**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure Resident #27's responsible party was notified of a change of condition. This affected one resident (#27) of one residents reviewed for notification of change. The facility census was 34. Findings include: Review of Resident #27 medical record revealed admission date of 02/27/25 with diagnosis of diabetes type II with foot ulcer, protein-calorie malnutrition, cognitive communication deficit, dysphagia, abnormal posture, benign prostatic hyperplasia, essential hypertension, fatigue, nonrheumatic aortic stenosis, polymyalgia rheumatica, major depressive disorder, history of traumatic brain injury, heart failure, history of pulmonary embolism, hypoglycemia, hyperlipidemia, dementia, mild cognitive impairment, and acquired absence of left leg above knee. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had a Brief Interview for Mental Status (BIMS) of 2, indicating severely impaired cognition. Review of court records dated 03/21/25 revealed there had been paperwork filed regarding guardianship for Resident #27. The records indicated a hearing was scheduled on 05/07/25 to establish guardianship. As of 06/18/25, the facility had not yet received notice of the outcome of the hearing. Review of an incident note dated 06/05/25 revealed the facility's management and physician were updated regarding Resident #27 having obtained new skin abrasions. The note stated Resident #27 was his own responsible party. Interview on 06/16/25 at 12:52 P.M. with Resident #27's spouse revealed the facility does not always update her of changes with Resident #27's care, and communication from the facility was not very good. Interview on 06/18/25 at 11:15 AM with the Director of Nursing (DON) and Regional Clinical Manager #272 revealed the facility determines if a resident is able to make their own decisions by their BIMS score. If residents had a BIMS score of less than 8, if the doctor has determined resident was incapable of making decisions, or if the resident has a guardian then residents would not be able to make their own decisions or be considered their own responsible party. Regional Clinical Manager #272 revealed the facility usually notified the next of kin if residents were in the process of obtaining guardianship. Review of the facility Notification of Change Policy dated 2024 revealed circumstances required notification include: accidents, significant change in the resident's status, circumstance that require a need to alter treatment, transfer or discharge, change of room or roommate assignment, and a change in resident rights. For competent individuals the facility must still contact the resident's physician and notify representative, if known. For residents incapable of making decisions the representative would make any decisions that have to be made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #30 revealed an admission date 09/07/23 with diagnoses bipolar, acute respiratory failure, post-traumatic stress disorder (PTSD), anxiety, and type II diabetes. Review of the Minimum Data Set 3.0 MDS comprehensive assessment, dated 05/23/25, revealed Resident #30 had moderate cognitive impairment and required substantial/maximum assistance from staff for activities of daily living. Review of the plan of care for Resident #30 dated 02/25/25 revealed a plan for alteration in mood and behavior related to bipolar disorder, anxiety, depression and unspecified mood disorder. Resident #30 shows little interest or pleasure in doing things and frequent crying. There was no evidence of a plan of care that addressed the resident's history of PTSD. Observation on 06/16/25 at 11:34 A.M. Resident #30 was in her room lying in bed grunting and yelling out. Interview on 06/18/25 at 11:28 A.M. with the Assistant Director of Nursing (ADON) #249 revealed Resident #30 yells out, cries frequently, and gets upset over things that happened long time ago such as her cat dying. ADON #249 reported redirection and spending time with Resident #30 was usually effective. Interview on 06/18/25 at 4:00 P.M. with the Regional Clinical Manager #272 verified Resident #30 had a diagnosis of PTSD and did not have a care plan that addressed the resident's PTSD. Review of the policy called Comprehensive Care Plans dated 2025 revealed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Based on medical record review and interview, the facility failed to ensure a comprehensive care plan was created and implemented for two residents (#4 and #30) of 14 residents reviewed for care plans. This facility census was 34. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of 03/14/24. Diagnoses included but were not limited to acute respiratory failure with hypoxia, hemiplegia and hemiparesis, and general anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] for Resident #4 revealed intact cognition. Resident #4 was noted to be dependent for the activities of daily living. Review of the annual activity assessment dated [DATE] for Resident #4 revealed he was somewhat interested in books, newspapers, and magazines to read, liked to listen to music, and liked to be around pets. It was also noted it was not important to do group activities, and somewhat important to do his favorite activities. Resident #4 was noted to prefer to stay in his room and participated in self-directed leisure pursuits. Staff were to encourage group participation, but respect the resident's right to refuse. Review of the care plan dated 05/16/25 for Resident #4 revealed no evidence of a care plan for activities. Interview on 06/17/25 at 7:48 A.M. with Activities Director #221 confirmed an activities care plan was never developed for Resident #4 following his admission on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policy and procedure, the facility failed to ensure infection prevention protocols were maintained for Resident #27, who required enhanced barrier precautions. This affected one resident (#27) of three residents reviewed for enhanced barrier precautions. The facility census was 34. Findings include: Review of the medical record revealed Resident #27 was admitted on [DATE] with diagnosis of diabetes type 2 with foot