**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, review of the concern log, and review of facility policy, the facility failed to ensure concerns were filed, addressed, and resolved in a timely manner. This affected one resident (#6) of three reviewed for dignity. The facility census was 52. Findings include: Review of the medical record for Resident #6 revealed an admission date of 02/22/24 with diagnoses that included unspecified fracture of left ulna, multiple sclerosis, and essential hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Review of the MDS assessment revealed Resident #6 was dependent on staff for Activities of Daily Living (ADLs). Review of the progress note dated 09/11/24 at 2:08 P.M. revealed Resident #6 went to the social service office and appeared upset, stating Social Service Director (SSD) #466 did not place a grievance for the staff member who stated they wanted Resident #6 to die. SSD #466 informed Resident #6 this was her first time hearing of the incident and did not know what happened. Further review of the progress note revealed SSD #466 informed the Administrator, Assistant Director of Nursing (ADON) #452, and the Director of Nursing (DON) #507. Interview on 10/06/24 at 11:19 A.M. with Resident #6 revealed a staff nurse, who she was unable to identify, stated that she wanted her to die and she reported the incident to SSD #466. Resident #6 revealed SSD #466 asked her to leave her office because she could not repeat what occurred word for word. Interview on 10/07/24 at 11:25 A.M. with SSD #466 revealed she was responsible for taking care of concerns and that she was familiar with Resident #6. SSD #466 revealed Resident #6 spoke with her in her office a few times over the last 3 months. SSD #466 revealed Resident #6 informed her that one of the staff nurses (unable to be identified) said she wanted Resident #6 to die. SSD #466 revealed Resident #6 was visibly upset and became disrespectful, so she asked Resident #6 to exit her office, but she refused. SSD #466 revealed she left her office. SSD #466 revealed she entered a note into Point Click Care (PCC) and sent a text to staff. Interview on 10/07/24 at 3:58 P.M. with the Administrator revealed she was not aware of the incident regarding staff nurse stating she wanted Resident #6 to die. Follow-up interview on 10/07/24 at 4:00 P.M. with SSD #466 revealed she did not complete and file a concern log form for Resident #6, but she informed ADON #452 during the standup morning meeting the following day. Interview on 10/08/24 at 9:10 A.M. with ADON #452 revealed she was not aware of the concern regarding Resident #6 and staff nurse who stated she wanted Resident #6 to die. ADON #452 revealed all concerns were to be documented on a grievance form and taken to the Administrator. Review of the concern log dated August, September, and October 2024, revealed no documented incidents dated 09/11/24 in regard to grievance placed with SSD #466 by Resident #6. Review of the facility document titled, Grievances/Resident/Family, revised 11/04/16, revealed the facility had a policy in place to document concerns and resolutions and identifying areas for improvement to promote customer satisfaction with facility care and services. Further review of the policy revealed the social services/designee would act as the grievance official and be responsible for overseeing the grievance process, receiving and tracking grievances through their conclusion and to take immediate action to prevent further potential violations of any resident right while alleged violation is investigated. This deficiency represents non-compliance investigated under Complaint Number OH00157038.

Based on record review and staff interview the facility failed to ensure authorizations for resident fund accounts were witnessed by non-facility staff. This affected two residents (#7 and #41) of five residents reviewed for resident fund accounts. The facility census was 52. Findings include: 1. Review of the authorization to manage funds for Resident #7, dated 10/17/23, revealed no non-facility affiliated witness signature was obtained as required. 2. Review of the authorization to manage funds for Resident #41, dated 03/16/23 and 11/09/23, revealed no non-facility affiliated witness signature was obtained as required. Interview on 10/07/24 at approximately 4:00 P.M., Business Office Manager (BOM) #448 verified the authorization forms were not witnessed for Residents #7 and #41.

