. Such notice was made by mail and/or telephone. The SS director and designee were responsible for contracting the resident's family and for maintaining records for such notices. The notices included date of the conference, time, location, name of each family member, date and time family was contacted. Method of contacting the family, input from family members when they were not able to attend, input from the resident when he/she was not able to attend, refusal of participation, and date and signature of the individual making the contact. 3. A review of Resident #92's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a stroke affecting the left non-dominant side, chronic obstructive pulmonary disease, major depressive disorder, pseudobulbar affect (PBA), generalized anxiety disorder, difficulty walking, and muscle weakness. A review of Resident #92's Minimum Data Set (MDS) 3.0 assessments revealed she had an admission MDS assessment completed on 02/18/22. Quarterly MDS assessments had been completed on 04/06/22, 07/01/22 and 10/01/22. The quarterly MDS assessment dated [DATE] revealed the resident did not have any communication issues and her cognition was moderately impaired. The assessment noted the resident was able to make herself understood and was able to understand others. No behaviors were noted. A review of Resident #92's Care Plan Conference Summary assessments revealed the resident had a care planning conference held on 08/08/22. The Care Plan Conference Summary indicated the resident's representative was in attendance of the meeting along with the interdisciplinary team. Record review revealed there was no evidence of the resident having been invited to attend the care planning conference. The attendee/ participant section was left blank with no signatures being obtained for any of those who were in attendance. The resident's medical record was absent for any documented evidence of any additional care planning conferences having been held since the resident's admission to the facility on [DATE]. On 10/31/22 at 5:55 P.M. an interview with Resident #92 revealed she did not feel she was involved in decisions about medications, therapy and other treatments. She stated she was on so many different medications she did not know what they were even for. She denied she had been part of any care planning conferences and could not recall ever being invited to attend any of them. On 11/07/22 at 8:20 A.M., an interview with SSD #84 revealed she had been the facility's social worker since July 2022. She confirmed she was responsible for coordinating care planning conferences. She stated she was still learning a lot about her position and her responsibilities. She stated she called families to see if they wanted a printed letter announcing the care planning conference, if they wanted emailed about the meeting, or if they declined wanting to attend. She documented how the notification was made or if the family had declined to attend. She would also ask the families which department heads they wanted to be a part of the care planning conference in case they had concerns in those departments they wanted to discuss. SSD #84 revealed the facility DON would print off a report of those due for a care planning conference and she made the arrangements based on that. She denied she scheduled care planning conferences in conjunction with the MDS schedule and was not sure what schedule the DON went by. SSD #84 revealed she believed the facility had a lot of issues with the prior social worker not doing what she was supposed to be doing. She was then asked if the resident was invited to attend and stated they would typically have the resident present for the meetings. She documented the care planning conferences in the social service progress notes and would complete the care conference summary assessment in the electronic health record (EHR). A review of the facility policy on Patient/ Family Initial Care Conferences revised 01/01/22 revealed each resident and his/ her family members were encouraged to participate in the development of the resident's comprehensive assessment and care plan. The resident and his/ her family and/ or the legal representative were invited to attend and participate in the resident's assessment and care planning conferences. Resident assessments were begun on the first day of admission and completed no later than the 14th day after admission. A comprehensive care plan was developed within seven days of completing the MDS. A care conference would be held 72 hours after admission for a quick review of the treatment plan and to ensure good customer service with the admission process. Notice of that meeting was to be given with the admission paperwork. Document the outcome of that meeting in the progress note. The comprehensive care conference was scheduled after the completion of the comprehensive care plan. Staff were to document the outcome of the meeting in the progress notes. The facility was to give seven days advanced notice of the care planning conference to the resident and interested family members for all conferences. Such notice was made by mail and/ or phone. The social services director was responsible for contacting the resident's family and for maintaining records of such notices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. a. On 10/31/22 at 2:43 P.M. and 11/02/22 at 8:46 A.M. observation of Resident #72's wall behind the resident's bed and to the left of the bed revealed large white patched areas in need of being painted. On 11/02/22 at 8:46 A.M. observation of the area with Maintenance Director (MD) #116 verified the wall was not in good repair and needed painted. b. On 10/31/22 at 10:58 A.M. observation of Resident #27's wall behind her bed revealed a large white patched area in need of being painted. On 11/02/22 at 8:50 A.M. observation of the area with MD #116 verified the wall was not in good repair and needed painted. c. On 10/31/22 at 3:11 P.M. observation of Resident #60's over bed table revealed the table had rough edges. Interview with Resident #60 at the time of the observation revealed the table had been like that for a while. Resident #60 reported it was rough on her arms and sometimes she would scratch herself on the table. On 11/02/22 at 8:48 A.M. observation with MD #116 verified the table was in disrepair and Resident #60 needed a new over bed table. Review of an over bed table audit completed by the facility revealed 19 residents, Resident #3, #5, #10, #23, #27, #32, #39, #47, #59. #60, #67, #71, #74, #91, #93, #98, #101, #106, and #260 had over bed tables which were in disrepair and needed replaced. Review of the facility policy titled Safe and Homelike Environment, reviewed/revised 01/01/22 revealed in accordance with residents' rights, the facility would provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Based on observation, record review, review of a facility concern log and interview the facility failed to exercise reasonable care for the protection of Resident #2's property and failed to ensure missing property was replaced timely. The facility also failed to ensure resident furniture and walls were in maintained in good repair. This affected one resident (#2) of three residents reviewed for missing personal property, three residents (#27, #60, and #72) whose rooms were observed during the initial resident pool and had the potential to affect 19 additional residents (#3, #5, #10, #23, #27, #32, #39, #47, #59. #60, #67, #71, #74, #91, #93, #98, #101, #106, and #260) identified by the facility to need a new over bed table. Findings include: 1. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including heart disease, type two diabetes, chronic obstructive pulmonary disease, restless leg syndrome, anxiety, and allergic rhinitis. Review of Resident #2's census data revealed the resident resided on the E unit from 11/24/21 to 12/08/21. Review of a facility concern log, dated 11/10/21 to 10/18/22 revealed no evidence Resident #2's name was listed on the concern log or evidence of any concerns with missing items. On 10/31/22 at 1:49 P.M. interview with Resident #2 revealed she had a red duffel bag that was missing that contained two books, Depends, tapes, jewelry and a death book. The resident stated she had to move to E hall for two weeks (in 2021) due to COVID and when she returned to her original room her duffel bag and belongings were missing. The resident stated she had reported the missing items to the previous Administrator, and the previous Administrator reported he would replace the bag; however, he never did. On 11/01/22 at 5:28 P.M. interview with the Director of Nursing (DON) revealed she remembered Resident #2 reporting the missing red bag; however, she thought the previous Administered had addressed the issue. The DON confirmed the resident's concern was not listed on the facility concern log and stated she would look to see if the previous Administer might have written anything on paper. The DON revealed the previous