ulcer, protein-calorie malnutrition, cognitive communication deficit, dysphagia, benign prostatic hyperplasia, essential hypertension, fatigue, nonrheumatic aortic stenosis, polymyalgia rheumatica, major depressive disorder, history of traumatic brain injury, heart failure, history of pulmonary embolism, hypoglycemia, hyperlipidemia, dementia, mild cognitive impairment, and acquired absence of left leg above knee. Review of Resident #27's physician order for enhanced barrier precautions dated 6/14/25 revealed a gown and gloves were required during high-contact care activities due to a chronic wound on the resident's right heel. Observation on 06/17/25 at 10:07 A.M. of Certified Nurse Assistant (CNA) #253 revealed CNA #253 entered Resident #27's room with gloves and a face mask on. CNA #253 closed the door to provide care and exited room with a mask and gloves on at 10:18 A.M. At 10:19 A.M., Licensed Practical Nurse (LPN) #215 placed a gown and gloves on before entering room to do wound care. Resident #27 refused wound care and LPN #215 removed gown while in room and placed it in the trash. CNA #253 then brought the hoyer lift inside the room and closed the door. LPN #215 and CNA #253 exited room at 10:24 A.M. with Resident #27 dressed and in his wheelchair. Interview with LPN #215 at 10:25 A.M. revealed they do not wear gowns during transferring and confirmed they transferred Resident #27 from the bed to his wheelchair with the hoyer. Interview with CNA #253 at 10:26 A.M. revealed she removed Resident #27 clothes, gave him a bed bath, and dressed him in new clothes. CNA #253 revealed she was told she only needed to wear a gown when residents wounds are seeping and Resident #27 wounds are not currently seeping and confirmed she was not wearing a gown during resident care. Interview on 06/17/25 at 10:34 A.M. with DON said they are required to wear gowns and gloves while providing showering, catheter care, transfers and other high-contact care activities. The DON stated she will re-educate staff. Review of the facility policy Enhanced Barrier Precautions dated 2025 revealed residents with wounds even if the resident is not known to be infected or colonized with a multi-drug resistant organism (MDRO) should be placed on precautions. Personal Protective Equipment (PPE) only needs to be used when performing high-contact care activities including: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, facility policy review, and review of manufacturer prescribing information, revealed the facility failed to ensure antibiotics were appropriately prescribed with a correct indication, dose, and duration. This affected one resident (#1) of five residents reviewed for unnecessary medications. The facility census was 34. Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, anxiety, type II diabetes, atrial fibrillation, and peripheral vascular disease. Review of Resident #1's hospital Discharge summary dated [DATE] revealed an order for Macrobid 100 milligrams (mg) every ten days to be administered at 9:00 A.M. and 9:00 P.M. Review of Resident #1's physician's orders revealed an order dated 11/27/24 for Macrobid 100 milligrams (mg), give one capsule by mouth two times a day, every ten days, for urinary tract infection (UTI) prophylaxis (prevention). Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had intact cognition and received scheduled and as needed pain medications, an antipsychotic, antidepressant and an antibiotic. Review of the Medication Administration Record revealed from November 2024 through June 2025 revealed Macrobid 100 mg was administered two times a day every ten days. Resident #1 received the Macrobid 100 mg two times a day on: 11/27/24, 12/07/24, 12/17/24. 12/27/24, 01/05/25, 01/16/25, 01/27/25, 02/05/25, 02/15/25, 02/25/25, 03/07/25, 03/17/25. 03/27/25, 04/06/25, 04/16/25, 04/26/25, 05/06/25, 05/16/25, 05/26/25, 06/05/25, and 06/15/25. Interview on 06/17/25 at 11:25 A.M. with Certified Nurse Practitioner (CNP) #273 stated he would never write an order for Macrobid to be administered prophylactially two times a day every ten days. CNP #273 stated the Macrobid order may have been written by a hospice provider. Interview on 06/18/25 at 8:13 A.M. with Pharmacist #269 stated the Macrobid order was written to give one capsule twice daily for ten days. Pharmacist #269 noted this was different than the facility's Macrobid order dated 11/27/24. Pharmacist #269 stated she would expect the nursing staff to call the provider for clarification. Pharmacist #269 stated the ordered dosage was not therapeutic for Resident #1. Interview on 06/18/25 at 9:34 A.M. with Pharmacist #270 stated recently the facility's pharmacy had merged to another pharmacy within the same corporation and the original order should have been canceled due to not meeting the Food and Drug Administration (FDA) approved dosage for UTI prophylaxis. Pharmacist #270 stated the pharmacy's original order called for Macrobid 100 mg to be administered twice daily for ten days, which differed from the facility's Macrobid order dated 11/27/25. Pharmacist #270 confirmed the pharmacy had not previously recommended the Macrobid order be clarified, but stated the pharmacy would be making a recommendation to clarify Resident #1's Macrobid order. Interview on 06/18/25 at 4:28 P.M. with the Director of Nursing (DON) revealed the order was brought to the attention of CNP #273, who would clarify the order. The DON stated Resident #1's monthly pharmacy reviews and recommendations did not indicate a clarification for the order. Review of the undated manufacturer's prescribing information revealed Macrobid is commonly used as an antibacterial agent specific for urinary tract infections. The prescribing information noted that a common adult dosage is one 100 mg capsule every twelve hours for a duration of seven days. The prescribing information noted that in the absence of a proven or strongly suspected bacterial infection, a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria. Review of the undated facility policy titled Medication Administration stated to compare the MAR to the medication and refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects.

