**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to maintain resident dignity when an indwelling urinary catheter drainage bag was not covered. This deficient practice affected one resident (Resident #48) of two reviewed for dignity. The facility census was 89. Findings Include: Review of the medical record for Resident #48 revealed an admission date of 03/12/18 with diagnoses including but not limited to unspecified injury at unspecified level of the cervical spinal cord, type two diabetes mellitus, paraplegia and neuromuscular dysfunction of the bladder. Review of the physician order dated 10/14/24 for Resident #48 revealed 16 French foley catheter with 10 cubic centimeter (cc) balloon to continuous drainage due to neuromuscular dysfunction of the bladder; Catheter care every shift; Change foley catheter as needed for signs and symptoms of infection, obstruction, system compromise dated 09/18/24. Review of the plan of care for Resident #48 dated 11/13/24 revealed an alteration in elimination colostomy, foley catheter, neurogenic bladder, constipation, duodenal ileus. Resident #48 refuses catheter securement device at times. Will be free of complications related to appliance use through target date. Interventions: Foley catheter care every shift and as needed (prn), empty foley catheter bag every shift and prn; Secure foley catheter tubing to prevent accidental dislodgement; Foley catheter bag in place. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 (out of a possible 15 points) indicating moderate cognitive impairment. Resident #48 was assessed to be dependent on staff for toileting, bathing, dressing, bed mobility, required a mechanical lift for transfers and had an indwelling urinary catheter. An observation on 01/13/25 at 9:33 A.M. of Resident #48 revealed the resident was lying in bed and the indwelling urinary catheter drainage bag was hanging on the right side of the bed frame. The catheter drainage bag was uncovered and urine that had collected in the catheter drainage bag was visible from the hallway. An observation on 01/14/25 at 7:41 A.M. revealed Resident #48 was lying in bed and the indwelling urinary catheter bag was hanging on the bed frame, exposing urine that had collected in the drainage bag and was visible from the hallway. Interview on 01/14/25 at 7:43 A.M. with certified nursing assist (CNA) #28 confirmed the indwelling urinary catheter bag was uncovered and was visible from the hallway.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility Management of Personal Funds form revealed the facility failed to have written authorization to manage Resident #54's funds. This affected one (Resident #54) of five residents reviewed for personal funds. The facility census was 89. Findings include: Review of the medical record revealed Resident #54 was admitted on [DATE] with diagnoses that included vascular dementia, peripheral vascular disease, type II diabetes, and major depressive disorder. Review of the Management of Personal Funds form dated 10/15/24 revealed the form was marked that Resident #54 did not wish to open a personal funds account and he would manage his own funds or have a person or entity other than the facility manage his money while at the facility. Resident #54 agreed to hold the facility harmless for any loss that occurred to their personal money. Lastly, the form was signed by Resident #54. The Medicare 5-day Minimum Data Set assessment dated [DATE] revealed Resident #54 had a brief interview mental status score of seven which indicated severe cognitive impairment. The fourth quarter Trust Statement, dated 11/06/24, revealed a deposit of $746.25 was made into Resident #54's account. Interview with Resident #54 on 01/13/25 at 10:25 A.M. revealed Resident #54 would like a haircut but did not know if he had money to pay for the haircut. Interview on 01/14/25 at 10:58 A.M. with Business Office Manager (BOM) #90 verified Resident #54 had money in an account for a haircut. An additional interview on 01/24/25 at 1:52 P.M. with BOM #90 verified a personal funds account had been opened for Resident #54 but a Management of Personal Funds form had not been signed. Review of the facility Management of Personal Funds form revealed every resident was encouraged to exercise the right of managing his/her financial affairs. However, upon written authorization of a resident, responsible party, or legal guardian, the facility will hold, safeguard, manage and account for the personal funds of the resident deposited with us.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record record review, observation, staff interview, and policy review, the facility failed to ensure fall interventions were implemented. This affected two (Resident #10 and Resident #34) of four residents reviewed for accidents. The facility census was 89. Findings include: 1. Review of Resident #34's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included dementia, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and pre-diabetes. Review of the plan of care dated 08/14/23 revealed Resident #34 is at risk for falls. Interventions included: Alarming floor mat beside the bed, taped down with brightly colored tape and a Motion Sensor to the floor while the resident is in the room to alert staff to attempts of unassisted ambulation and transfers. Check function and placement every shift. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was not intact. She used a walker for ambulation, and required supervision or touching assistance with eating, oral hygiene and personal hygiene, substantial/maximal assistance for toileting, and shower/bathing. Review of the Physician's Order revealed orders on 11/20/24 Motion Sensor Alarm to floor while resident is in room, to alert staff to attempts of unassisted transfers/ambulation. Check function and placement every shift and on 11/20/24 Alarming floor mat on floor beside bed. Check function and placement every shift. Review of the fall assessment dated [DATE] revealed she was at risk for falls. Observations on 01/13/25 at 2:45 P.M. revealed the motion sensor alarm was observed lying on the dresser. This was verified during interview with Licensed Practical Nurse (LPN) #121 at 2:47 P.M. On 01/14/25 at 1:15 P.M. and 3:35 P.M. observation revealed Resident #34 was seated in the recliner in her room, watching television. The mat to the floor was under the bed and no bright colored tape was observed. On 01/15/25 at 8:32 A.M. observation revealed Resident #34 was sitting up in the recliner with the sensor alarm lying on the bed and in the off position. The mat remained under the bed with no bright colored tape observed. At 8:35 A.M. interview with LPN #72 verified the sensor alarm was off and on the bed and the floor mat was not taped to the floor with brightly colored tape. 2. Review of the medical record revealed Resident #10 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, heart disease, pulmonary embolism, absence of right leg above the knee, tachycardia, depression, and Raynaud's syndrome. A plan of care dated 01/03/23 revealed Resident #10 was at risk for falls. Interventions included the bed to be in the lowest position, the bed locked, and call light within reach. The quarterly MDS dated [DATE] revealed Resident #10 was cognitively intact. Observation on 01/13/25 at 9:22 A.M., revealed Resident #10 was lying in bed with eyes closed. Resident #10's bed was not in the lowest position. Observation on 01/15/24 at 8:49 A.M. revealed Resident #10 was lying in bed with eyes closed. Resident #10's bed was not in the lowest position Interview on 01/15/24 at 8:57 A.M. Certified Nursing Assistant (CNA) #109 verified Resident #10's bed was not in the lowest position. Review of the Fall Management policy and procedure dated 10/17/16 revealed Each resident will be assessed throughout the course of treatment for different parameters such as; cognition, safety awareness, fall history, mobility, medications, or predisposing health conditions that may contribute to fall risk. An interdisciplinary team will attempt to balance safety needs, resident rights and quality of life issues that will positively impact each resident's situation and reduce the risk of occurrence. Residents who experience a fall will receive prompt medical attention. Immediate needs will be quickly assessed and responded to. A plan will be identified and implemented as necessary to protect the resident and/or others from recurrence.

Based on record review and interview, the facility failed to maintain an accurate medical record for Resident #47. This affected one resident (#47) of 16 reviewed. The facility census was 89. Findings include: Review of the medical record for Resident #47 revealed an admission date of 02/25/21. Diagnoses included paralytic syndrome following cerebral infarction bilateral, type two diabetes mellitus, respiratory disorders, obstructive sleep apnea, vascular dementia with behavioral disturbance, cognitive social or emotional deficit following cerebral infarction, dysphagia following cerebral infarction, chronic kidney disease stage three, major depressive disorder, chronic pain syndrome, gout, hypertension, hyperlipidemia, allergic rhinitis, heart disease, fibromyalgia, gastroesophageal reflux disease, polyneuropathy, cluster headache syndrome, insomnia, anxiety disorder, and epididymitis. The comprehensive list of diagnoses in the electronic medical record for Resident #47 did not include psychosis or any other severe mental health diagnoses. Review of the psychiatry notes dated 03/07/24 and 11/07/24 indicated Resident #47 was receiving psychiatric services for cognitive impairment secondary to vascular dementia, insomnia, and psychosis secondary to general medical condition. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/28/24, revealed Resident #47 had no cognitive impairment. The assessment indicated Resident #47 had a diagnosis of non-Alzheimer's dementia and had a cerebrovascular accident/transient ischemic attack/stroke, he did not have diagnoses of schizophrenia, bipolar disorder, psychotic disorder other than schizophrenia, or post-traumatic stress disorder, and the resident had received an antipsychotic medication within the seven day lookback period. The assessment also indicated Resident #47 had delusions and did not have any hallucinations. Review of the physician's orders for January 2025 identified orders for Risperidone tablet 0.25 milligrams (mg) by mouth twice daily to be given with the 0.5 mg tablet to equal 0.75 mg for vascular dementia (ordered 11/06/24) and Risperdal tablet 0.5 mg by mouth twice daily to be given with the 0.25 mg tablet to equal 0.75 mg for vascular dementia (ordered 11/06/24). On 01/14/25 at 11:33 A.M., an interview with the Director of Nursing (DON) verified Resident #47 had an order for Risperidone/Risperdal to treat vascular dementia. A follow-up interview at 2:30 P.M. verified Resident #47 did not have a diagnosis of psychosis in the comprehensive list of diagnoses. On 01/15/25 at 1:06 P.M., an interview with Psychiatric (Psych) Physician #133 confirmed Resident #47 had a diagnosis of psychosis secondary to a general medical condition. He further stated Resident #47 was receiving Risperidone to treat delusions and psychosis not related to dementia behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of self-reported incident (SRI), review of facility investigation, review of witness statements, medical record review, resident interview, staff