**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed and transmitted within 14 days. This affected two (Residents #401 and #402) of six residents reviewed for assessments. The facility census was 38 residents. Findings include: 1. Review of the medical record for Resident #401 revealed an admission date of 03/29/25 with diagnoses including cellulitis of the left finger, asthma, and type two diabetes mellitus and a discharged from the facility on 04/21/25. Review of the admission Minimum Data Set (MDS) assessment for Resident #401 dated 04/04/25 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the discharge return anticipated (DRA) MDS assessment for Resident #401 dated 04/19/25 revealed the MDS was in progress and had not been transmitted. Review of the progress note for Resident #401 dated 04/19/25 timed at 11:42 A.M. revealed the resident's representative called the urologist and was instructed to take the resident to the emergency room (ER). Resident #401 left the facility with two friends and his representative in an automobile. Review of the progress note for Resident #401 dated 04/20/25 timed at 7:18 P.M. revealed the resident returned to the facility at 6:50 P.M. Review of the DRA MDS assessment for Resident #401 dated 04/21/25 revealed the MDS was in progress and had not been transmitted. Review of the progress note for Resident #401 dated 04/21/25 timed at 11:55 A.M. revealed the resident had discharged home. Interview on 05/12/25 at 3:46 P.M with MDS Licensed Practical Nurse (LPN) #215 confirmed the DRA MDS assessments dated 04/19/25 and 04/21/25 for Resident #401 had not been transmitted within 14 days as required. 2. Review of the medical record for Resident #402 revealed an admission date of 07/11/24 with diagnoses including cerebral infarction, generalized anxiety disorder, major depressive disorder, and a discharge date of 04/30/25. Review of the admission MDS assessment for Resident #402's dated 01/16/25 revealed the resident was cognitively intact and required assistance with ADLs. Review of the quarterly MDS assessment for Resident #402 dated 04/18/25 revealed the MDS was in progress and had not been transmitted. Review of the DRA MDS assessment for Resident #402 dated 04/30/25 revealed the MDS was in progress and had not been transmitted. Review of the progress note for Resident #402 dated 04/30/25 timed at 7:38 P.M. revealed the resident was transported to the emergency room (ER). Interview on 05/12/25 at 3:46 P.M with MDS LPN #215 confirmed the quarterly MDS assessment dated [DATE] and the DRA MDS assessment dated [DATE] for Resident #402 had not been transmitted within 14 days as required.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure medications in the medication cart were labeled and stored in proper containers. This affected all of the residents residing in the facility. The facility census was 38 residents. Findings include: Observation on 05/12/25 at 9:00 A.M of the nurse two medication cart on the skilled care hallway revealed there were 19 loose pills of various shapes and colors in the bottom of the medication cart. Interview on 05/12/25 at 9:00 A.M. with Registered Nurse (RN) #221 confirmed there were 19 loose pills of various shapes and colors in the bottom of the nurse two medication cart on the skilled care hallway. RN #221 confirmed she was not able to identify the 19 pills nor to whom the 19 pills were prescribed. Observation on 05/12/25 at 9:26 A.M of the nurse two medication cart on the long-term care hallway revealed there were 92 loose pills of various shapes and colors in the bottom of the medication cart. Interview on 05/12/25 at 9:26 A.M with RN #221 confirmed there were 92 loose pills of various shapes and colors in the bottom of the nurse two medication cart on the long-term care hallway. RN #221 confirmed she was not able to identify the 92 pills nor to whom the 92 pills were prescribed. Observation on 05/12/25 at 9:32 A.M of the nurse one medication cart on the long-term care hallway revealed there were 130 loose pills of various shapes and colors in the bottom of the medication cart. Interview on 05/12/25 at 9:32 A.M with Licensed Practical Nurse (LPN) #224 confirmed there were 130 loose pills of various shapes and colors in the bottom of the nurse one medication cart on the long-term care hallway. LPN #224 confirmed she was not able to identify the 130 pills nor to whom the pills were prescribed. Review of the facility policy titled Medication Storage dated November 2021 revealed drugs should dispensed and stored in the manufacturer's original container. This deficiency represents noncompliance investigated under Complaint Number OH00165462.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the Ombudsman was notified of hospital transfers. This impacted one (#25) of one resident reviewed for hospitalization. The facility census was 31. Findings include: Review of the medical record of Resident #25 revealed an admission date of 02/23/23. The resident transferred to the hospital on [DATE], readmitted on [DATE], transferred to the hospital on [DATE], readmitted [DATE], transferred to the hospital on [DATE], readmitted [DATE], and transferred to the hospital on [DATE], and readmitted on [DATE]. Diagnoses included cerebral infarction, tracheostomy status, gastrostomy status, chronic respiratory failure with hypoxia, contractures of left hand, right elbow, right hand, dysphagia, acute kidney failure, severe sepsis with septic shock, pneumonia, essential hypertension, hyperlipidemia, and unspecified disorder of thyroid. Review of the medical record revealed no evidence of the Ombudsman being notified of Resident #25's transfers to the hospital on [DATE], 03/18/23, 03/29/23, and 04/29/23. Interview on 06/01/23 at 1:24 P.M., with Social Services (SS) #280 verified there was no evidence of Ombudsman notification of Resident #25's discharges to the hospital. SS #280 stated she was previously unaware of the need to notify the Ombudsman of discharges. Interview on 06/01/23 at 1:39 P.M., with the Administrator verified Ombudsman notification is required when residents transfer to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a discharge summary was completed upon discharge from the facility. This affected one (#28) of two residents reviewed for discharge. The facility for census was 31. Findings include: Review of the medical record of Resident #28 revealed an admission date of 02/28/23. The resident transferred to another skilled nursing facility on 03/30/23. Diagnoses included malignant neoplasm of prostate, gout, chronic viral hepatitis C, obstructive sleep apnea, type 2 diabetes mellitus, morbid obesity, essential hypertension, gastro-esophageal reflux disease, and hypothyroidism. Review of the comprehensive minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the Multidisciplinary Discharge summary dated [DATE] revealed the documentation was incomplete. Social Services and Nursing completed their sections on 03/28/23 and 03/30/23, respectively. Therapy, dietary, and activity sections were not completed. Interview on 05/31/23 at 2:23 P.M., the Director of Nursing verified the discharge summary was incomplete and should have been completed at the time the resident discharged .