Based on observation and staff interview, the facility failed to ensure the food stored in a designated refrigerator for resident use and resident personal room refrigerators were labeled, dated and expired items were disposed of timely. This affected three (Residents #8, #11, and #18) of five residents reviewed for personal resident refrigerators. The facility indicated 17 residents had personal refrigerators in their rooms. This had the potential to affect all 34 residents at the facility using facility refrigeration for personal food items. The facility census was 34. Findings include: Observation on 06/17/25 at 11:05 A.M. with the Assistant Director of Nursing (ADON) #249 of the nutrition refrigerator for resident use located on the 300 hall revealed the following concerns: - A four ounce (oz) nutritional shake with a use by of 06/05/25. - An undated, unlabeled foil wrapped breadstick and red sauce that appeared to be hard and stale. - An unlabeled, undated 16-ounce bottle with unidentified liquid with separated particles. - A one-cup container of a facility prepared side salad that was unlabeled, undated and was visibly wilted and moldy - A four-ounce vanilla yogurt with use by date of 03/17/25. - A four-ounce raspberry yogurt with use by date of 05/01/25. - A four-ounce vanilla yogurt with use by date of 05/29/25. - An unlabeled, undated, foil-wrapped and partially eaten baked potato with sour cream with mold. The above-mentioned concerns were confirmed by ADON #249 at the time of the observations. Observation on 06/17/25 at 11:20 A.M. with ADON #249 of five resident personal room refrigerators revealed the following concerns: - Resident #8's personal refrigerator had an eight oz cream cheese spread with a use by date of 03/04/25, an 11.5 ounce protein shake with a use by date of 05/29/24, a four-ounce raspberry yogurt with a use by date of 06/03/25, a four-ounce vanilla yogurt with a use by date of 01/20/25, and a six pack of four-ounce rice pudding with a use by date of 05/11/25. - Resident #11's personal refrigerator had a four-ounce vanilla yogurt with a use by date of 06/03/25. - Resident #18's personal refrigerator had an opened and undated 64-ounce jar of pickles slices with a use by date of 05/30/25. The above listed concerns were confirmed by ADON #249 at the time of the observations. Review of the facility policy called Use and Storage of Food Brought in by Family or Visitors revised 2025 revealed all food items that are already prepared by the family or visitor brought in must be labeled with content and dated. The prepared food must be consumed by the resident within three days. If not consumed within three days, food will be thrown away by the facility staff. All items not maintained are subjected to being thrown away if not removed by the resident or/or resident representative.

Based observation, review of pest control service inspection report, review of a maintenance request form, and interview, the facility failed to ensure an effective pest control program. This affected seven residents (Residents #23, #15, #11, #14, #35, #2 and #4) and had the potential to affect all residents who resided at the facility. The census was 35. Findings include: Observation on 05/05/25 at 9:05 A.M. revealed Resident #23 was lying in bed, watching television with his half-eaten breakfast meal tray on the overbed table next to him. There were several tiny flying insects swarming around his face and meal. There were approximately 20 tiny flying insects on the wall, in the sink, on the toilet and the door of his bathroom. Interview, during the observation, with Resident #23 revealed his room had a gnat problem for a couple of weeks and the facility had sprayed his room and bathroom and poured a chemical down his drain to eradicate the gnats. Interview on 05/05/25 at 9:19 A.M. with Housekeeper #1 revealed the facility had a gnat problem for a week and he believed the gnats were coming out of the drainpipes. Housekeeper #1 stated he had tried to pour chemicals and run hot water down the drains and set out gnat traps. Housekeeper #1 reported the gnats to his manager to notify the pest control company. Observation on 05/05/25 at 9:23 A.M. revealed Resident #15 was lying in bed, feeding himself breakfast from his overbed table. There were several tiny flying insects swarming around his face and meal and two tiny flying insects in his bathroom. Interview, during the observation, with Resident #15 revealed he had been having trouble with flying insects for the past month. Observation on 05/05/25 at 9:33 A.M. revealed Resident #11 was lying in bed, feeding himself breakfast from his overbed table. There were two tiny flying insects swarming around his face and meal and one tiny flying insect on the bathroom door. Interview, during the observation, with Resident #11 revealed he has had a gnat problem for a short time. Interview on 05/05/25 at 9:40 A.M. with Certified Nurse Aide (CNA) #3 revealed she saw gnats here and there however the gnat problem was especially bad in Resident #23's room. CNA #3 believed the gnat problem was linked to his use of a bed pan. Observation on 05/05/25 at 9:48 A.M. revealed Resident #14 was lying in bed, feeding herself breakfast from the overbed table. There were two tiny flying insects swarming around her meal. Interview on 05/05/25 at 10:16 A.M. with Resident #35 revealed he had concerns with flies in the facility. Observation on 05/05/25 at 10:19 A.M. of the 200-hall shower revealed there were eight small flying insects on the walls and floors of two shower stalls. Interview on 05/05/25 at 10:25 A.M. with Dietary Manager #5 and Dietary Assistant (DA) #6 revealed gnats would fly out of the meal cart when the dietary staff opened the meal cart door which stored the meal plates and trays from the prior night's dinner. DA #6 stated five gnats flew out from the meal cart that morning. Observation on 05/05/25 at 10:30 A.M. revealed Resident #2 was sitting on the edge of the bed, watching