Administrator left the facility in June 2022. On 11/02/22 at 8:28 A.M. interview with the current (Interim) Administrator revealed he could not find any paperwork regarding Resident #2's red bag that was reported to the pervious Administrator as missing. The Administrator reported he just went and spoke to the resident, and stated the resident told him she was not worried about replacing the contents of the bag, however, she would like the red bag replaced. The Administrator revealed he showed the resident some red bags on Amazon, and she agreed on one, the facility would order it and it would be here in a few days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of Resident #72's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including type one diabetes, Crohn's disease, hemiplegia affecting left non-dominant side, and essential hypertension. Review of Resident #72's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/24/22 revealed the resident was cognitively impaired. Review of a facility self-reported incident (SRI), tracking number 222753, dated 06/13/22 revealed Resident #73 reported an employee was rough with him during care on 06/10/22. Review of the SRI revealed two witness statements from STNA #122 and STNA #16. There were no interviews from the rest of the staff working the unit or from other residents in the SRI investigation provided for review. Review of the working schedule for 06/10/22 revealed the following staff were working Resident #73's floor: Registered Nurse (RN) #49, RN #90, State Tested Nursing Assistant (STNA) #8, STNA #16, STNA #68, STNA #88, STNA #107, STNA #122, and STNA #126. Seven staff members who were working the date of the alleged abuse/incident were not interviewed as part of the facility investigation. Review of the Daily Census for 06/13/22 revealed Resident #73 had two roommates, Resident #23 and Resident #91 at the time of the incident. No interviews were obtained from Resident #72's roommates or any of the other 22 residents residing on the unit. There were a total of 25 residents on Resident #72's unit. On 11/03/22 at 11:02 A.M. interview with the DON verified not all staff members or any other residents were interviewed during the investigation and therefore, the investigation was not thorough. Review of facility policy titled Abuse, Neglect and Exploitation, revised on 10/24/22 revealed under the section titled Investigation of Alleged Abuse, Neglect and Exploitation the written procedures for investigations included identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 2. Medical record review revealed Resident #101 was admitted to the facility on [DATE] with diagnoses including hemiplegia, diabetes mellitus, heart disease, failure to thrive, anxiety, and major depressive disorder. Review of Resident #101's Minimum Data Set (MDS) 3.0 quarterly assessment, dated 10/11/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 (out of 25), which indicated intact cognition. The MDS further revealed Resident #101 required extensive, two-person physical assistance with dressing, bed mobility, and transfers. Review of a psychiatric progress note, dated 10/14/22, revealed Resident #101 had chronic pain, chronic worry, and poor sleep. Medical record review revealed Resident #23 was initially admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dementia, hemiplegia and hemiparesis, anxiety, and cognitive communication disorder. Review of the care plan, dated 05/31/22 revealed Resident #23 exhibited sexually inappropriate behavior with interventions including to intervene as necessary to protect the rights and safety of others and to remove the resident from the situation and take to alternative location. Review of Resident #23's Minimum Data Set (MDS) 3.0 annual assessment, dated 08/10/22, revealed a BIMS score of 06 (out of 15), which indicated severely impaired cognition. The MDS further revealed Resident #23 had no psychosis and no physical or verbal behaviors. The resident required set-up assistance and supervision of locomotion on the unit. Review of the facility Self-Reported Incident (SRI), tracking number 227734 revealed on 10/06/22 at 4:20 P.M., staff reported Resident #23 made inappropriate physical contact with Resident #101 while sitting in the dining room. The residents were immediately separated by the staff to different parts of the unit. A head-to-assessment was completed with no apparent injuries noted to Resident #23 or Resident #101. Both residents denied pain or discomfort. As part of the facility investigation, Resident #55 reported to the nurse she saw Resident #101 perform inappropriate oral contact with Resident #23. Resident #101 denied any inappropriate contact. Resident #23 was unable to provide any meaningful information based on his diagnosis of dementia. Social Services completed psychosocial assessments on Resident #101 and #23. The facility's investigation concluded the allegation did not occur. Review of the facility investigation, dated 10/06/22 failed to provide evidence of interviews with all staff and residents present during the incident, a list of the residents who were physically examined, or evidence of staff abuse education provided following the incident. During interview on 11/03/22 at 3:30 P.M., the Director of Nursing (DON) confirmed the investigation did not include documentation of interviews of all staff present during the incident, interviews with residents, a list of the residents who were physically examined, or of staff abuse training/education provided following the incident. A review of the facility Abuse, Neglect, and Exploitation Policy, revised 07/28/20 revealed the section under Investigation of Alleged Abuse, Neglect and Exploitation indicated the facility staff were to identify and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 3. Medical record review revealed Resident #71 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, epilepsy, dementia with agitation, bipolar disorder, schizophrenia, and major depressive disorder. Review of Resident #71's care plan, dated 02/18/19 revealed Resident #71 was physically aggressive and observed to hit staff and other residents. Review of Resident #71's Minimum Data Set (MDS) 3.0 quarterly assessment, dated 09/23/22 revealed a Brief Interview for Mental Status (BIMS) score of 03 (out of 15), which indicated severely impaired cognition. The resident did have delusions and exhibited physical behaviors. The MDS further revealed Resident #71 required extensive, two-person physical assistance with dressing, toileting, bed mobility, and transfers. Medical record review revealed Resident #10 was initially admitted to the facility on [DATE], with diagnoses including dementia, alcoholic liver disease, anxiety, bipolar disorder, chronic kidney disease stage 3, and cognitive communication deficit. Review of the care plan, dated 07/21/21 revealed Resident #10 was verbally aggressive at times with interventions including to guide the resident away from a source of distress and to intervene before agitation escalates. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment, dated 02/08/22 revealed a BIMS score of 03 (out of 15), which indicated severely impaired cognition. The MDS further revealed Resident #10 required limited, one-person physical assistance with dressing, toileting, bed mobility, and transfers. Review of Resident #10's nursing progress note, dated 04/29/22 at 1:45 P.M. revealed Resident #71 stated Resident #10 was trying to steal her unicorn, so she punched him in the face. Resident #10 did not remember the incident and there were no injuries noted. Review of the facility self-reported incident (SRI), tracking number 220985 revealed on 04/29/22 at 1:18 P.M., staff reported Resident #71 made physical contact with Resident #10 while sitting in the dining room. The residents were immediately separated by the staff to different parts of the unit. A head-to-assessment was completed with no apparent injuries noted and Resident #10 denied pain or discomfort. Review of the facility investigation, dated 04/29/22 failed to include evidence of interviews with all staff present during the incident. There were no observations or assessments of other residents residing on the memory care unit during the time of the incident. During interview on 11/03/22 at 3:35 P.M. the Director of Nursing (DON) confirmed the investigation did not include documentation of evidence of staff interviews or resident assessments following the incident. Reviewed facility policy titled Abuse, Neglect, and Misappropriation, dated 07/28/20 revealed it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Investigation of Alleged Abuse: an immediate investigation was warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation. Written procedures for investigations include: identifying staff responsible for the investigation; identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations; providing complete and thorough documentation of the investigation. The facility would make efforts to ensure all residents were protected from physical and psychosocial harm during and after the investigation. Examples include but were not limited to: responding immediately to protect the alleged victim and integrity of the investigation; examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; increase supervision of the alleged victim and residents; room or staffing changes, if necessary, to protect the residents from the alleged perpetrator. 