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, and staff interview, the facility failed to ensure a resident who required assistance was provided assistance with hair washing. This affected one (#7) of 13 residents reviewed for activities of daily living (ADLs). The facility census was 31. Findings include: Review of the medical record for Resident #7 revealed an admission date of 04/19/22, with diagnoses including cerebral infarction, Diabetes Mellitus (DM), lymphedema, major depressive disorder, anemia, and venous insufficiency. Review of the Minimum Data Set (MDS) assessment for Resident #7 dated 05/11/23 revealed resident was cognitively intact and required extensive assistance of staff with ADLs. Review of the care plan for Resident #7 dated 06/16/22 revealed resident was resistive to care related to preference of taking bed baths. Residents would refuse showers and state she had a bad experience at another nursing facility with her showers. Interventions included the following: allow resident to make decisions about treatment regime, to provide sense of control, educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care, encourage as much participation/interaction by the resident as possible during care, if resident resists ADLs reassure resident, leave and return, praise resident when behavior is appropriate, provide consistency in care to promote comfort with ADLs, maintain consistency in timing of ADLs, caregivers and routine, as much as possible, provide resident with opportunities for choice during care provision. Review of the care plan for Resident #7 dated 07/13/22 revealed resident had an ADL self-care performance deficit and required assistance with ADLs related to activity intolerance, decreased mobility, impaired balance, and incontinence. Interventions included the following: resident requires extensive assistance with bathing, resident prefers to only have bed baths, staff participation with hygiene and personal care. Review of the [NAME] for Resident #7 undated revealed resident was to have bed baths only. Review of the shower sheets for Resident #7 revealed resident received a bed bath on the following dates in the month of May 2023: 05/03/23 05/06/23, 05/10/23, 05/13/23, 05/17/23, 05/20/23, 05/24/23 05/27/23. Shower sheets did not indicate the resident had her hair washed on any of these dates. Observation on 05/30/23 at 12:34 P.M., of Resident #7 revealed resident's hair was chin length and appeared greasy and unwashed. Interview on 05/30/23 at 12:34 P.M., with Resident #7 confirmed she was unsure of the last time staff offered assistance to wash her hair. Resident #7 confirmed she preferred bed baths, and there had been times in the past when staff were able to wash her hair while she was on bed, but this had not occurred during the month of May 2023. Resident #7 confirmed she felt her hair was dirty, and she would like to have her hair washed during her bed bath at least once per week. Interview on 05/30/23 at 2:06 P.M., with Licensed Practical Nurse (LPN) #265 confirmed Resident #7's hair looked greasy and appeared unwashed. LPN #265 reviewed Resident #7's shower sheets for the month of May 2023 and confirmed resident had only received bed baths for the month. LPN #265 confirmed the only way resident could get her hair washed was if she allowed the staff to take her to the shower room. Interview on 05/31/23 at 12:55 P.M., with the Director of Nursing (DON) confirmed the facility had no rinse shampoo on hand and available to wash hair for residents who either could not get out of bed or preferred not to get out of bed to have their hair washed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a pressure ulcer was adequately monitored. This affected one (#25) of one resident reviewed for pressure ulcers. The facility census was 31. Findings include: Review of the medical record of Resident #25 revealed an admission date of 02/23/23. The resident transferred to the hospital on [DATE], readmitted on [DATE], transferred to the hospital on [DATE], readmitted [DATE], transferred to the hospital on [DATE], readmitted [DATE], and transferred to the hospital on [DATE], and readmitted on [DATE]. Diagnoses included cerebral infarction, tracheostomy status, gastrostomy status, chronic respiratory failure with hypoxia, contractures of left hand, right elbow, right hand, dysphagia, acute kidney failure, severe sepsis with septic shock, pneumonia, essential hypertension, hyperlipidemia, and unspecified disorder of thyroid. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition could not be assessed. The resident exhibited inattention and an altered level of consciousness continuously during the survey period. The resident was dependent on two staff for bed mobility, transfers, and toileting. Review of the nursing progress note dated 05/09/23 at 3:28 P.M., revealed the resident readmitted to the facility from the hospital. A head-to-toe assessment was completed, and identified a deep tissue injury to the bottom of the left great toe, measuring 2.5 cm (centimeters) by 1.5 cm. The area was painted with betadine and the resident was to follow up with wound care. Review of the plan of care dated 05/11/23 revealed the resident was at risk for skin breakdown related to decreased mobility, decreased strength, and incontinence. The resident was noted on 05/09/23 to have been readmitted to the facility with skin breakdown on her right great toe. Interventions included to monitor, document, and report to the physician PRN (as needed) changes in skin status including appearance, color, and signs/symptoms of infection. Review of physician orders revealed an order dated 05/10/23 to paint area to bottom of right great toe with betadine BID (twice per day). Review of the medical record revealed no evidence of skin rounds, wound progress notes, nor measurements noted after identification of the area on the right great toe on 05/09/23. Interview on 05/31/23 at 3:28 P.M., with the Director of Nursing (DON) verified there were no wound progress notes nor measurements present in Resident #25's chart since identifying the area on 05/09/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and review of policy, the facility failed to ensure fall prevention/management interventions were in place for a resident assessed at risk for falls. This affected two (#9 and #24) of three residents reviewed for accidents. The facility census was 31. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 04/13/23, with diagnoses including: cerebral infarction, diabetes mellitus (DM), alcoholic cirrhosis of the liver, traumatic subarachnoid hemorrhage, aphasia, dysphagia, hypertension (HTN), hyperlipidemia, spinal stenosis, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 04/20/23 revealed resident was cognitively impaired and required extensive assistance of one staff with bed mobility and ambulation and extensive assistance of two staff with transfers. Review of the fall risk assessment for Resident #9 dated 04/14/23 revealed resident was at risk for falls. Review of the care plan for Resident #9 dated 04/14/23 revealed resident was at risk for falls related to falls at home, impulsivity, care plan, non-compliant with safety recommendations, antihypertensive medications, decreased mobility, impaired cognition, poor balance secondary to right hemiparesis. Interventions included the following: anticipate and meet resident needs, educate about safety reminders and what to do if a fall occurs, encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensure call light is within reach and encourage resident to use it for assistance as needed, nonskid footwear, staff to ensure wheels of the bed are locked at all times for safety, therapy evaluation as needed. Review of the undated [NAME] for Resident #9 revealed the resident should have fall mats to both sides of the bed for fall prevention/management. Review of the nurse progress note for Resident #9 dated 05/19/23 (Friday) revealed the hospice nurse would be ordering fall mats for resident which would be delivered over the weekend. Review of the hospice nurse assessment for Resident #9 dated 05/26/23 revealed the resident was at risk of falling. Review of the hospice nurse visit note for Resident #9 dated 05/27/23 revealed fall precautions would be initiated to minimize the incident of falls which included the following: keep bed in lowest position and locked with fall mats in place, instruct caregivers in safety precautions to prevent injury, review hospice plan of care with facility staff. Observation on 05/30/23 at 10:23 A.M., revealed the resident was resting in bed on a low air loss mattress with a fall mat on the floor to the right side of resident's bed. There was another fall mat which was propped up against the wall on the other side of the room away from resident's bed. Interview on 05/30/23 at 10:25 A.M., with State Tested Nursing Assistant (STNA) #270 confirmed Resident #9 did not have a fall mat to the floor to the left side of his bed. STNA #270 confirmed Resident #9 was supposed to have fall mats to both sides of the bed at all times because resident was at risk for falls. Interview on 05/31/23 at 11:57 A.M., with Licensed Practical Nurse (LPN) #250 confirmed Resident #9 should have fall mats to both sides of his bed when he was in bed because he was at high risk for falls out of bed. LPN #250 confirmed Resident #9 was unable to ambulate by himself and/or remove the fall mats. 2. Review of the medical record for Resident #24 revealed an admission date of 10/28/22, with diagnoses including: multiple sclerosis (MS), metabolic encephalopathy, chronic respiratory failure with hypoxia, and quadriplegia. Review of the care plan for Resident #24 dated 11/01/22 revealed resident was at risk for falls related to decreased mobility, poor balance, poor safety awareness, use of diuretic med secondary to diagnosis of MS, encephalopathy, muscular dystrophy. Interventions included the following: anticipate and meet resident needs, educate about safety reminders and what to do if a fall occurs, encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, encourage use of call light/EZ pad call button in reach, fall mats to both sides of bed for safety, follow facility fall protocol, therapy to evaluate and treat as ordered, review information on past falls and attempt to determine cause of fall, record possible root causes, alter/remove any potential causes if possible, staff to ensure wheels of the bed are locked at all times for safety. Review of the Minimum Data Set (MDS) assessment for Resident #24 dated 05/18/23 revealed resident was cognitively impaired and required extensive assistance of two staff with bed mobility and was totally dependent on assistance of staff with transfers. Resident #24 was non-ambulatory. Review of the fall risk assessment for Resident #24 dated 05/22/23 revealed resident was at risk for falls. Review of the undated [NAME] for Resident #24 revealed resident should have fall mats to both sides of the bed for safety. Observation on 05/30/23 at 12:08 P.M., of Resident #24 revealed resident was resting in bed on a low air loss mattress with a fall mat in place on the floor to the left side of the bed. There was no fall mat on the right side of the bed. A fall mat was folded up and stored underneath the bed. Interview on 05/30/23 at 12:26 P.M., with STNA #225 confirmed Resident #24's fall mat was folded up and being stored underneath the bed. STNA #225 confirmed Resident #24 was a fall risk and should have fall mats on both sides of the bed. Observation on 05/30/23 at 12:26 P.M., revealed STNA #225 pulled fall mat which was folded up and stored under Resident #24's bed. STNA #225 used her foot to pull the fall mat out from under the bed and positioned the mat next to the right side of the resident's bed after discussion with the surveyor. STNA #225 did not unfold the mat after positioning to the right side of the bed. The mat was folded into three sections. Interview on 05/30/23 at 12:29 P.M., with LPN #160 confirmed Resident #24 was at high risk for falls and should have fall mats to both sides of the bed at all times while in bed. LPN #160 confirmed the fall mat on the right side of the bed was folded up and should be unfolded to provide fuller coverage and minimize the risk of injury in the event of a fall. Review of the undated policy titled Fall Risk Education revealed the facility would ensure appropriate communication methods to ensure direct care staff and management are aware of residents who are at risk for falls and will communicate fall interventions via the following: 24-hour report, the resident's care plan, nurse aide assignment sheets, visual cues.