television and there were several tiny flying insects swarming around the room. There were several tiny flying insects swarming around her bathroom plus a sticky trap with approximately 30 tiny flying insects stuck to it that was hanging from her bathroom mirror. Interview, during the observation, with Resident #2 revealed she had a gnat problem since she was admitted . Interview on 05/05/25 at 11:35 A.M. with Director of Maintenance (DM) #7 revealed he was told about the gnat problem two weeks ago. DM #7 stated the housekeepers had used a homemade remedy of dish soap to set out in a cup and wipe down surfaces in the resident rooms and bathrooms. DM #7 was not sure if the pest control company had visited to eradicate the gnats. DM #7 believed the gnats were coming from the drainpipes. Observation on 05/05/25 from 11:50 A.M. to 12:05 P.M. with DM #7 revealed several swarms of tiny flying insects continued in Residents #23, #15 and #2's room and bathrooms and there were four tiny flying insects in Resident #4's bathroom. Interview, during the observation, with DM #7 verified the swarms of gnats in Residents #23, #15, #2 and #4's room. Interview on 05/05/25 at 12:10 P.M. with Human Resources Director/Business Office Manager #8 revealed the facility had gnats since April 2025 and the facility has tried everything to get rid of the gnats. The nurse aides made sure there was not food such as banana peels left in resident rooms. Interview on 05/05/25 at 12:15 P.M. with the Administrator verified the facility had been trying to eradicate the gnat problem and the Administrator had told DM #7 to buy and pour commercial gnat products in the drains a couple of weeks ago. Review of the maintenance request form dated 04/10/25 revealed Resident #2 had a fly infestation. Review of the pest control service inspection report dated 04/10/25 revealed no fly activity was noted at the time of service. This deficiency represents non-compliance investigated under Complaint Number OH00165118.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure call lights were within reach and accessible for Residents #14, #28 and #30. This affected three residents (Resident's #14, #28 and #30) of 32 residents reviewed for call light placement. The facility census was 32. Findings include: 1. Record review revealed Resident #14 was admitted to the facility on [DATE] and a readmission date of 07/15/22 with diagnoses including diabetes mellitus, atherosclerotic heart disease, and chronic kidney disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 was cognitively intact and required extensive assistance with activities of daily living. Review of the care plan dated 11/22/19 for Resident #14 revealed Resident #14 was a risk for falls. Interventions included but were not limited to encourage call light to be pinned to gown while in bed. Observation of Resident #14 on 10/24/22 at 11:50 A.M. revealed Resident #14 was lying in bed and call light was not within reach. Interview with Licensed Practical Nurse (LPN) #32 on 10/24/22 at 11:50 A.M. verified the call light was out of reach. 2. Record review revealed Resident #28 was readmitted to the facility on [DATE] with diagnoses including Alzheimer's, major depressive disorder, spinal stenosis, and chronic obstructive pulmonary disease. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #28 had moderately impaired cognition and required extensive assistance with activities of daily living. Review of the care plan dated 01/04/21 for Resident #28 revealed Resident #28 was a risk for falls. Interventions included but were not limited to be sure the resident's call light is within reach. Observation of Resident #28 on 10/24/22 at 10:44 A.M. revealed Resident #28 was sitting up in bed; the call light was located on the floor behind bed and not within reach. Interview with LPN #32 on 10/24/22 at 10:44 A.M. verified the call light was out of reach and that Resident #28 would be able to use the call light if it was within reach. 3. Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including polyosteoarthritis, hypertension, history of falling, anxiety, and major depressive disorder. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #28 had moderately impaired cognition and required supervision with activities of daily living except for bed mobility, walking in room and dressing which required limited assistance with one staff. Review of the care plan dated 10/06/22 for Resident #30 revealed Resident #30 was a risk for falls. Interventions included but were not limited to call light within reach. Observation of Resident #30 on 10/24/22 at 9:34 A.M. revealed Resident #30 was sitting up in bed, and the call light was located on floor and not within reach. Interview on 10/24/22 at 9:34 A.M. with the Director of Nursing verified the call light was out of reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to provide written notice of transfer to the hospital for Resident #17. This affected one (Resident #17) of one resident reviewed for hospitalization. The facility census was 32. Findings include: Review of the medical record for Resident #17 revealed an admission date of 02/17/20 with diagnoses including chronic kidney disease, dementia, type two diabetes mellitus, anxiety, bipolar disorder, and schizoaffective disorder. Resident #17 was transferred to the hospital on [DATE]. Review of the 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 had moderate cognitive impairment. Resident #17 required extensive assistance of one or two staff for activities of daily living. Review of the progress note dated 09/10/22 at 11:46 P.M. revealed Resident #17 was transferred to the hospital for increased confusion. Facility staff notified the physician and Resident #17's sister of the transfer via phone calls. There was no evidence that the resident's representative was notified of the transfer in writing. On 10/27/22 at 2:40 P.M., interview with the Director of Nursing (DON) verified resident families and representatives were notified via phone calls of transfers to the hospital and not in writing. The DON stated she did not know why it was necessary to notify them in writing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, resident interview, staff interview, and facility policy review the facility failed to ensure Resident #4 had oxygen on as ordered and failed to ensue oxygen equipment was stored properly when not in use for Resident's #4 and #15. This affected two residents (Resident's #4 and #15) of three reviewed for respiratory care. The facility census was 32. Findings include: 1. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, dementia, acute respiratory failure, atherosclerotic heart disease, and opioid dependence. Review of the five-day Medicare Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had intact cognition and did not have oxygen. Resident #4 required extensive assistance for all activities of daily living. Review of the October 2022 physician's orders revealed Resident #4 had an order for oxygen (O2) continuously at two liters via nasal cannula (NC) for hypoxemia dated 09/28/22. Observation on 10/26/22 at 1:50 P.M. revealed Resident #4 did not have her O2 on, and the NC was draped across the top pf the O2 concentrator through the handle. The NC was not in a protective bag to prevent contamination. Interview on 10/26/22 at 1:50 P.M. Resident #4 indicated the staff only put her O2 on her if her O2 level drops below 90 percent (%). Interview on 10/26/22 at 2:10 P.M. Agency Nurse #17 indicated she was not sure of the facility policy on the storage of O2 NCs when not in use. She verified Resident #4 did not have her O2 NC in a protective bag and it was laying on top of the oxygen concentrator. Observations on 10/27/22 at 9:00 A.M., 9:30 A.M., 10:00 A.M. and 1:15 P.M. revealed Resident #4 did not have her O2 on and the NC was still laying on top of the O2 concentrator not in a protective bag. Interview on 10/27/22 at 11:37 A.M. Licensed Practical Nurse (LPN) #38 indicated oxygen tubing was changed weekly and should be placed in a protective bag when not in use. Observation on 10/27/22 at 1:20 P.M. LPN #33 preformed an oxygen saturation (SpO2) test on Resident #4 and the results were 88% on her left middle finger and 84% on her right middle finger with her oxygen off. She placed her oxygen on and had not changed immediately but did come up to 89%. She verified at this time her O2 was continuous and should have been on. She stated prior to getting the order for oxygen her SpO2 levels would stay in the 80's but after they got the order they read in the 90's. She stated the NC should be stored in a protective bag when not in use. Observation on 10/27/22 at 2:50 P.M. with LPN #33 revealed the SpO2 for Resident #4 was 98% with her O2 on at two liters. Review of the undated facility policy titled, Oxygen revealed the purpose was to deliver oxygen to the resident when insufficient oxygen was being carried by the blood to the tissues. 2. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included diabetes, acute respiratory failure, hypertension, major depressive disorder, COVID-19, obstructive sleep apnea, chronic pain, and narcolepsy. Review of the five-day Medicare MDS 3.0 assessment dated [DATE] revealed Resident #15 had intact cognition and did not have oxygen. She required extensive assistance for all activities of daily living. Review of the October 2022 physician's orders revealed Resident #15 had an order to titrate O2 to maintain SpO2 of 92% or greater with O2 at two liters as needed for shortness of breath. Observation on 10/26/22 at 1:58 P.M. revealed Resident #15 did not have his O2 on and the NC was draped across the top of the O2 concentrator through the handle. The NC was not in a protective bag to prevent contamination. Interview on 10/26/22 at 2:10 P.M. Agency Nurse #17 indicated she was not sure of the facility policy on the storage of O2 NCs when not in use. She verified Resident #15 did not have his O2 NC in a protective bag and it was laying on top of the oxygen concentrator. Interview on 10/27/22 at 11:37 A.M. LPN #38 indicated oxygen tubing was changed weekly and should be placed in a protective bag when not in use. Review of the undated facility policy titled, Oxygen revealed the purpose was to deliver oxygen to the resident when insufficient oxygen was being carried by the blood to the tissues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure the pharmacy recommendations approved by the physician were updated in the medical record. This affected one (Resident #28) of five (Resident's #10, #17, #19, #27 and #28) reviewed for unnecessary medications. The facility census was 32. Findings include: Record review revealed Resident #28 was readmitted to the facility on [DATE] with diagnoses including Alzheimer's, major depressive disorder, spinal stenosis, and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 had moderately impaired cognition and required extensive assistance of activities of daily living. Review of the monthly pharmacy recommendations to the attending physician dated 10/19/22, revealed the pharmacist made a recommendation to evaluate Buspirone 5 milligram (mg) for a gradual dose reduction (GDR) from three times day to twice a day. The physician addressed the pharmacist recommendations to decrease Buspirone to twice a day on 10/25/22. Review of the physician's orders dated October 2022 revealed Resident #28 was on Buspirone 5 milligram three times a day. Interview on 10/27/22 at 11:14 A.M. with Licensed Practical Nurse (LPN) #2 revealed that when the pharmacist recommends a GDR, we would call the doctor or nurse practitioner (NP) and they agree or disagree. LPN #2 verified that there were no orders in the hard or electronic chart for Resident #28's Buspirone to be reduced to twice a day. Interview on 10/27/22 at 11:36 A.M. with LPN #38 revealed she called the NP and stated that Resident #28 should not have a GDR. LPN #38 verified that no