4. Record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including anxiety, major depression, bipolar, heart disease, and muscle weakness. Review of a facility self-reported incident and investigation, revealed on 05/08/22 at 8:30 P.M., staff reported Resident #50 voiced that staff (unidentified) were rough with care on 05/06/22 resulting in skin tears. A head-to-toe assessment was completed by the nurse with skin tears were noted on the resident's bilateral hands with bruising. Documentation supported the resident being combative with care on 05/05/22 resulting in the above injuries. Staff were educated on the abuse policy and resident's right to refuse care. The facility unsubstantiated an allegation of abuse as they determined there was no intent to harm the resident. Review of two undated staff witness statements revealed an incident occurred on 05/06/22 at 4:00 P.M., (not 05/05/22 per the above narrative summary and nursing progress note). State Tested Nursing Assistant (STNA) #68 reported STNA #47 and herself went into the residents room to change the resident because the resident and her bed were soaked. The statement revealed STNA #68 asked the resident if she could change her. The resident responded whatever and started screaming and fighting them. They then called STNA #122 for help and the resident started hitting and scratching STNA #122. The incident was reported to the nurse. STNA #122's statement indicated STNA #68 and STNA #47 went into change Resident #50 and the resident reported she was fine and then she started screaming and fighting when staff went to turn her. They asked if STNA #122 could come in and help. She went in and helped. The resident started hitting and kicking them and the bed rails. The incident was reported to the nurse. Review of a statement from Resident #48 (Resident #50's roommate at the time of incident), dated 05/09/22 revealed an incident had occurred on 05/05/22. The resident reported staff members had come in the room last week and were providing incontinence care Resident #50 and the resident started yelling, screaming, hitting, and kicking. Staff were trying to put the resident's (incontinence) brief on, and she heard them (staff) say watch her hands. The resident thought Resident #50 had kicked one of the girls. Record review revealed there was no statement obtained from STNA #48 or Resident #50 regarding the incident. On 11/03/22 at 3:40 P.M. and 11/07/22 at 12:15 P.M. interview with the Director of Nursing (DON) revealed she had found dementia education she had provided to all staff on 11/06/22 after the incident, but prior to it being reported that was not included in the facility self reported incident. The DON verified there was no evidence statements were obtained from Resident #50 or STNA #48 as part of the investigation. Review of the facility Abuse, Neglect, and Exploitation policy and procedure, dated 07/28/20 and revised 10/24/22 revealed the policy was to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Staff should be trained on understanding behavioral symptoms of residents that may increase risk of abuse and neglect, aggressive/catastrophic reactions, resistance of care, and outburst or yelling. The investigation should include investigating different types of alleged violations. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrators, witness, or others who might have knowledge of the allegation. Provide complete and thorough documentation and investigation. The facility will make efforts to ensure the residents are safe during the investigation. 5. Review of Resident #7's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on 10/28/22 with diagnoses including dementia, unsteadiness on feet, insomnia, dysphagia, anxiety, depression, and anemia. Review of a facility self-reported incident revealed on 03/01/22 the resident had a bruise on the right forearm and left shoulder of unknown source. The narrative summary of incident included at approximately 10:30 A.M. on 03/01/22 staff reported the resident had a bruise noted to the right inner forearm and left shoulder. The resident was not able to provide any meaningful information. After gathering staff witness statements and like resident assessments, the facility determined no abuse was suspected. The resident's roommate was unable to provide any additional information related to a diagnosis of dementia. Like residents were assessed with pain/skin with no abnormal findings noted. Further review of the SRI and investigation revealed no evidence of staff or resident statements or evidence of the original assessments of like residents completed for pain and skin. On 11/01/22 at 1:55 PM and 11/03/22 at 3:40 P.M. interview with the DON verified the facility was unable to provide any staff or witness statements or the original resident assessments completed. The DON reported she assessed all resident's and not just like residents and did not find anything abnormal, however she could not find the actual written original assessments. The DON revealed she printed the census on 10/31/22 for 03/01/22 and signed it because she could not find the original assessment and submitted it to the surveyor upon request to review this SRI investigation. The DON confirmed the investigation documentation were not maintained to ensure a complete and thorough investigation had been completed. Review of the facility Abuse, Neglect, and Exploitation policy and procedure, dated 07/28/20 and revised 10/24/22 revealed the policy was to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Staff should be trained on understanding behavioral symptoms of residents that may increase risk of abuse and neglect, aggressive/catastrophic reactions, resistance of care, and outburst or yelling. The investigation should include investigating different types of alleged violations. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrators, witness, or others who might have knowledge of the allegation. Provide complete and thorough documentation and investigation. The facility will make efforts to ensure the residents are safe during the investigation. Based on record review, review of facility self-reported incidents and related investigations, facility policy and procedure review and interview the facility failed to ensure all allegations of abuse and misappropriation were thoroughly investigated. This affected eight residents (Resident #7, #10, #23, #50, #71, #72, #101, and #102) reviewed in 10 facility self-reported incidents. The facility census was 100. Findings include: 1. The following self-reported incidents (SRIs) were reviewed involving Resident #102: a. Self-reported incident (SRI) tracking number 218831 revealed an allegation of misappropriation of medications was made by Resident #102 on 03/09/22. Resident #102 alleged his medications, including Methadone 10 milligrams (mg) and Adderall 20 mg that were scheduled to be given as a scheduled dose on 03/09/22 at 12:00 P.M. and 2:00 P.M. respectively were misappropriated by Licensed Practical Nurse (LPN) #510. The resident denied he received either medication as scheduled. The facility indicated they obtained witness statements from staff as part of their investigation. The allegation of misappropriation was unsubstantiated due to a lack of evidence to prove the resident did not receive his medications. The resident's controlled medications had been signed out on the narcotic book and were documented as having been provided on the medication administration record (MAR). A review of the facility's investigation file for their investigation into SRI tracking number 218831 revealed witness statements were obtained from Resident #102, Registered Nurse (RN) #90, LPN #510, State Tested Nursing Assistant (STNA) #88 and STNA #107. STNA #88 and STNA #107 were scheduled to work on the secured unit on 03/09/22 and were not the STNA's that were working F- Hall (where Resident #102 resided). No statements were obtained from the STNA's assigned to work on F- Hall on 03/09/22 to see if they had any knowledge about the alleged misappropriation or to see if they could verify whether or not LPN #510 was observed to administer medications to Resident #102 on that date. Findings were verified by the Director of Nursing (DON). On 11/08/22 at 3:07 P.M., an interview with the DON revealed the facility investigation determined Resident #102's Methadone and Adderall had not been misappropriated on 03/09/22, as alleged by the resident. It was believed, after their investigation, the resident received his Adderall early around 11:09 A.M. at the same