Based on record review, observation, staff interview, and review of policy, the facility failed to ensure gastrostomy tubes (g-tubes) ands supplies were maintained in a sanitary manner. This had the potential to affect one (#24) of one residents reviewed for tube feedings. The facility identified three residents with g-tubes. The facility census was 31. Findings include: Review of the medical record for Resident #24 revealed an admission date of 10/28/22, with diagnoses including: multiple sclerosis (MS), metabolic encephalopathy, chronic respiratory failure with hypoxia, and quadriplegia. Review of the Minimum Data Set (MDS) for Resident #24 dated 05/18/23 revealed resident was cognitively impaired and required extensive assistance of one staff with eating. Review of the care plan for Resident #24 dated 12/19/22 revealed resident required tube feeding related to dysphagia and aspiration risk. Resident may have pureed foods for pleasure, and tube feed remains primary source of nutrition. Interventions included the following: check for tube placement and gastric contents/residual volume per facility protocol and record, discuss with me/family/caregivers any concerns about tube feeding, advantages, disadvantages, potential complications, follow physician orders for tube feeding and water flushes, keep head of bed elevated during and thirty minutes after tube feeding. Review of May 2023 monthly physician orders for Resident #24 included an order dated 01/09/23 for a continuous tube feeding at 43 milliliters (ml) per hour and to flush tube with 160 ml of water every four hours. Observation on 05/30/23 at 12:05 P.M., of Resident #24 revealed the resident had a continuous tube feeding of Fibersource running via pump at 43 ml per hour. There was a bag of water running via pump set to flush 160 ml of water every four hours. There was a tube feeding syringe at Resident #24's bedside which was not dated. Interview on 05/30/23 at 12: 29 P.M., with Licensed Practical Nurse (LPN) #160 confirmed she had used the syringe hanging at resident's bedside for medication administration that morning and it was undated. LPN #160 further confirmed she was unsure how long the syringe had been at the bedside because it was undated. LPN #160 confirmed g-tube syringes should be changed daily and should be dated upon opening. Interview on 06/01/23 at 8:44 A.M., with the Director of Nursing (DON) confirmed g-tube syringes should be replaced daily and the staff should write the date it was placed at the bedside on the syringe or the plastic bag in which it was stored. Review of the policy titled Enteral Tube Medication Administration dated November 2021, revealed the facility would assure safe and effective administration of enteral formulas and medications via enteral tubes. The nurse will use a 60 ml enteral syringe for flushing the tube, checking the tube for appropriate placement, checking tube for residual, and administration of medications and enteral formulas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #21 revealed an admission date of 04/21/23. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, congestive heart failure, chronic kidney disease, stage three A, and major depressive disorder. Review of the admission MDS assessment dated [DATE] revealed Resident #21 had moderate cognitive impairment and was assessed to require one-person extensive assistance with transfers, dressing, and toileting, supervision with eating, and one-person total dependence with bathing. Review of the care plan dated 05/09/23 revealed Resident #21 had a nutritional problem related to CHF, depression, anxiety, significant weight decreases for last 30 days on 05/09/23. Interventions included administering medications as ordered and monitoring and documenting side effects and effectiveness. Staff to assist with developing a support system to aid in weight loss efforts. Staff to encourage healthy eating habits. Staff to monitor weight per protocol. Staff provide a calm and quiet setting at mealtimes with adequate eating time. Dietician to evaluate and make diet change recommendations as needed. Review of the physician order dated 04/21/23 revealed Resident #21 was ordered Megestrol Acetate oral suspension 40 milligrams (mg)/milliliter (ml), give 10 ml by mouth two times a day related to adult failure to thrive. Review of the progress notes dated 05/23/23 through 05/30/23, for Resident #21, revealed Megestrol Acetate was not available for administration and awaiting from pharmacy. Review of the medication administration record (MAR) for May 2023 revealed Resident #21 did not receive Megestrol Acetate on 05/23/23, 05/24/23, 05/26/23, 05/27/23, 05/28/23, and 05/30/23. Interview on 05/30/23 at 9:01 A.M., with LPN #160 verified Resident #21 had been out of his Megestrol Acetate since last Tuesday or Wednesday. LPN #160 reported pharmacy had not been notified, but the facility had still not received the medication. Review of the policy titled, Medication Administration - General Guidelines, dated November 2021 revealed medications were prepared only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to prepare and administer medications. If a dose of regularly scheduled medications was withheld, refused, not available, or not given at a time other than the scheduled time, the space provided on the front of the MAR for that dosage administration was initialed and circled. An explanatory note was entered on the reverse side of the record. If three consecutive doses or per facility protocol, of a vital medication were withheld, refused, or not available, the physician was notified. Nursing documented the notification and physician response. 2. Review of the medical record of Resident #05 revealed an admission date of 05/24/12. Diagnoses included unspecified sequalae of unspecified cerebrovascular disease, hemiplegia affecting right dominant side, type 2 diabetes mellitus, chronic obstructive pulmonary disease, aphasia, dementia with behavioral disturbance, major depressive disorder, arthroplasty, and mood disorder. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required extensive assistance of two for bed mobility and toileting and was dependent on two for transfers. Review of a physician order dated 01/30/23 revealed an order to decrease Seroquel to 50 milligrams (mg) by mouth twice per day, then, on 02/13/23, decrease Seroquel to 25 mg by mouth twice per day. Review of physician orders revealed a completed physician order dated 01/31/23 and discontinued the same date for Seroquel-50 mg by mouth twice per day and an active order dated 01/30/23 for Seroquel 25 mg by mouth twice per day. Interview on 05/31/23 at 10:54 A.M., with Licensed Practical Nurse (LPN) #345 verified the Seroquel order dated 01/30/23 was not entered correctly. Based on record review, resident interview, staff interview, and review of policy, the facility failed to ensure staff administered medications as ordered by the physician. This affected three (#5, #7, and #21) of six residents reviewed for medications. The census was 31 residents. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 04/19/22, with diagnoses including: cerebral infarction, diabetes mellitus (DM), lymphedema, major depressive disorder, anemia, and venous insufficiency. Review of the Minimum Data Set (MDS) assessment for Resident #7 dated 05/11/23 revealed resident was cognitively intact and required extensive assistance of staff with ADLs. Review of eye doctor visit note for Resident #7 dated 11/10/22 revealed the resident had primary glaucoma to both eyes. The eye doctor made a recommendation for the resident to add brimonidine eye drops to her treatment regime. Review of the May 2023 monthly physician orders for Resident #7 revealed an order dated 11/13/22 for resident to receive brimonidine tartrate 0.2% solution eye drops with instructions to instill one drop in each eye twice daily for glaucoma. Review of the May 2023 Medication Administration Record (MAR) for Resident #7 revealed the 8:30 A.M. and 4:30 P.M. doses of brimonidine were not signed off as administered on 05/02/23, 05/03/23, and 05/04/23. Review of nurse progress notes for Resident #7 dated 05/02/23 timed at 10:16 A.M., 05/02/23 at 4:36 P.M., 05/03/23 at 4:30 P.M., 05/04/23 at 10:41 A.M., and 05/04/23 timed 5:37 P.M., revealed the resident did not receive brimonidine eye drops which were scheduled to be administered twice daily at 8:30 A.M. and 4:30 P.M., due to eye drops were not available for administration. Interview on 05/30/23 at 12:34 P.M., with Resident #7 confirmed she had been diagnosed with glaucoma and was followed by the facility eye doctor. Resident #7 confirmed the facility had run out of her brimonidine eye drops earlier in the month of May and she went several days without receiving her medication. Interview on 06/01/23 at 1:12 P.M., with the Director of Nursing (DON) confirmed Resident #7 did not receive brimonidine eye drops on 05/02/23, 05/03/23, and 05/04/23. DON confirmed the bottle of brimonidine got lost or accidentally discarded so she had to give approval for the facility to provide a new bottle.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected two (#05 and #13) of five residents reviewed for unnecessary medications. The facility census was 31. Findings include: 1. Review of the medical record of Resident #13 revealed an admission date of 04/14/22. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, frontal temporal neurocognitive disorder, type 2 diabetes mellitus, dysphagia, major depressive disorder, attention-deficit hyperactivity disorder, post-traumatic stress disorder, dementia without behavioral disturbance, and hypothyroidism. Review of the annual Minumum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident required extensive assistance of one staff for bed mobility, limited assist of one staff for transfers, toileting, and ambulation, and supervision for eating. Review of a list titled, Consultant Pharmacist's Medication Regimen Review, for recommendations created between 01/01/23 and 06/01/23 revealed the following recommendations: a. Recommendations dated 03/03/23 and 05/05/23 revealed the resident was taking levothyroxine 75 micrograms (mcg) daily. No recent TSH (thyroid stimulating hormone)/thyroid panel was able to be located in the medical record. Recommendations were made to consider monitoring a TSH/thyroid panel on the next lab day, then yearly thereafter if within normal limits. b. Recommendation dated 03/03/23 revealed the resident was receiving insulin and a recent A1c was unable to located in the chart. Recommendations were made to check the A1c every three months. c. Recommendation dated 03/03/23 revealed the resident was receiving atorvastatin (Lipitor) for dyslipidemia and a recent fasting lipid panel was unable to be found in the record. Recommendations were made to consider monitoring a fasting lipid panel on the next lab day and then yearly after that if within normal limits. Review of the medical record revealed no evidence of A1c, TSH/Thyroid panel, nor lipid panel being completed as recommended. Interview on 06/01/23 at 10:25 A.M., with the Director of Nursing (DON) verified the resident did not have any of the labs completed as recommended by pharmacy. 2. Review of the medical record of Resident #05 revealed an admission date of 05/24/12. Diagnoses included unspecified sequalae of unspecified cerebrovascular disease, hemiplegia affecting right dominant side, type 2 diabetes mellitus, chronic obstructive pulmonary disease, aphasia, dementia with behavioral disturbance, major depressive disorder, arthropathy, and mood disorder. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required extensive assistance of two for bed mobility and toileting and was dependent on two for transfers. Review of a list titled, Consultant Pharmacist's Medication Regimen Review, for recommendations created between 01/01/23 and 06/01/23 revealed a recommendation dated 04/06/23 indicating Resident #05 was receiving Lipitor (atorvastatin) 20 milligrams (mg) daily for dyslipidemia. The most recent serum lipid profile noted was normal (124). Recommendations were made to evaluate the continued need and consider taper to Lipitor 20 mg every other day and do follow up lipids in three months. Review of the medical record revealed no evidence of a serum lipid panel being obtained following the pharmacy recommendations dated 04/06/23. Interview on 06/01/23 at 11:49 A.M., with the DON verified lab work had not been completed as recommended by the pharmacy recommended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #18 revealed an admission date of 03/08/23. Diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, generalized anxiety disorder, atrial fibrillation, and pneumonia. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #18 had intact cognition and assessed to require one-person extensive assistance with transfers, dressing, and toileting, supervision with eating, and one-person total dependence with bathing. Review of the care plan dated 04/21/23 revealed Resident #18 used anti-anxiety medications related to anxiety disorder. Interventions included to give anti-anxiety medications ordered by physician and monitor and document side effects and effectiveness. Staff to monitor for drowsiness, dizziness, tiredness, muscle weakness, and headache. Staff to educate about risks, benefits, and side effects and/or toxic symptoms. Review of the physician order dated 05/29/23 revealed Resident #18 was ordered Lorazepam two milligrams (mg)/milliliter (ml), give 0.25 ml by mouth every six hours as needed for anxiety. The physician order revealed there was no end date. Interview on 06/01/23 at 1:12 P.M., with the Director of Nursing (DON) verified Resident #18 did not have an end date for the Lorazepam order. Review of the policy titled, Medication Monitoring and Management, dated January 2018 revealed residents do not receive as needed (PRN) medications unless necessary to treat a diagnosed specific condition which must be documented in the record. PRN orders for psychotropic medications which were not antipsychotic medications were limited to 14 days. The attending physician may extend the order beyond 14 days if he or she believes it was appropriate. If the attending physician extended the PRN for the psychotropic medication, the medical record must contain a documented rationale and determined duration. Based on record review, staff interview, and review of policy, the facility failed to ensure physician's orders for as needed anti-anxiety medications included a stop date or duration for the order. This affected two (#9 and #18) of six residents reviewed for medications. The facility census was 31. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 04/13/23 with diagnoses including cerebral infarction, diabetes mellitus, alcoholic cirrhosis of the liver, traumatic subarachnoid hemorrhage, aphasia, dysphagia, hypertension, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 04/20/23 revealed resident was cognitively impaired and required extensive assistance of one staff member with activities of daily living (ADLs.) Review of the May 2023 monthly physician orders for Resident #9 revealed orders dated 05/18/23 for resident to receive Ativan tablets 1 milligram (mg) or 2 mg every two hours as needed for anxiety. There was no stop date or duration indicated for the Ativan order. Interview on 06/01/23 at 1:12 P.M., with the Director of Nursing (DON) confirmed Resident #9's as needed Ativan orders dated 05/18/23 did not include stop dates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, and staff interview, the facility failed to ensure residents were examined by a dentist. This affected one (#7) of 13 residents sampled. The facility census was 31. Findings include: Review of the medical record for Resident #7 revealed an admission date of 04/19/22 with diagnoses including cerebral infarction, diabetes mellitus, lymphedema, major depressive disorder, anemia, and venous insufficiency. Review of the Minimum Data Set (MDS) assessment for Resident #7 dated 05/11/23 revealed resident was cognitively intact and required extensive assistance of staff with activities of daily living (ADL). Review of the care plan for Resident #7 dated 07/13/22 revealed resident had an ADL self-care performance deficit and required assistance with ADLs related to activity intolerance, decreased mobility, impaired balance, and incontinence. Interventions included staff should assist residents with oral hygiene. The care plan did not include documentation regarding dental consult and/or resident's missing teeth. Review of the medical record for Resident #7 revealed the record did not include documentation regarding dental consultations for resident during her stay at the facility. Observation on 05/30/23 at 12:34 P.M., revealed Resident #7 had natural teeth with a few missing teeth on the bottom front section of her mouth. Interview on 05/30/23 at 12:34 P.M., with Resident #7 confirmed she was missing several bottom front teeth due to decay. Resident #7 confirmed she had occasional mouth pain which did not inhibit her ability to consume adequate nutrition, and she would like to be seen by a dentist. Resident #7 confirmed she had been a resident of the facility since April 2022 and had not been offered the opportunity to be examined by a dentist. Interview on 06/01/23 at 1:12 P.M., with the Director of Nursing (DON) confirmed Resident #7 had not been examined by a dentist during her stay at the facility, and resident had been admitted on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #23 revealed an admission date of 11/19/22. Diagnoses included osteomyelitis of vertebra, sacral, and sacrococcygeal region, chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, major depressive disorder, atrial fibrillation, and generalized anxiety disorder. Review of the quarterly (MDS) assessment dated [DATE] revealed Resident #23 had moderate cognitive impairment. This resident was assessed to require two-person total dependence with transfers, one-person extensive assistance with dressing, supervision with eating, and two-person extensive assistance with toileting. Review of the care plan dated 02/22/23 revealed Resident #23 was at risk for skin breakdown related to admitted with osteomyelitis stage four to sacral, decreased mobility, decreased strength, preferred to stay laying on back, and refused to wear heel protectors. Interventions included administering medications as ordered and monitor/document for side effects and effectiveness. Staff to administer treatments as ordered and monitor for effectiveness. Staff to assess, record, and monitor wound healing. Staff to educate as to the causes of skin breakdown including transfer and positioning requirements, importance of good nutrition, and frequent repositioning. Staff provide diet and any supplements as ordered and monitor and record intake. Review of the care conferences for 2022 and 2023 revealed Resident #23 had no documentation of care conferences provided by the facility. Interview on 05/30/23 at 10:10 A.M. with Resident #23 revealed he had not had any care conferences since admission. Interview on 06/01/23 at 1:21 P.M., with Clinical Manager #230 verified there was no documentation to prove Resident #23 had any care conferences in the last 12 months. Interview on 06/01/23 at 1:23 P.M. with social services #280 verified there was no formal documentation for care conferences for Resident #23 for the last 12 months. 