documented evidence was noted in the hard or electronic chart about the conversation or a rationale for declining the pharmacist's recommendation for the GDR. LPN #38 found an unsigned verbal order about the GDR without rationale on her desk but never entered it into Resident #28's medical record. Review of the undated facility policy titled, Psychotropic Medication Use revealed residents who use psychotropic medications will receive gradual dose reductions and behavioral interventions in an effort to discontinue these medications, unless clinically contraindicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and facility policy review the facility failed to ensure Resident #4 was offered the pneumonia vaccine. This affected one resident (Resident #4) of five reviewed for vaccines. The facility census was 32. Findings include: Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, dementia, acute respiratory failure, atherosclerotic heart disease, and opioid dependence. Review of the five-day Medicare Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had intact cognition and required extensive assistance for all activities of daily living. Further review of the medical record revealed no documented evidence Resident #4 had been administered the pneumonia vaccine and she did not have a consent filled out refusing the pneumonia vaccine or indicating the vaccine was medically contraindicated. Interview on 10/27/22 at 12:10 P.M. Licensed Practical Nurse (LPN) #38 verified the facility had no documented evidence Resident #4 had been offered or given the pneumonia vaccine. Review of the facility policy titled, 'Pneumococcal Immunizations, dated 09/17, revealed each resident would be offered the pneumococcal immunization unless the immunization was medically contraindicated, or the resident had been already immunized. For those residents who had not been immunized or the immunization was medically contraindicated, provide a consent form on admission to each resident or legal representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and review of activities records the facility failed to ensure activities were held to meet residents' needs and preferences. This affected six (Resident's #2, #5, #14, #17, #21 and #28) of 18 residents reviewed for activities. The facility census was 32. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 01/07/20 with diagnoses including congestive heart failure, chronic kidney disease, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had no cognitive impairment. Review of the activity care plan dated 01/15/20 revealed Resident #2 was interested in bingo, computers, puzzles, sports, music, and pet visits. Interventions included invite and encouraged resident to attend activities, provide an activities calendar, notify of any changes to the calendar, and give verbal reminders of activities. Review of the activities attendance reports for October 2022 revealed there was no documented evidence of activities held on the weekends. On 10/25/22 at 1:00 P.M., during the Resident Council Meeting, Residents #6, #21, #22, and #134 stated there were no activity staff in the facility on the weekends. On 10/25/22 at 2:32 P.M., interview with Activities Assistant Director #8 verified there were no activity staff on the weekends. She stated activity staff worked Monday through Friday from 8:00 A.M. to 4:30 P.M. She also verified that attendance at weekend activities was not documented, and she could not provide documented evidence indicating weekend activities were completed as scheduled. On 10/25/22 at 3:10 P.M., interview with the Administrator confirmed the facility activity staff only worked Monday through Friday, and he was unable to say who led activities on the weekends. On 10/27/22 at 10:38 A.M., interview with Licensed Practical Nurse (LPN) #32 stated residents complained to her about being bored on the weekends. On 10/27/22 at 10:53 A.M., interview with Resident #2 stated there were no activities on the weekends and she had to keep herself busy to prevent boredom. 2. Review of the medical record for Resident #5 revealed an admission date of 03/08/21 with diagnoses including anxiety, Parkinson's disease, and major depressive disorder. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #5 had no cognitive impairment. Review of the activity care plan dated 04/19/21 revealed Resident #5 was interested in bingo, church, television, movies, music, reading, and puzzles. Interventions included invite and encouraged resident to attend activities, provide an activities calendar, notify of any changes to the calendar, and give verbal reminders of activities. Review of the activities attendance reports for October 2022 revealed there was no documented evidence of activities held on the weekends. On 10/25/22 at 1:00 P.M., during the Resident Council Meeting, Residents #6, #21, #22, and #134 stated there were no activity staff in the facility on the weekends. On 10/25/22 at 2:32 P.M., interview with Activities Assistant Director #8 verified there were no activity staff on the weekends. She stated activity staff worked Monday through Friday from 8:00 A.M. to 4:30 P.M. She also verified that attendance at weekend activities was not documented, and she could not provide documented evidence indicating weekend activities were completed as scheduled. On 10/25/22 at 3:10 P.M., interview with the Administrator confirmed the facility activity staff only worked Monday through Friday, and he was unable to say who led activities on the weekends. On 10/27/22 at 10:38 A.M., interview with LPN #32 stated residents complained to her about being bored on the weekends. On 10/27/22 at 11:00 A.M., interview with Resident #5 stated there were not enough activities at the facility and no activities on the weekends. 