time he was given his scheduled Methadone by LPN #510. They had camera video that showed the nurse entered the resident's room around that time with what appeared to be a medicine cup. They concluded, based on that, the Adderall was administered as well. She denied a thorough investigation had been completed as the facility failed to obtain witness statements from the STNA's who were assigned to work Resident #102's hall on 03/09/22. She agreed the facility should have interviewed those STNA's as they were working with the nurse who was alleged to have misappropriated the resident's medications on the unit the resident resided on. These staff might have been able to provide additional information if they had any first hand knowledge of the situation or if the resident might have reported anything to them. The DON also agreed any additional staff who routinely worked with LPN #510 could have been interviewed to see if they had any concerns of the LPN possibly misappropriating medications from any other residents or if the nurse appeared to be under the influence while working on 03/09/22. The nurse was terminated from her employment with the facility due to administering medications before their scheduled administration times. b. SRI tracking number 220196 revealed another allegation of misappropriation was reported by Resident #102 on 04/11/22 at 5:15 P.M. Again, the allegation of misappropriation pertained to the resident's Adderall. LPN #600 was the nurse accused of the misappropriation of the medication. The resident reported he did not receive his scheduled dose of Adderall on that date and it was three and a half hours past due. The facility indicated in the SRI that, after gathering staff witness statements and like residents were assessed, it was determined that no misappropriation was suspected. The facility based their findings on the fact that the narcotic count was correct when the off going nurse counting with the oncoming nurse. A narcotic audit was completed with no discrepancies being noted. The medication was signed out on both the MAR and the narcotic book. A review of the facility's investigation file for their investigation associated with SRI tracking number 220196 revealed statements were obtained from Resident #102 and LPN #600 by the facility's prior Administrator. Statements were not obtained from any other staff who were on duty at the time the alleged misappropriation occurred. There was no evidence other staff, who commonly worked with LPN #600, were interviewed to see if they had any knowledge or concerns of LPN #600 possibly misappropriating any resident medications. The facility's investigation file was also absent for any evidence of the facility's prior Administrator reviewing the video from the cameras in the hall as part of the investigation to see if it could be determined if the nurse had entered Resident #102's room around the time the Adderall was documented as having been given. Findings were verified by the DON. On 11/08/22 at 5:05 P.M., an interview with the DON confirmed the investigation file they provided for review was all the investigation they had. She acknowledged the facility did not complete a thorough investigation as statements were not obtained from any of the staff that were working Resident #102's hall on 04/11/22 at the time he alleged his medication was misappropriated. She also denied there was evidence of the facility's prior Administrator reviewing camera footage as part of their investigation to see if LPN #600 even entered the room on 04/11/22 at 1:11 P.M. when she signed that she gave the resident his Adderall on that day. She confirmed they reviewed camera video as part of their investigation during other allegations of misappropriation of medication. She was not sure why he did not review it then. She acknowledged the facility could not assume a medication had not been misappropriated just by basing it on what was signed out on the narcotic sheet and what was documented as having been given on the MAR. The nurse could have signed it out but not given it to the resident, which was a definition of misappropriation. She agreed reviewing the camera video could have confirmed whether or not the nurse had entered the room to possibly administer the Adderall to the resident as she documented or if the medication was in fact misappropriated. c. SRI tracking number 228222, dated 10/19/22 revealed an allegation of physical abuse was made by Resident #102. The resident was the initial source of the allegation and a facility staff member was the alleged perpetrator. The SRI did not identify the alleged perpetrator by name. The narrative summary of the incident revealed on 10/19/22 at approximately 11:00 A.M. Resident #102 reported an STNA slapped him on 10/18/22 at approximately 6:00 P.M. The resident refused to allow a skin assessment to be completed and refused to answer questions about the alleged incident after he had reported it. Staff and like residents were assessed with no abnormal findings being noted. A review of the facility's investigation file that pertained to SRI tracking number 228222 revealed the facility DON initiated her investigation regarding Resident #102's allegation of physical abuse on 10/19/22 beginning at 11:00 A.M. Her investigation included a hand written account of what was initially reported by the resident claiming he had video of an STNA admitting she slapped him. She also documented her interview with two STNAs involved in the alleged incident. The DON indicated she, along with the unit manager, and scheduler were present and watched the video. The facility staff determined the video did not reveal evidence of abuse occurring. The DON's account of her interviews with STNA #75 and #77 revealed she interviewed STNA #77 on 10/19/22 at 1:21 A.M., and was told Resident #102 put his call light on. She responded to the room with STNA #75. The resident began cussing at them upon entering his room. STNA #75 picked up one of the resident's tools he had in his room and told the resident he did not need to talk to them like that. The resident began swinging his arms and was cussing at them. He told them to get the expletive word out. She turned the resident's call light off and they both left the resident's room. She denied STNA #75 had went into the resident's room without her. She denied STNA #75 had slapped the resident as he alleged. She was in another resident's room feeding that resident, when she heard the resident going down the hall while recording STNA #75. A written account of the DON's conversation with STNA #75 revealed Resident #102's call light did go off and she responded to the room with STNA #77. STNA #77 had asked her to go in with her. The resident said get this (expletive words) off the floor. They informed him that he did not have to talk to them that way and they exited the room. STNA #75 denied that she touched the resident. She then went and got a nurse because the resident was swinging at her. The facility's investigation revealed no evidence of any other interviews being conducted with any other staff who were working at the time of the alleged abuse. There was no evidence of any co-workers being interviewed who commonly worked with STNA #75's to see if they had knowledge of her being abusive towards Resident #102 or any other residents. Other residents were interviewed and skin assessments were completed to see if there was any evidence of other abuse incidents occurring. The facility educated staff on the abuse policy and provided the directive, if any of the trigger events occurred (including allegations of abuse), it was imperative they ensured resident safety and then notify the DON. On 11/08/22 at 5:10 P.M., an interview with the facility DON confirmed she did not obtain interviews with any other staff who were present at the time the alleged abuse occurred. She did not obtain a statement from the nurse who was on duty at the time of the alleged incident. She also denied they had obtained interviews with any other staff who commonly worked with STNA #75 to see if they had ever known her to be abusive towards the resident or any other resident when working with her. A review of the facility Abuse, Neglect, and Exploitation Policy, revised 07/28/20 revealed the section under Investigation of Alleged Abuse, Neglect and Exploitation indicated the facility staff were to identify and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, anxiety, and depression. Review of Resident #2's Medication Administration Records (MAR) and current orders for 10/2022 revealed the resident was ordered Lamictal 25 milligrams (mg) two tablets at bedtime for a diagnosis of bipolar disorder. Further review of MAR revealed the resident did not receive the Lamictal on 10/29/22, 10/30/22 or 10/31/22 as it was not available from pharmacy. Review of Resident #2's progress notes revealed the resident's physician was not notified the medication was not available or administered until 11/01/22. On 11/07/22 at 1:55 P.M., interview with the Director of Nursing (DON) revealed the pharmacy had the order entered incorrectly as 25 mg, one tablet at bedtime instead of two tablets at bedtime. The DON reported the pharmacy system was kicking out the orders and the pharmacy was having to re-enter them; however, it didn't affect the facilities orders. The DON confirmed the physician was not notified until 11/01/22 the resident did not receive the medication on 10/29/22. 