Based on record review and staff interview, the facility failed to ensure all required notices of potential financial obligation were given to residents prior to the discontinuation of skilled services while using their Medicare Part A benefit. This affected two residents (#17 and #55) of three residents reviewed for beneficiary notices. The facility census was 52. Findings include: 1. Review of the beneficiary notice worksheet provided by facility during the annual survey revealed Resident #17 was discharged from skilled therapy services while using his Medicare Part A benefit on 05/14/24. Review of the notices provided to Resident #17 upon discontinuation of skilled services revealed no Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) was given to Resident #17 as required. 2. Review of the beneficiary notice worksheet provided by facility during the annual survey revealed Resident #55 was discharged from skilled therapy services while using his Medicare Part A benefit on 09/03/24. Review of the notices provided to Resident #55 upon discontinuation of skilled services revealed no SNF ABN was given to Resident #55 as required. Interview 10/07/24 at 2:54 P.M. with Business Office Manager (BOM) #448 verified Residents #17 and #55 did not receive a SNF ABN. BOM #448 stated she thought those forms were only given to residents who were on Medicare Part B.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interviews, facility policy review, and review of ancillary documentation, the facility failed to ensure residents received timely ancillary services. This affected one resident (12) of one resident reviewed for ancillary services. The facility census was 52. Findings include: Review of the medical record for Resident #12 revealed she was admitted to the facility on [DATE] with diagnoses of low back pain, hearing loss, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Review of the MDS assessment revealed Resident #12 had difficulty hearing. Review of the care plan dated 07/17/24 revealed Resident #12 had a communication problem related to a hearing deficit with interventions that included monitor and/or record confounding problems such as ear discharge and cerumen (wax) accumulation and refer to audiology for hearing consult as ordered. Review of the physician orders dated 07/15/24 revealed an order to see the audiologist as needed. Review of the physician orders dated 09/26/24 revealed an order for debrox solution (Debrox Otic Solution 6.5 percent) to be given five drops in both ears two times a day, for removal of earwax and to follow-up with the audiologist to clean ears. Interview on 10/06/24 at 11:12 A.M. with Resident #12 revealed she needed her ear cleaned out and that she had drops placed in her ear in preparation to be seen by the audiologist two weeks ago. Resident #12 revealed the audiologist never showed up and her right ear was still blocked. Resident #12 revealed her right ear was blocked and was uncomfortable. Resident #12 reported no staff had followed-up with her regarding her ear or the audiologist. Interview on 10/03/24 at 9:03 A.M. with Business Office Manager (BOM) #448 revealed Social Service Director (SSD) #466 was responsible for scheduling the ancillary services including the audiology appointments. BOM #448 revealed after SSD #466 adds residents to the list, the audiology team sends over an email of who they will see and the date. BOM #448 revealed the schedule is then placed at the nursing station the day of the appointment to prepare scheduled residents for the audiologist's arrival. BOM #448 revealed all ancillary services were provided in-house unless outpatient services were required. BOM #448 revealed, after all procedures were completed, all notes were uploaded into Point Click Care (PCC) under the miscellaneous tab. Interview on 10/08/24 at 9:05 A.M. with Licensed Practical Nurse (LPN) #408 revealed audiology appointments were scheduled monthly, and SSD #466 was responsible for coordinating the authorization and appointments. LPN #408 revealed Resident #12 had a hearing deficit due to ear wax buildup in her ear and required services by audiology. Interview on 10/08/24 at 3:40 P.M. with the Director of Nursing (DON) revealed she was unaware of Resident #12 was still in need of being seen by the audiologist. The DON confirmed and verified physician orders for debrox with no follow-up with the audiologist or added to the list to be seen on the upcoming visit. Interview on 10/09/24 at 10:13 A.M. with Resident #12 revealed she was not experiencing minor pain in her right ear and now it was aggravating. Resident #12 said she received the initial ear drops but no follow-up occurred. Interview on 10/09/24 at 10:15 A.M. with LPN #501 revealed Resident #12 informed her that her right ear was clogged with wax. LPN #501 revealed Resident #12 received an order to debrox and informed the DON and Assistant Director of Nursing (ADON) #452. Review of the medical record for Resident #12 revealed no documented physician orders, uploaded progress notes, or no indication that she was scheduled, seen, and provided audiology services. Review of the audiology ancillary visit history, since Resident #12's admission, revealed the audiology services were provided in the facility on 08/30/24 and 10/04/24. Review of the visit history revealed Resident #12 was not seen for either visit or not added to the list. Review of the facility document titled, Hearing and Vision Services, undated, revealed the facility had a policy in place to ensure all residents had access to hearing and vision services and receive adequate adaptive equipment as indicated. Further review of the policy revealed the social worker/social service designee would be responsible for assisting residents in locating and utilizing available resources for the provision of hearing services the resident needs, making appointments, and arranging transportation.