3. Review of the medical record for Resident #14 revealed an admission date of 05/27/21 with diagnoses including communicating hydrocephalus, major depressive disorder, and chronic kidney disease. Review of the annual MDS 3.0 assessment dated [DATE] revealed Resident #14 had no cognitive impairment. Review of the activity care plan dated 12/02/19 revealed Resident #14 was interested in bingo, church, computers, pet visits, sports, television, movies, and music. Interventions included invite and encouraged resident to attend activities, provide an activities calendar, notify of any changes to the calendar, and give verbal reminders of activities. Review of the activity's attendance report for Resident #14 for October 2022 indicated Resident #14 refused to participate in most activities. On 10/24/22 at 11:39 A.M., interview with Resident #14 stated the facility does not provide activities that meet his preferences. He said he preferred to stay in his room and the facility did not bring him anything to do. On 10/27/22 at 11:32 A.M., interview with Activity Director #20 stated Resident #14 would join activities when he wanted. She also stated Resident #14 refused a lot of activities but made no mention of what was being offered as a replacement when he refused. 4. Review of the medical record for Resident #17 revealed an admission date of 02/17/20 with diagnoses including dementia, major depressive disorder, bipolar disorder, and schizoaffective disorder. Review of the 5-day MDS 3.0 assessment dated [DATE] revealed Resident #17 had moderate cognitive impairment. Review of the activities attendance reports for October 2022 revealed there was no documentation of activities held on the weekends. On 10/25/22 at 1:00 P.M., during the Resident Council Meeting, Residents #6, #21, #22, and #134 stated there were no activity staff in the facility on the weekends. On 10/25/22 at 2:32 P.M., interview with Activities Assistant Director #8 verified there were no activity staff on the weekends. She stated activity staff worked Monday through Friday from 8:00 A.M. to 4:30 P.M. She also verified that attendance at weekend activities was not documented, and she could not provide documented evidence indicating weekend activities were completed as scheduled. On 10/25/22 at 3:10 P.M., interview with the Administrator confirmed the facility activity staff only worked Monday through Friday, and he was unable to say who led activities on the weekends. On 10/27/22 at 10:38 A.M., interview with LPN #32 stated residents complained to her about being bored on the weekends. On 10/27/22 at 10:58 A.M., interview with Resident #17 stated he got bored on the weekends because there were no activities. 5. Review of the medical record for Resident #21 revealed an admission date of 01/28/09 with diagnoses including anxiety, heart failure, and hypothyroidism. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #21 had no cognitive impairment. Review of the activity care plan dated 09/13/17 revealed Resident #21 was interested in crafts, angels, and gardening. Interventions included provide a program of activities of interest and provide craft supplies for independent activities as desired. Review of the activities attendance reports for October 2022 revealed there was no documentation of activities held on the weekends. On 10/25/22 at 1:00 P.M., during the Resident Council Meeting, Residents #6, #21, #22, and #134 stated there were no activity staff in the facility on the weekends. On 10/25/22 at 2:32 P.M., interview with Activities Assistant Director #8 verified there were no activity staff on the weekends. She stated activity staff worked Monday through Friday from 8:00 A.M. to 4:30 P.M. She also verified that attendance at weekend activities was not documented, and she could not provide documented evidence indicating weekend activities were completed as scheduled. On 10/25/22 at 3:10 P.M., interview with the Administrator confirmed the facility activity staff only worked Monday through Friday, and he was unable to say who led activities on the weekends. On 10/27/22 at 10:38 A.M., interview with LPN #32 stated residents complained to her about being bored on the weekends. On 10/27/22 at 10:51 A.M., interview with Resident #21 stated she was bored on the weekends because the facility did not have any activities. She stated the facility used to offer activities on Saturdays, but not anymore because the staff member that led those activities quit. 6. Review of the medical record for Resident #28 revealed an admission date of 03/17/22 with diagnoses including anxiety, dementia, and major depressive disorder. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #28 had mild cognitive impairment. Review of the activity care plan dated 01/24/19 revealed Resident #28 was interested in arts and crafts, bingo, pet visits, puzzles, reading, television, and movies. Interventions included invite and encouraged resident to attend activities, provide an activities calendar, notify of any changes to the calendar, and give verbal reminders of activities. Review of the activities attendance reports for October 2022 revealed there was no documentation of activities held on the weekends. On 10/25/22 at 1:00 P.M., during the Resident Council Meeting, Residents #6, #21, #22, and #134 stated there were no activity staff in the facility on the weekends. On 10/25/22 at 2:32 P.M., interview with Activities Assistant Director #8 verified there were no activity staff on the weekends. She stated activity staff worked Monday through Friday from 8:00 A.M. to 4:30 P.M. She also verified that attendance at weekend activities was not documented, and she could not provide documented evidence indicating weekend activities were completed as scheduled. On 10/25/22 at 3:10 P.M., interview with the Administrator confirmed the facility activity staff only worked Monday through Friday, and he was unable to say who led activities on the weekends. On 10/27/22 at 10:38 A.M., interview with LPN #32 stated residents complained to her about being bored on the weekends. On 10/27/22 at 10:57 A.M., interview with Resident #28 stated it was boring on the weekends with no activities.