10/30/22 or 10/31/22. The DON reported she would need to do a medication error report and do immediate staff education regarding the incident. This deficiency is an example of non-compliance investigated under Control Number OH00136939 and Control Number OH00136889. Based on record review, facility self-reported incident review and related investigation, facility policy and procedure review, review of Controlled Drug Receipt/ Record/Disposition Forms, review of narcotic shift count sheets and interview the facility failed to ensure routine medications were provided to residents as ordered and failed to provide adequate pharmaceutical services to meet the needs of each resident. The facility failed to ensure controlled narcotic pain medication was timely/appropriately documented when administered to residents and proper shift to shift reconciliation counts of controlled medication were completed to identify any discrepancies in the counts. The facility also failed to ensure medications were available for administration from their contracted pharmacy. This affected three residents (#86, #102 and #110) of three residents reviewed for misappropriation of medication and one resident (#2) of five residents reviewed for unnecessary medication use. Findings include: 1. A review of Resident #86's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including a left hip fracture, the presence of a right and left artificial hip joint, and low back pain. A review of Resident #86's physician's orders revealed the resident had an order in place to receive Percocet (a narcotic pain medication used in the treatment of moderate to severe pain) 5- 325 milligrams (mg) by mouth every six hours as needed (PRN) for pain. The order included parameters in which to give one tablet or two based on the resident's pain level. The resident was to receive one tablet for a pain level between three and six on a 1-20 scale and two tablets for a pain level between seven and 10. A review of Resident #86's Controlled Drug Receipt/ Record/ Disposition Form for his Percocet 5- 325 mg tablets revealed the resident was provided 60 tablets of Percocet 5- 325 mg on 10/07/22 from the facility's contracted pharmacy. The receipt of the controlled narcotic pain medication was signed by the pharmacist but was not signed by the nurse who received it upon delivery from the pharmacy. It was also not witnessed by another nurse to confirm 60 tablets of the Percocet 5- 325 mg had been received on 10/07/22. The nurses started signing out doses from that supply beginning 10/07/22 at 1:00 P.M. A review of the narcotic shift count sheet for A/B Hall (where Resident #86 resided when he was in the facility) revealed the off going nurse and the on coming nurse did not consistently document they compared the controlled medication cards on hand with the controlled medication count sheets to identify any discrepancies between the two which could indicate medication diversion/ misappropriation. The narcotic count sheets with missing documentation was for the time period between 10/09/22 and 10/13/22. Findings were verified by the DON. A review of facility self-reported incident (SRI) tracking number, 228015 revealed an allegation of misappropriation was made on 10/13/22 by Resident #86. The resident was the initial source of the allegation and a facility staff member was indicated to be the alleged victim. Resident #86 was noted to have been able to provide meaningful information when interviewed and the date/ time/ occurrence of the alleged incident was 10/13/22 at 5:40 A.M. in the resident's room. Resident #86 alleged he was given something other than his ordered as needed (PRN) pain medication (Percocet) for complaints of pain by Registered Nurse (RN) #125. As part of the facility's investigation, narcotic sheets were reviewed for the resident and other like residents. As a result of the facility's investigation, it was determined nursing policies in regard to medication and documentation were violated. The involved nurse (RN #125) was terminated from employment. A review of RN #125's employee personnel file revealed it contained a Performance Improvement Form, dated 10/20/22 that indicated counseling/corrective actions were taken against the nurse for standards of conduct. The employee was indicated to have violated company policy related to documentation not taking place at the time medication was being administered. The employee was also indicated to have violated company policy related to the improper wasting of a controlled narcotic involving another resident that was found by the DON during the course of the investigation. The employee had been discharged from employment as a result of those violations. A review of a complaint form to the State of Ohio Board of Nursing, dated 10/27/22 revealed RN #125 had been reported to the Board of Nursing by the facility's Director of Nursing (DON). The complaint form was part of the facility's investigation file for the allegation of misappropriation of Resident #86's medication in SRI number 228015. RN #125 was indicated to have been suspended pending an investigation into allegations of misappropriation. The investigation identified concerns with improper documentation related to the signing of MAR's at the correct times and the improper wasting of a narcotic. RN #125 was terminated based on three violations of company policy. On 11/02/22 at 5:38 P.M., an interview with the facility DON revealed she was involved in the facility's investigation of SRI tracking number 228015. She confirmed the facility identified concerns with controlled medication documentation; when they were used, the reconciliation of controlled medications between shifts and not having two nurses sign controlled medication receipts when the controlled medication was delivered from the pharmacy. She stated two nurses should be signing off that a controlled medication had been received from the pharmacy. She confirmed there was no documentation to show two nurses had signed receipt of Resident #86's Percocet when it was delivered on 10/07/22. She also reported the off going nurse and on coming nurse should be recording the number of controlled medication cards that were in the medication administration cart with the sheets for those controlled medications as a means to ensure medication diversion/ misappropriation did not occur. She indicated, by recording the cards to sheet count, it verified that the two nurses were actually counting the controlled medication to ensure the doses they had on hand was the same as the remaining count on the count sheets. If the amount of the controlled medication on hand did not match with the amount remaining on the sheet balance, the nurses were to determine what happened and to account for the discrepancy noted. A review of the facility policy on Controlled Substance Administration and Accountability policy, revised 01/01/22 revealed it was the policy of the facility to promote safe, high quality patient care, compliant with State and federal regulations regarding monitoring the use of controlled substances. The facility would have safeguards in place in order to prevent loss, diversion or accidental exposure. Controlled medications must be counted upon delivery. The nurse receiving the delivery, along with the person delivering the medication, must count the controlled substance together. Both individuals must sign the designated narcotic record. When a resident refused controlled medications or it was not given, the medication shall be destroyed. All destructions must be conducted in the presence of two licensed nurses or a pharmacist. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. Documentation should be made on the shift verification sheet. 