Based on personnel record review, staff interview and review of facility policy, the facility failed to ensure all new employees were screened through the State of Ohio Nurse Aide Registry (NAR) prior to employment to identify if an employee had a finding concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. This had the potential to affect all 52 residents residing in the facility. The facility census was 52. Findings include: Review of the personnel file for Physical Therapist Aide (PTA) #424 revealed a hire date of 11/21/23. There was no evidence PTA #424 was checked against the NAR prior to employment. Review of the personnel file for Licensed Practical Nurse (LPN) #531 revealed a hire date of 11/21/23. There was no evidence LPN #531 was checked against the NAR prior to employment. Review of the personnel file for Registered Nurse (RN) #421 revealed a hire date of 07/24/24. There was no evidence RN #421 was checked against the NAR prior to employment. Review of the personnel file for Dietary Manager (DM) #469 revealed a hire date of 08/02/24. There was no evidence DM #469 was checked against the NAR prior to employment. Review of the personnel file for Director of Rehabilitation (DOR) #491 revealed a hire date of 11/14/23. There was no evidence DOR #491 was checked against the NAR prior to employment. Review of the personnel file for Housekeeper #537 revealed a hire date of 03/21/24. There was no evidence Housekeeper #537 was checked against the NAR prior to employment. Review of the personnel file for Dietary Aide (DA) #493 revealed a hire date of 07/18/24. There was no evidence DA #537 was checked against the NAR. The interview on 10/06/24 at 10:01 A.M. with Human Resource Manager (HR) #428 revealed she was not aware that all new employees were required to be checked against the NAR and confirmed she had not performed the checks prior to the first day of employment. HR #428 verified PTA #424, LPN #531, RN #421, DM #469, DOR #491, Housekeeper #537 and DA #493 had not been screened through the NAR prior to working. Review of the facility policy titled Resident Right to Freedom from Abuse, Neglect and Exploitation Policy and Procedure, dated 2022, revealed the facility will not employ or otherwise engage individuals who have had a finding into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, staff interviews, review of staff schedules, review of the staffing tool, review of the concern logs, and review of the facility assessment, revealed the facility failed to ensure adequate staffing to meet the needs of the residents. This had the potential to affect all 52 residents residing in the facility. Findings include: An interview on 10/06/24 at 10:51 A.M. with Receptionist (RCT) #414 revealed the daily staffing sheets were completed daily, but residents complained about not enough aides to assist with call lights and bathroom needs. RCT #414 revealed residents called the receptionist desk phone more on the weekends. An interview on 10/06/24 at 11:14 A.M. with Resident #5 revealed there was never enough staff due to staff calling off, especially during the night shift. An interview on 10/06/24 at 11:19 A.M. with Resident #6 revealed she had to wait over 15 minutes for her call light to be answered and when they answered the call light, staff turned it off and never returned. An interview on 10/06/24 at 11:29 A.M. with State Tested Nursing Assistant (STNA) #431 revealed sometimes the facility was short on aides and operated the facility with only one to two aides on the floor. An interview on 10/07/24 at 6:20 A.M. with Registered Nurse (RN) #432 revealed there were only two aides for the overnight shift. RN #432 revealed the two aides were not enough staff to meet the needs of the residents. RN #432 revealed the night shift was responsible for getting 22 residents up for the morning and it would not be completed. Observation on 10/07/24 at 6:25 A.M. revealed Resident #6, #7, and #12 call lights were activated. Resident #6 revealed she needed incontinence care, Resident #12 revealed she needed to get up for the day as requested, and Resident #7 revealed he requested water and never received it. Observation revealed call lights were still unanswered as of 6:45 A.M. An interview on 10/07/24 at 6:27 A.M. with STNA #495 revealed there were not enough staff for the night shift. STNA #495 revealed there were only two aides currently and that was not enough to complete tasks such as check and change, answer call lights timely, and get them up for the morning. Observation on 10/07/24 at 6:30 A.M. revealed two nurses, #401 and #432, and two aides, #495 and #603. Observation revealed floor staff did not match