3. Review of the medical record for Resident #12 revealed an admission date of 11/05/19. Diagnoses included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, DM II, chronic kidney disease, stage four, dependence on renal dialysis, and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #12 had moderate cognitive impairment. This resident was assessed to require one-person extensive assistance with transfers, dressing, and toileting, supervision with eating, and one-person total dependence with bathing. Review of the care plan dated 09/07/18 revealed Resident #12 had a potential for complications related to dialysis and chronic renal failure. Interventions included do not draw blood or take blood pressure in arm with graft. Staff to encourage resident to squeeze foam ball as tolerated in fistula arm. Staff to maintain fluid restriction as ordered. Staff to monitor intake and output. Staff to monitor labs and report to physician as needed. Staff to monitor and document peripheral edema. Staff to provide dialysis center with name and phone number of contact and other pertinent information for continuity of care. Review of the progress note dated 03/15/23 at 5:31 P.M., revealed the facility reached out to Resident #12's Power of Attorney (POA) to reschedule care conference on 03/16/23 at 11:00 A.M. Review of the care conferences for the last 12 months revealed only one care conference was completed on 03/16/23. Interview on 05/30/23 at 2:04 P.M., with Resident #12 revealed he could not recall if he had any care conferences in the last 12 months. Interview on 06/01/23 at 1:23 P.M., with SS #280 verified there was one care conference completed in March 2023 but completed phone interviews with POA without documentation. Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure care conferences were held on a regular basis. This affected four (#01, #07, #12, and #23) of five residents reviewed for care conferences. The facility census was 31. Findings include: 1. Review of the medical record of Resident #01 revealed an admission [DATE]. Diagnoses included cerebral palsy, chronic obstructive pulmonary disease, dementia without behavioral disturbance, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition. The resident required supervision for all activities of daily living (ADLs). Interview on 05/30/23 at 11:52 A.M., with Resident #01 stated she could not recall having any recent care conferences. Review of the medical record revealed the most recent care conference was held 07/19/22. Interview on 06/01/23 at 1:24 P.M., with Social Service (SS) #280 verified Resident #01's last care conference documented was 07/19/22. 4. Review of the medical record for Resident #7 revealed an admission date of 04/19/22, with diagnoses including cerebral infarction, diabetes mellitus (DM), lymphedema, major depressive disorder, anemia, and venous insufficiency. Review of the MDS assessment for Resident #7 dated 05/11/23 revealed resident was cognitively intact and required extensive assistance of staff with activities of daily living (ADLs.) Review of the medical record for Resident #7 revealed it did not include documentation of any care conferences held for residents in the previous 12 months. Interview on 05/30/23 at 1:51 P.M., with Resident #7 confirmed she had not had a care conference to discuss her care during her entire stay at the facility, and she had been admitted in April 2022. Interview on 06/01/23 at 1:45 P.M., with the Director of Nursing (DON) confirmed the facility had no documentation regarding any care conferences held for Resident #7. DON confirmed care conference should be held at least quarterly, and the resident and/or resident's representative should be invited to provide an opportunity for participation in care planning. Review of the policy titled Care Conference dated 02/02/06, revealed the facility would have regular interdisciplinary care conferences which would include the resident and/or resident's representative in order to facilitate communication regarding resident's condition and care interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, observations and policy reviews, the facility failed to ensure infection control logs were completed for tracking trends and patterns, complete tuberculous testing for newly hired employees, develop and follow a Legionella water management policy, and ensure hand sanitation was followed during resident care. This had the potential to affect all 31 residents. The facility census was 31. Findings include: 1. Review of the Infection Control Logs dated January, February, and April 2023 revealed the logs lacked tracking of the disease organism isolation type identification, and culture dates. For months January, March and April 2023, there was no organism mapping of the organism location in the facility. March 2023 logs revealed there were no date of infections, signs and symptoms appeared, date of culture, or isolation type. Review of the Infection Control Logs revealed no entries of infections for May 2023. Interview on 06/01/23 at 1:20 P.M., with the Director of Nursing (DON) verified the Infection Control Logs of January, February, March, April, and May 2023, including facility organism mapping, was incomplete. The DON stated the infection control logs should have been completed to enable tracking of the infection's locations, identify isolation procedures and to monitor infection resolution. Review of the undated policy titled, Infection Control Policy and Procedure, revealed the facility policies and procedures surveillance shall include data to properly identify disease and infections before they spread. The policies and procedures include identifying the infection signs and symptoms, analysis of the number of residents who developed the infection and identification of infection trends and patterns. 