2. A review of Resident #110's closed medical record revealed revealed the resident was admitted to the facility on [DATE] with diagnoses including the presence of a left artificial knee joint, aftercare following joint replacement surgery, and osteoarthritis of the right knee. A review of Resident #110's physician's orders revealed an order, dated 10/11/22 for Hydrocodone- Acetaminophen (Norco) 5- 325 mg by mouth every four hours as needed (PRN) for pain rated between six and 10 on a 1-10 scale. A review of Resident #110's Controlled Drug Receipt/ Record/ Disposition Form revealed a dose of the Norco 5-325 mg was signed out by RN #125 on 10/12/22 at 5:52 A.M. A review of Resident #110's medication administration record (MAR) for October 2022 revealed RN #125 did not document a dose of Norco was given on 10/12/22 at 5:52 A.M. as was indicated on the Controlled Drug Receipt/ Record/ Disposition Form. She did document a dose was given on 10/12/22 at 1:44 A.M. but no additional doses was indicated as having been given by the nurse that night. A review of RN #125's employee personnel file revealed she received counseling/ corrective action on 10/20/22 for violating company policy related to the improper wasting of narcotics. It was indicated to have been found by the facility's DON during the course of the facility's investigation into SRI #228015 pertaining to the misappropriation of medication. On 11/02/22 at 2:50 P.M., an interview with the DON revealed RN #125 was found to have improperly wasted a narcotic pain medication for Resident #110, when she was investigating another resident's allegation of misappropriation of his controlled narcotic pain medication. She stated the facility determined RN #125 had wasted a dose of Norco ordered for Resident #110 that was ordered on an as needed (PRN) basis. She stated the nurse signed the dose of Norco out on the Controlled Drug Receipt/ Record/ Disposition Form but had struck the dose out on the MAR. She reported the nurse told her she wasted the dose but did not have the destruction of the controlled medication witnessed by another nurse. RN #125's employment at the facility was terminated as a result of violating company policy. 3. A review of SRI tracking number 218831 revealed an allegation of misappropriation was made by Resident #102 on 03/09/22. Resident #102 was the initial source of the allegation and a facility staff member was indicated to be the alleged perpetrator. Resident #102 was able to provide meaningful information when interviewed. The date and time of the occurrence was 03/09/22 at 6:30 P.M. The resident alleged he was not given his scheduled doses of Methadone (a narcotic used to treat moderate to severe pain or could also be used to treat narcotic drug addiction) that was to be given at 12:00 P.M. or his Adderall (a stimulant used in the treatment of attention deficit hyperactivity disorder or narcolepsy) that was to be given at 2:00 P.M. The nurse alleged as having misappropriated the resident's medication was LPN #510. A witness statement from LPN #510 (that was obtained as part of the facility's investigation for SRI tracking number 218831) obtained via phone revealed the nurse was asked by the DON if she gave Resident #110 the medication he (the resident) alleged to not have received. The nurse reported she gave the Methadone and Adderall at 1:13 P.M. A review of Resident #102's MAR for March 2022 revealed LPN #510 did sign the MAR to reflect she had administered the resident his scheduled dose of Methadone 10 mg as ordered three times a day at 12:00 P.M. She also signed the MAR to reflect she had given him his scheduled dose of Adderall 20 mg tablet as ordered twice a day at 2:00 P.M. A review of Resident #102's Controlled Drug Receipt/ Record/ Disposition Forms for his Methadone 10 mg tablets and Adderall 20 mg tablets revealed LPN #510 signed out his dose of Methadone and Adderall on 03/09/22 at 1:13 P.M. A review of a Medication Administration Audit Report for Resident #102 revealed the report showed when those two medications had been administered to the resident on 03/09/22. The resident was indicated to have been given his Methadone by LPN #510 at 11:12 A.M. despite the Controlled Drug Receipt/ Record/ Disposition Form showing the controlled medication was not signed out until 1:13 P.M. The medication audit report documented the administration of the Methadone as being 1:13 P.M. The administration audit report showed the Adderall 20 mg tablet had been administered at 1:12 P.M. by LPN #510 on 03/09/22. She documented the administration of the Adderall on the MAR at 1:13 P.M., which was consistent with what was documented on the Controlled Drug Receipt/ Record/ Disposition Form. On 11/08/22 at 2:50 P.M., an interview with the DON revealed the facility believed Resident #102 received his medications (Methadone and Adderall) as scheduled on 03/09/22, but thought LPN #510 just did not complete her documentation on the MAR or on the Controlled Drug Receipt/ Record/ Disposition Form until later that day when the scheduled Adderall was given. She stated the nurse should be documenting the administration of a controlled medication on the MAR at the time the medication was actually administered and should also sign it out on the Controlled Drug Receipt/ Record/ Disposition Form at the time of administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review revealed Resident #71 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, epilepsy, dementia with agitation, bipolar disorder, schizophrenia, and major depressive disorder. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment, dated 09/23/22 revealed a Brief Interview for Mental Status (BIMS) score of 03 (out of 15), which indicated severely impaired cognition. The assessment revealed the resident did have delusions and exhibited physical behaviors. The MDS further revealed Resident #71 required extensive, two-person physical assistance with dressing, toileting, bed mobility, and transfers. Review of the Monthly Regimen Review (MRR), dated 03/25/2022 revealed a pharmacy recommendation was made. Record review revealed no evidence the physician addressed or signed the pharmacy recommendation. Review of the MRR, dated 04/28/22 revealed a pharmacy recommendation was made. The physician did not address or sign the pharmacy recommendation. During interview on 11/08/22 at 2:36 P.M., the Director of Nursing (DON) confirmed there was no evidence of the physician addressing Resident #71's pharmacy recommendations for March and April 2022. Based on record review and interview the facility failed to ensure pharmacy recommendation were addressed timely. This affected four residents (#2, #21, #39 and #71) of five residents reviewed for unnecessary medication use. Findings include: 1. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, anxiety, and depression. Review of Resident #2's pharmacy medication reviews from 10/2021 to 10/2022 revealed the pharmacist made recommendations on 10/22/21, 11/23/21, 12/21/21, 01/27/22, 02/25/22, 03/25/22, 04/28/22, 06/30/22, 08/26/22, 09/28/22 and 10/26/22. Further review revealed no evidence the physician addressed the recommendations made during the 10/22/21, 11/23/21, 12/21/22, 03/25/22, 04/28/22, 06/30/22 or 09/28/22 reviews. On 11/03/22 at 3:34 P.M. interview with the Director of Nursing (DON) revealed she was not able to find or provide evidence of Resident #2's pharmacy recommendations from 10/22/21, 11/23/21, 12/21/22, 03/25/22, 04/28/22, 06/30/22 or 09/28/22 being acted on/addressed by the physician. 2. Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, diabetes, hypothyroidism, atrial fibrillation, anxiety, depression, hallucinations, and schizoaffective disorder. Review of Resident #21's pharmacy medication reviews from 11/2021 to 10/2022 revealed the pharmacist made recommendations on 11/23/21, 02/25/22, 04/28/22, 06/30/22, 08/26/22, and 10/26/22. Further review revealed no evidence the physician addressed the recommendations from the 11/23/21, 02/25/22, 04/28/22 or 06/30/22 reviews. On 11/03/22 at 3:34 P.M. interview with the DON revealed she was not able to find or provide evidence of Resident #21's pharmacy recommendations for 11/23/21 or 02/25/22 to ensure they had been addressed timely by the physician. The DON reported she found the recommendations for the 04/28/22 which included a gradual dose reduction (GDR) of the resident's Zoloft (anti-depressant) and the recommendation from the 06/30/22 review which included a GDR for the resident's Seroquel (antipsychotic). However, the recommendations had not been addressed by the physician. 3. Record review revealed Resident #39 was admitted to the facility originally on 06/23/22 and re-admitted on [DATE] with diagnoses including dementia with moderate behavioral disturbance, major depression, anxiety, psychosis, and insomnia. Review of Resident #39's pharmacy recommendation revealed the pharmacist made recommendations during reviews completed on 07/18/22 and 09/28/22. On 11/08/22 at 8:35 A.M. interview with the DON revealed she had no evidence the pharmacy recommendations were addressed from the recommendations made on 07/18/22 or 09/28/22. The DON reported she was actually not able to find the recommendations from the 07/18/22 or the 09/28/22 reviews.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure and interview the facility failed to provide timely dental services. This affected five residents (Resident #38, #50, #54, #81, and #92) of six residents reviewed for dental services. Findings include: 1. Review of Resident #38's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypercapnia, hereditary spastic paraplegia, moderate protein-calorie malnutrition, and essential hypertension. Review of Nursing admission Evaluation, dated 08/18/22 revealed Resident #38 came into the facility with upper and lower dentures. Documentation revealed the resident informed the facility at that time she did not wear her dentures because they did not fit properly. Review of Resident #38's Authorization Form for Ancillary and Medical Services, dated 08/19/22 revealed authorization had been provided for dental services. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 08/25/22 revealed Resident #38 was cognitively intact, had no broken or loosely fitting full or partial denture and had no natural teeth or tooth fragments. Review of a facility provided resident list for past dental appointments did not include Resident #38's name on it. Review of a facility provided resident list for future dental appointments did not include Resident #38's name on it. On 10/31/22 at 11:26 A.M. an interview with Resident #38 revealed her dentures did not fit properly and the facility was supposed to get them fixed but didn't. An observation at the time of the interview revealed Resident #38 was edentulous (without teeth). On 11/06/22 at 10:26 A.M. an interview with Resident #38 revealed her sister had her dentures. An observation revealed the resident remained without dentures in at that time. On 11/06/22 at 11:32 A.M. an interview with the Director of Nursing (DON) revealed at the time of admission on [DATE], the physician should have been notified of the resident's concerns related to the ill-fitting upper and lower dentures to obtain a dental referral. On 11/06/22 at 11:39 A.M. an interview with Licensed Practical Nurse (LPN) #94, revealed she dropped the ball regarding obtaining a referral for dental from Resident #38's physician. 2. Review of the medical record for Resident #54 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, morbid obesity, and type two diabetes. Review of Resident #54's annual Minimum Data Set (MDS) 3.0 assessment, dated 09/06/22 revealed the resident was cognitively intact and had no abnormal mouth tissue, no obvious or likely cavity or broken teeth, no inflamed or bleeding gums or loose natural teeth and no mouth or facial pain, discomfort, or difficulty with chewing. Review of Resident #54's Authorization Form for Ancillary and Medical Services, dated 09/07/21 revealed authorization had been provided for dental services. Review of a facility list of residents who had been seen by in house dental services revealed Resident #54 was seen by dental on 10/05/22. Review of a future dental appointment list revealed Resident #54 was on the list written by hand to be seen in house dental services in 01/2023. On 10/31/22 at 5:27 P.M. an interview with Resident #54 revealed he had had been seen by an in house dentist in October 2022, who couldn't help him. Resident #54 reported he was to be referred to a different dentist outside the facility. Resident #54 reported he had not seen a different dentist or been told when that appointment would be as of this date. Resident #54 reported the facility was not good with arranging outside appointments. Resident #54 denied (oral/dental) pain at the time but wanted to get his dental concern cared for. On 11/06/22 at 8:32 A.M. an interview with the DON revealed she could not locate any information with Activities Director (AD) #106 regarding Resident #54 going to any outside dentist. The facility was unable to locate the dental notes from the in house dental appointment on 10/05/22. She reported Resident #54 was on the in house dental list for January 2023 due to the resident's request to be seen again. On 11/06/22 at 9:12 A.M. an interview with Licensed Practical Nurse (LPN) #94 revealed Resident #54 did not receive a printed copy of the written referral for an outside dental appointment based on an interview she had with Resident #54. Per her report, the activities person was to schedule Resident #54 with an outside dentist on 11/07/22. She verified the resident was Medicaid recipient. On 11/07/22 at 8:01 A.M. an interview with the DON revealed Resident #54 was to be sent out for a tooth extraction. She provided a copy of the in house dental note, dated 10/05/22 which revealed Resident #54 was to be sent out for a dental extraction. The DON verified the facility did not schedule the appointment with an outside dentist as they should have. Review of the facility policy titled Dental Services, reviewed/revised 01/01/22 revealed oral health services were available to meet the resident's individual needs. Social services would be notified of a resident's need for dental services and to assist the resident/family in making dental appointments and transportation arrangements needed. 3. Medical record review revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including encounter for orthopedic aftercare, type 2 diabetes mellitus, morbid obesity, atrial fibrillation, anxiety, colostomy, bipolar disease, schizoaffective disorder, muscle weakness, and spinal stenosis. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/30/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 (out of 15), which indicated intact cognition. There were no behaviors or rejection of care. The MDS 3.0 assessment, further revealed Resident #81 required extensive, one-person assistance with personal hygiene, bed mobility, and toileting. There were no broken or loose-fitting dentures, and no mouth pain with chewing noted on the assessment. On 10/31/22 at 11:19 A.M. interview with the resident revealed she had concerns about her teeth being sensitive to hold and cold foods and she would like to be seen for a visit. The resident stated she had spoken with the social worker about her concerns. Review of the dental schedule revealed the dental services provider visited the facility on 06/23/22 and Resident #81 was not listed on the schedule of residents to be examined. During interview on 11/03/22 at 1:47 P.M. Social Service Designee (SSD) #84 revealed the facility had issues with the dental provider and was in the process of switching to another company. SSD #84 confirmed the resident had not been seen by dental services following her admission to the facility in December 2021. 5. Record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including heart disease, diabetes and gastric reflux disease. Review of Resident #50's oral/dental health problems plan of care, dated 03/28/18 and revised 06/20/21 revealed interventions included to coordinate arrangements for dental care and monitor, document, and report and signs and symptoms to the nurse/physician. Review of Resident #50's annual Minimum Date Set (MDS) 3.0 assessment, dated 09/01/22 revealed the resident had no noted dental concerns. Review of Resident #50's nursing note, dated 10/16/22 revealed the doctor was in the facility and was informed the resident had a toothache and right side of her jaw was swollen. New orders were received for oral antibiotic treatment and dental consult for possible abscess. The resident was oriented and informed of the new treatments. Review of a facility undated future dental visit list revealed no evidence the resident on was on the list to be seen for dental services. Further review of Resident #50's medical record revealed no evidence a dental appointment had been scheduled. Interview on 10/31/22 at 1:49 P.M., with Resident #50 revealed she had told the staff she had had a toothache for two to three weeks but she had not seen the dentist. Interview and observation on 11/03/22 at 2:35 P.M., with Resident #50 revealed the resident reported she had a tooth on the bottom right that was painful. The resident's teeth were observed to appear to be decayed. On 11/08/22 at 7:57 A.M. interview with Activates Director (AD) #106 revealed she was not aware of the dental consult recommendation from 10/16/22 until the surveyor had inquired. She called the local dentist office and left a message Friday and then called back yesterday to follow up. December 7, 2022 was the first appointment which was probably not soon enough, however that dentist office was the only one in the area who takes the resident's Medicaid insurance. Review of the dental policy, dated 10/18/20 and revised 01/01/22 revealed routine and 24 hours emergency dental services were available to meet the resident's oral health services in accordance with the resident assessment and plan of care. 4. A review of Resident #92's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including a history of a stroke with hemiplegia/ hemiparesis affecting the left non-dominant side, pseudobulbar affect, major depressive disorder and generalized anxiety disorder. A review of Resident #92's ancillary service consent form revealed the resident consented to receive dental services while residing in the facility. The consent was signed on 02/11/22. A review of Resident #92's quarterly Minimum Data Set (MDS) assessment, dated 10/01/22 revealed the resident did not have any communication issues and her cognition was moderately impaired. The assessment revealed the resident was not known to display any behaviors and required an extensive assist of two staff for personal hygiene. The