the required daily needed to meet the needs of the residents. An interview on 10/07/24 at 6:32 A.M. with RN #401 revealed the night shift needed at least 3 aides to provide sufficient care to the residents that resided in the facility. RN #401 also revealed call lights went unanswered for long period of time and there were 22 residents to get up for the first shift and they were running behind schedule. Review of the staffing tool with Staffing Coordinator (SC) #526, on 10/07/24 at 11:00 A.M., for coverage from 09/22/24 through 09/28/24 revealed the facility did not have registered nursing coverage for two days, 09/23/24 and 09/24/24. SC #526 revealed staffing was based on the census and required two to three nurses and four to five aides during the day shift and two nurses and four aides on the night shift to adequately and sufficiently provide care to residents. Review of the staffing schedules dated 10/06/24 revealed the facility scheduled two registered nurses, RN #401 and #432, from 6:30 P.M. to 7:00 A.M., one Licensed Practical Nurse (LPN) #417, and three STNAs #413, #495, and #459. Interview with SC #526 on 10/07/24 at 11:00 A.M. revealed two aides (#413 and #459) had called off for their night shift on 10/06/24. SC #526 confirmed and verified the facility lacked adequate staffing as indicated in the above findings. An interview on 10/09/24 at 1:30 P.M. with Resident #6's daughter, revealed there were never enough aides and she had to provide care for Resident #6 when staff was not available. Review of the concern logs dated September 2023 through August 2024 revealed concerns regarding call light response times, getting up on time as requested, and staffing issues. Review of the facility assessment dated [DATE], revealed the facility assessment was in place and utilized, to determine the resources necessary to care for the facility residents and meet the needs for day-to-day operations including nights and weekends. Review of the assessment revealed the facility based the staffing levels on an average census of 53 residents with a need of one to two registered nurses per shift, one to two licensed practical nurses per shift (12 hour shifts) and three to four state tested nurse assistants for days and three to four state tested nurse assistants per nights (12 hour shifts). Review of the facility assessment revealed the facility did not implement the facility assessment in regard to maintain adequate staffing levels. This deficiency represents non-compliance investigated under Complaint Number OH00157038.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility assessment review, staffing tool review, and staff interview, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 52 residents residing in the facility. Findings include: Review of the staffing tool with Staffing Coordinator (SC) #526 on 10/07/24 at 11:00 A.M., for coverage from 09/22/24 through 09/28/24, revealed the facility did not have RN coverage for two days, 09/23/24 and 09/24/24. SC #526 verified there was no RN coverage for those two days due to call-offs and no replacement RNs were put in place. Review of the facility assessment dated [DATE], revealed the facility assessment was in place and utilized to determine the resources necessary to care for the facility residents and meet the needs for day-to-day operations including nights and weekends. Review of the assessment revealed the facility based staffing levels of an average census of 53 residents, with a need of one to two registered nurses per shift. Review of the facility assessment revealed the facility did not implement the facility assessment in regard to maintaining RN coverage. This deficiency represents non-compliance investigated under Complaint Number OH00157038.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure call lights were within reach at all times for Residents #32, #5, and #25. This affected three of three residents reviewed for environmental concerns. The facility census was 46. Findings include: 1. Resident #32 was admitted to the facility on [DATE] with diagnoses of cerebellar stroke syndrome, atherosclerotic heart disease, hypertension, difficulty walking, muscle weakness and cognitive communication deficit. Her comprehensive assessment dated [DATE] revealed she was severely cognitively impaired for decision making and had functional limitations of both hands. Observation on 07/09/19 at 10:42 A.M. of Resident #32 revealed her push button type call light was not within her reach. This was verified by State Tested Nursing Assistant (STNA #132) at the time of the observation. On 07/09/19 at 10:46 A.M. interview with Resident #32's daughter revealed she was concerned that her mother could not reach the call light. The daughter said she was unsure if her mother could push the button due to contracted fingers on both hands and thought a flat, touch-pad type of call light would be easier. This was verified by STNA #132 who revealed she was unsure why Resident #32 was not provided with a touch-pad type of call light. 