2. Review of employee files revealed Business Office Manager, (BOM) #110 and Activity Director, (AD) #100 were hired in July 2022 and there was no evidence of Tuberculosis testing prior to hire and the second testing two weeks after hire. Interview on 05/31/23 at 12:06 P.M. with Scheduler #270 verified BOM #110 and AD #100 did not have evidence of tuberculosis testing prior to and after hiring. Scheduler #270 verified BOM #110 and AD #100 should have had tuberculosis testing completed prior to hire and two weeks after hire. Review of the facility Tuberculous Risk Assessment, dated August 2022, revealed the facility tests all health care workers upon hire. 3. Review Legionella notebook and documentation revealed evidence of a water management program which included control measures, testing protocols and corrective actions when control limits are not maintained. Interview on 06/01/23 at 10:35 A.M., with Maintenance Director (MD) #135 verified there was no Legionella water management policy. MD #135 stated he received no formal training. He studied online how to manage Legionella. MD #135 was able to verbalize how to monitor for Legionella. Interview on 06/01/23 at 11:18 A.M., with the Administrator verified there was no policy or procedure for a Legionella water management program. 5. Review of the medical record for Resident #130 revealed an admission date of 05/12/23. Diagnoses included metabolic encephalopathy, chronic respiratory failure with hypoxia, major depressive disorder, generalized anxiety disorder, atrial fibrillation, and tracheostomy status. Review of the Medicare-Five Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #130 was not able to complete a Brief Interview for Mental Status (BIMS). This resident was assessed to require two-person total dependence with transfers, two-person extensive assistance with dressing, and one-person total dependence with eating, toileting, and bathing. Review of the care plan dated 04/21/23 revealed Resident #130 had a tracheostomy related to respiratory failure. Interventions included to ensure trach ties were secured at all times. Staff to administer humidified oxygen as prescribed. Staff to keep at bedside back up trach number six uncuffed Shiley and number four uncuffed Shiley. Staff monitor and document for restlessness, agitation, confusion, increased heart rate, and bradycardia. Staff use universal precautions and assist with coughing as needed. Observations on 06/01/23 between 11:18 A.M. and 11:27 A.M., revealed Licensed Practical Nurse (LPN) #265 perform trach care on Resident #130. LPN #265 applied gloves and then went to search for a trash can. LPN #265 located a trash can near the entrance to Resident #130's room and brought it to the bedside. LPN #265 then changed the glove of the hand utilized to carry the trash can and did not perform hand hygiene prior to applying the new glove. LPN #265 then opened a new container of trach supplies and proceeded to apply the sterile gloves from inside the container, over the gloves she was already wearing. LPN #265 then completed trach care on Resident #130. Interviews on 06/01/23 at 11:28 A.M. and 11:37 A.M., with LPN #265 verified she did not perform hand hygiene when changing her glove. LPN #265 further verified she applied sterile gloves over her regular gloves before performing trach care on Resident #130. LPN #265 verified hand hygiene should have been completed prior to donning the new glove and should not have placed the sterile gloves over another pair of gloves. Review of the policy titled, Tracheostomy Care, dated 04/04/22, revealed an aseptic technique should be utilized when providing care for the resident with a tracheostomy. Hand antisepsis should be performed before applying gloves. 4. Observation on 05/30/23 at 12:20 P.M., revealed State Tested Nursing Assistant (STNA) #225 arrived on the unit to assist with passing room trays and donned gloves before taking Resident #7's tray off the cart. STNA #225 then delivered lunch trays to Residents #7 and #11. STNA #225 assisted residents with setting up their meal trays and ensuring they were appropriately positioned in bed. STNA #225 then entered Resident #24's and responded to her call light and assisted resident with repositioning. STNA #225 exited Resident #24 's room, and the Director of Nursing (DON) pointed to aide's gloves and gestured that the aide should remove the gloves. STNA #225 then doffed the gloves and continued with tray pass. STNA #225 was not observed performing hand hygiene at any time during passing trays and assisting residents. Interview on 05/30/23 at 12:26 P.M., with STNA #225 stated the last time she had washed her hands was after taking out the trash and just before entering the unit to assist with meal service. STNA #225 confirmed she had donned a pair of gloves before delivering trays and assisting Residents #7, #11, and #24. STNA #225 confirmed she did not remove gloves and/or wash or sanitize hands between resident contact. Interview on 06/01/23 at 1:12 P.M., with the DON confirmed she had witnessed STNA #225 wearing gloves in the hallway during lunch meal service and going from room to room wearing the same pair of gloves. DON confirmed staff should perform appropriate hand hygiene between each resident contact. Review of the policy titled Handwashing/Hand Hygiene dated 04/06/23 revealed the use of gloves did not replace hand washing/hand hygiene. Hand hygiene should be performed after removing gloves, after contact with items in the immediate vicinity of the resident, before and after direct contact with residents, before and after handling food, before and after assisting a resident with meals.

Based on record reviews, staff interview, and policy review, the facility failed to monitor antibiotic use appropriately as part of an antibiotic stewardship plan. This had the potential to affect all 31 residents. The facility census was 31. Findings include: Review of documents dated January, February, March, April, and May 2023, provided by the Director of Nursing, (DON), revealed there was no documentation and analysis of appropriate indications for the use of antibiotics. Interview on 06/01/23 at 1:20 P.M., the Director of Nursing, (DON) stated the facility uses the McGeer monitoring criteria for the antibiotic stewardship program. The DON had no evidence of how the facility was monitoring antibiotic medications using the McGeer criteria. The DON verified there was no documentation of an antibiotic stewardship program. Review of the undated policy titled, Antibiotic Stewardship -Orders for Antibiotics, revealed antibiotics will be prescribed and administered to residents under the guidance of facility's antibiotic stewardship program, including appropriate indications for use. Indications of use included criteria must be met for clinical definition of an active infection and pathogen susceptibility.