prior admission MDS 3.0 assessment, completed on 02/18/22 revealed the resident was not known to have any obvious or likely cavities or broken natural teeth. A review of Resident #92's active care plans revealed the resident had an activities of daily living care plan that indicated she had her own teeth. Staff were to report any changes to the nurse. The resident's active care plans did not include a care plan that specifically addressed her dental or oral health status. A review of Resident #92's physician's orders revealed an order dated, 08/09/22 revealed an order for the resident to see a dentist for a broken tooth. Resident #92's medical record was absent for any dental consults since her admission to the facility on [DATE]. There was also no evidence of her being seen by a dentist on or after 08/09/22, when the physician referred her to the dentist for a broken tooth. A review of a list of residents seen by the facility's contracted dentist during their last visit to the facility on [DATE] revealed Resident #92 was not one of the residents seen during that dental visit. She was also not on the list of residents that were to be seen on the next dental visit for a date that had yet to be determined. A review of Resident #92's nursing progress notes revealed there was no documentation in the nursing progress notes regarding the resident's referral to a dentist for her broken tooth, after it had been ordered on 08/09/22. There was no note to indicate the referral had ever been made, the resident was seen, or that the appointment had to be rescheduled for one reason or another. There was not a progress note addressing her dental need until 11/01/22, when an appointment had been made for 12/06/22 at 11:20 A.M. at a local community dental office. On 10/31/22 at 5:58 P.M., an interview with Resident #92 revealed she broke two teeth while residing in the facility. She stated she broke one tooth on a bone that was in chicken and noodles and broke another on a popcorn kernel. She reported it was about two months ago when she broke her first tooth and she informed the staff of such. The resident denied she had been seen by a dentist yet, even after informing the staff. She thought the activity staff was supposed to make her dental appointment but when she asked the activity director about it she got expletive word (meaning hateful, mean, or vicious). On 11/07/22 at 10:30 A.M., an interview with Registered Nurse (RN) #90 revealed Resident #92 had her own teeth. She was asked if the resident had any dental problems and mentioned the resident had one tooth that she had placed special and that tooth came up missing. RN #90 revealed staff had been working on a referral with a local community dental office but there was a three month wait. She reported the resident verbalized an issue with a tooth about three weeks ago and did complain of some discomfort with it. She notified her unit manager and she also asked about their contracted dental company. She thought for some reason the resident didn't qualify to be seen by them. She acknowledged the resident had a prior physician's order, dated 08/09/22 to see the dentist and that referral was for a broken tooth. The facility's contracted dental company could not see her or they could not take care of her issue. A referral was put in with the activity department but RN #92 was not sure if the activities person, who set up those appointments, put it in. On 11/07/22 at 10:51 A.M., an interview with SSD #84 revealed Resident #92 had spoken with the facility's prior social worker about needing dental services. She denied any referrals had been made for the resident to be seen by a dentist. She stated she just had the resident fill out the necessary paperwork to be able to be seen by the dentist. She followed up on the resident's dental concerns and verified the resident had a cap or crown that had fallen off causing it to rub on the inside of her lip. She also had another tooth that had been broken at the gum line that needed to be taken care of. She informed the resident the broken tooth would need a referral to an oral surgeon as their contracted dental company did not pull teeth. She denied the resident was verbalizing any discomfort at that time. She acknowledged the resident had a physician's order written on 08/09/22 for her to be seen by a dentist due to a broken tooth. She denied she was able to find any evidence that referral was made as there were no dental consults to support she had been. She confirmed they just made an appointment for the resident to be seen by a local community dentist (with the appointment being scheduled for 12/06/22). A review of the facility policy on Dental Services, revised 01/01/22 revealed routine and 24 hour emergency dental services were available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Routine and emergency dental services were provided to the residents through a contract agreement with a local dentist or mobile group, referral to the resident's personal dentist, referral to a community dentist or referral to other healthcare organizations that provide dental services. Social services would be notified of a resident's need for dental services. Social services would assist the resident/ family in making dental appointments and transportation arrangements as necessary.

Based on observation, facility policy and procedure review and interview the facility failed to ensure pureed food was prepared to the correct consistency. This had the potential to affect 10 residents (#1, #33, #51, #59, #62, #71, #73, #76, #106 and #310) of ten residents who received pureed diets. The facility census was 100. Findings include: On 11/01/22 at 9:00 A.M. Dietary Aide (DA) #157 was observed completing the pureed meal process. DA #157 pureed pork using all of the juices the pork was in and after tasting it reported the pork was ready to serve. This surveyor then tasted the pork, however, it was not the appropriate pureed texture and needed to be chewed. DA #157 then verified it did need to be chewed and was not the correct puree consistency. DA #157 then continued to pureed the pork again with four tablespoons of thickener and then again with three more tablespoons of thickener to achieve the correct puree consistency. DA #157 continued the process and pureed potatoes and after tasting it reported the potatoes were ready to serve. This surveyor then tasted the potatoes, however, they were not the appropriate pureed texture and had chunks of potato in it. The Dietary Manager (DM) then tasted the potatoes and verified there were potato chunks in the puree, and it was not the correct pureed consistency. DA #157 then pureed the potatoes again to achieve the correct puree consistency. The facility indicated 10 residents, Resident #1, #33, #51, #59, #62, #71, #73, #76, #106 and #310 who received pureed diets. Review of the facility policy titled Therapeutic Diet Orders, reviewed/revised 01/01/22, revealed the facility provided all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physicians, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences.

Based on observation, facility policy and procedure review and interview the facility failed to ensure pureed foods were prepared in a sanitary manner to prevent potential contamination and/or food borne illness. This had the potential to affect 10 residents (#1, #33, #51, #59, #62, #71, #73, #76, #106 and #310) of 10 residents identified by the facility to receive pureed foods. The facility census was 100. Findings include: On 11/01/22 at 9:00 A.M. Dietary Aide (DA) #157 was observed preparing pureed foods. After preparing brussels sprout puree, DA #157 washed the puree processor in the facility dishwasher. Once the processor came out of the dishwasher, DA #157 used her bare hands to reassemble the inner workings of the processor. She then put pork into the processor before the processor was dry and proceeded to process the pork. After preparing the pork puree, DA #157 washed the puree processor in the facility dishwasher. She then used gloved hands at this time to reassemble the inner workings of the processor. DA #157 then placed potatoes into the processor before the processor was dry and proceeded to puree the potatoes. Twice during the observation, food items were placed into the processor before it had adequately dried resulted in a potentially unsanitary condition. On 11/01/22 at 9:30 A.M. an interview with Dietary Manager (DM) #154 verified not letting the processor completely dry and DA #157 using her bare hands to reassemble the processor resulted in the pureed food not being prepared in accordance with professional standards for food safety. The facility identified 10 residents, Resident #1, #33, #51, #59, #62, #71, #73, #76, #106 and #310 who received pureed foods. Review of the facility policy titled Food Preparation and Service, reviewed/revised 01/01/22 revealed food preparation staff would adhere to proper hygiene and sanitary practices to prevent the spread of food borne illness.