2. Resident #5 was admitted to the facility on [DATE] with diagnoses of dementia, heart failure, morbid obesity, hypertension, osteoarthritis, anxiety, shortness of breath, muscle weakness and psychosis. Her comprehensive assessment dated [DATE] revealed she had functional limitations of both hands. Observation on 07/09/19 at 10:51 A.M. of Resident #5 revealed her call light was not within her reach. This was verified at 10:52 A.M. by STNA #162. On 07/09/19 at 10:52 A.M. interview with STNA #162 revealed Resident #5 was not able to use the push button type call light, but might be able to use a touch-pad call light. STNA #162 verified all residents' call lights must be kept within reach at all times. 3. Resident #25 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, and a history of falling. His comprehensive assessment dated [DATE] revealed he required extensive assistance for bed mobility and had limited range of motion. Observation on 07/09/19 at 11:01 A.M. of Resident #25 revealed his call light was not within reach. This was verified by STNA #132 who stated he used his call light frequently. On 07/12/19 at 2:11 P.M. interview with the Director of Nursing (DON) revealed touch-pad type call lights were available. The DON verified all call lights must be kept in reach of the resident, and they should have recognized the need for a more suitable call light (touch-pad) for Resident #5 and Resident #32. Review of the call light policy dated November 2015 revealed all residents must have a working call light and it must be in their reach at all times while in their room. Staff must remind the resident where it was and show them how to use it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of manufacturer's instructions the facility failed to maintain a medication error rate of less than five percent. There were two errors out of 35 opportunities for a medication administration error rate of 5.71 percent. This affected one (Resident #3) of three residents observed for medication administration. The facility census was 46. Finding include: Resident #3 was admitted to the facility on [DATE] with diagnoses including hypertension and diabetes. Review of the July 2019 physicians orders revealed an order for insulin according to a sliding scale (a dose based on the resident's blood sugar level) to be given prior to meals and at bedtime. There was also an order for Metoprolol 12.5 milligram (mg) to be given by mouth twice daily for high blood pressure. There were no parameters or further instructions ordered pertaining to the Metoprolol. Observation of medication administration on 07/10/19 at 8:15 A.M. for Resident #3 with Licensed Practical Nurse (LPN) #133 revealed Resident #3 received insulin per a Novolog Flexpen (a device to administer insulin). LPN #133 prepared the dose of insulin using the Novolog Flexpen without first priming the pen (pressing the button on the device to remove air bubbles that may have collected in the cartridge) and gave the injection of insulin in the resident's right upper forearm. LPN #133 took Resident #3's blood pressure and did not administer the Metoprolol. Review of the Medication Administration Record (MAR) time stamped 8:35 A.M. on 07/10/19 revealed the Metoprolol 12.5 mg was signed off as administered. Interview on 07/11/19 at 8:36 A.M. with LPN #133 revealed she did not give the resident's Metoprolol due to a blood pressure of 107/48 and a heart rate of 66 beats per minute. LPN #133 verified she made a mistake and signed off the Metoprolol as administered and stated the physician did not need to be notified unless two doses were held. LPN #133 also verified she did not prime the Flexpen to expel air bubbles to ensure an accurate dose of insulin was administered. On 07/11/19 at 10:35 A.M. interview with the Director of Nursing (DON) revealed the facility's policy was to hold blood pressure medication if the heart rate was under 60 beats per minute and to notify the physician if blood pressure medication was not administered. The DON verified LPN #133 did not administer Resident #3's insulin or Metoprolol as ordered which resulted in a medication error rate of 5.71 percent. Review of the Novolog Flexpen manufacturer's instructions revealed to prime the cartridge to remove any air bubbles prior to injection.