Based on observations, interview, and facility policy review, the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect all 32 residents in the facility. Findings include: Observation during the initial tour of the kitchen on 10/24/22 from 8:00 A.M. through 8:20 A.M. with the Director of Nursing (DON) revealed the following items were not stored properly in the reach-in freezer: Salisbury steak and premade French toast were not labeled or dated. In the reach-in refrigerator, a pastry brush in butter that was in a measurer and sliced cheese was not labeled or dated. In a storage bin, there was a bag of pasta and a bag of sugar not properly sealed, labeled, or dated. The microwave had dried food splatter in it, and the door of the microwave was damaged. These findings were verified by the DON at the time of the observation. Review of the undated facility policy titled, Food Safety revealed the facility must store, prepare, distribute, and serve food in accordance with professional standards for food safety.

Based on observation, review of Centers for Disease Control (CDC) guidance, review of Occupational Safety and Health (NIOSH) Personal Protective Technology (PPT), and staff interview the facility failed to provide the appropriate personal protective equipment for the laundry staff when transporting COVID-19 contaminated linens. This had the potential to affect all residents residing in the facility. The facility census was 32. Findings include: Observation of the laundry room on 10/27/22 at 3:30 P.M. with Housekeeper #4 revealed there were no gowns in the laundry room for the staff to wear when placing contaminated laundry into washing machine. Interview on 10/27/22 at 3:32 P.M. with Housekeeping #4 indicated they do not have gowns in the laundry room to wear while placing the soiled and wet laundry into the washing machine. Housekeeping #4 stated they just place the contaminated and isolation laundry directly in to the washing machine without a gown on. She stated they do wear gloves. The facility identified six residents (Resident's #3, #7, #23, #25, #38 and #134) positive for COVID-19 on 10/25/22. Review of the CDC's guidance for personal protective equipment (PPE) revealed the NIOSH PPT Program's mission was to prevent work-related injury, illness, and death by advancing the state of knowledge and application of PPT. PPT in this context was defined as the technical methods (e.g., fit testing methods), processes, techniques, tools, and materials that support the development and use of PPE worn by individuals to reduce the effects of their exposure to a hazards. Isolation gowns were used as specified by Standard and Transmission-Based Precautions, to protect the Healthcare worker's arms and exposed body areas and prevent contamination of clothing with blood, body fluids, and other potentially infectious material. Wear a gown, that was appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and patient-care activities when contact with blood, body fluids, secretions, or excretions was anticipated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review the facility failed to maintain accurate care plans for turning and positioning assistance devices This affected one of 16 residents (Resident #20) reviewed for accuracy of care plans. The facility census was 36. Finding Included: Review of the medical record for Resident #20 revealed an admission date 08/18/19; diagnoses included dementia, muscle weakness and history of falling. Review of the restraint/ side rails assessment dated [DATE] revealed the resident used side rails for bed mobility. Review of the plan of care dated 08/20/19 revealed no care plan for bilateral side rails on bed. Observation on 10/16/19 at 9:00 A.M. of Resident #20's room revealed bilateral side rails on the bed Interview on 10/18/19 at 1:15 P.M. with the Director of Nursing (DON) revealed when it was determined that a resident needed side rails, the plan of care was to be updated. The DON verified that Resident #20's plan of care did not include a plan of care for bilateral side rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review the facility failed to provide and maintain infection prevention during incontinence care. This affected one of one residents (Resident #9) reviewed for incontinence care. The facility census was 36. Finding Included: Review of the medical record of Resident #9 revealed an admission date of 10/29/18 with diagnoses including dementia, cyst of kidney and benign prostatic hyperplasia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/19/19, revealed the resident had impaired cognition. The resident required extensive assistance of two staff for toileting. The resident was identified to be incontinent of bowel and bladder. Review of the plan of care dated 10/29/18 revealed the resident was incontinent of bladder due to benign prostatic hyperplasia. Interventions included check for incontinence, wash, rinse and dry perineum. Change clothing as needed after incontinence episodes. Review of the bowel and bladder assessment dated [DATE] revealed the resident was incontinent of bowel and bladder. Observation on 10/18/19 at 10:00 A.M. of incontinence care for Resident #9 with State Tested Nurse Assistant (STNA) #300 and STNA #301 revealed STNA #301 was assisting with Resident #9's incontinence care and rolled Resident #9 toward himself so the dirty pad and wash cloth could be removed from under Resident #9. STNA #300 gathered the dirty pad and wash cloth up and dropped the dirty items on the floor beside the bed. Interview on 10/18/19 at 10:20 A.M. with STNA #300 verified that when she removed Resident #9's dirty pad during incontinence care she rolled it up and dropped it on the floor beside the bed. STNA #300 stated no dirty items or linens are to be put on the floor, they are to be put into a bag and taken to the dirty linen room.