interview, and review of the policy, the facility failed to timely report an allegation of abuse to the Ohio Department of Health and report the allegation to the local Police Department. This affected one (#93) of three residents reviewed for abuse. The facility census was 98. Findings include: Review of the SRI dated 03/14/24 at 1:12 P.M., for the category of sexual abuse, revealed on 03/14/24 at 1:30 A.M., a female resident, (Resident #93) reported that a male resident (Resident #70) who has dementia was in her bed. Staff witnessed Resident (#70) walking in the hallway fully clothed at the time of the allegation. Resident (#93) was noted to be lying in bed fully clothed and denied skin to skin contact. Upon further questioning, the female resident (#93) stated she thought he (Resident #70) was wanting to have sex with her. Immediately the Director of Nursing (DON) and Administrator were notified and began an investigation. Resident (#70) denied going into the room and was not able to give much information related to dementia status. The summary of incident included Resident #93 reported Resident #70 was in her bed lying on top of her and Resident #93 was able to remove Resident #70 herself easily with a verbal request. Resident #70 exited her room, when Resident #93 entered the hallway. Resident #93 found staff and reported what happened. Review of the SRI revealed the police were not notified. Review of the Witness Statement dated 03/14/24, no time, completed by State Tested Nurse Assistant (STNA) #300 revealed when she went to pass water on 03/13/24 (per DON, 03/13/24 was in error) Resident #70 was walking into his room. Resident #93 came running out of her room arms shaking and upset that a man was on top of her, he was too heavy to push off. STNA #300 asked Resident #93 who it was? Resident #93 said she did not remember his name, but he was tall, big, and black. STNA #300 took her to her room and got her to calm down enough, until STNA #300 could get the nurse. Review of the statement dated 03/14/24, no time, completed by DON, revealed an interview with Resident #93 was conducted this day 03/14/24 regarding incident at approximately 2:00 A.M. Resident #93 stated she awoke with a man lying on top of her making thrusting motions on top. Resident #93 denies any skin-to-skin contact, they were fully dressed, and no penetration occurred. Resident #93 states she was easily able to ask him to get off and he walked out of her room. She got herself up to get staff when she met STNA #300 in hallway. Resident #93 was not able to verbalize where Resident #70 was. I did not get raped. I don't feel threatened, I just don't want him around me. Spoke about how she loves the facility and feels safe. Claims Resident #70 has never sexually approached her before. Review of Resident #93's medical record revealed an admission date of 08/04/23. Diagnoses included chronic obstructive pulmonary disease, lack of coordination, need assist with personal care, muscle weakness, difficulty in walking, sciatica, dementia, polyneuropathy, mild cognitive impairment, personal history of urinary tract infections, personal history of traumatic brain injury, anxiety disorder, and insomnia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #93 had a Brief Interview of Mental Status score of 11, (moderately cognitively impaired). Resident #93 never socially isolated herself. Resident #93 had a history of hallucinations and delusions. Resident #93 had no impairment of upper extremities and impairment to one side of the lower extremity. Resident #93 used no mobility device. Resident #93 required supervision or touching assist with dressing, personal hygiene, bed mobility, transfers, and ambulation. Resident #93 was always continent of bowel and bladder. Review of the health status note dated 03/14/24 at 2:15 A.M., completed by LPN #240 for Resident #93 revealed Resident #93 indicated a male resident had strong hold to her right wrist, no visible mark was found. Review of the health status note dated 03/14/24 at 2:16 A.M., completed by LPN #240 for Resident #93 revealed Resident #93 remained awake alert, orientated times three (person, place, and time). Resident #93 was watching TV from bed, a small light remained on for her security. Review of the health status note dated 03/14/24 at 2:54 A.M., completed by LPN #243 for Resident #93 revealed the note was a late entry and included at approximately 2:00 A.M., a STNA alerted her that assistance was needed with Resident #93. LPN #243 included when she entered Resident #93's room, Resident #93 was crying. Resident #93 revealed That man across the hallway just entered my room and got in bed with me and got on top of me. I told him to get out of my room and he left. Resident #93 was moved to B Wing for the evening. Interview on 03/25/24 at 9:04 A.M., with Registered Nurse (RN) #257 revealed she worked on the secured unit for years and worked frequently with Resident #93 and #70. RN #257 revealed Resident #70's room was catty cornered from Resident #93's room. RN #257 revealed Resident #93 had a history of dementia, but she really increased in her capacity and stabilized. Resident #93 generally slept in a nightgown on top of her blanket. RN #257 revealed Resident #93 told her about the occurrence the following day and that she woke up with a black man with one tooth on top of her. RN #257 revealed there was only one black man in the unit, Resident #70 and revealed Resident #93 was very upset and said to her, he was on top of her hard boned humping. Interview on 03/25/24 at 9:45 A.M., with Resident #93 revealed she was recently moved to the current room she was in. Resident #93 revealed she missed her friends in the other area. Resident #93 stated, I was molested by a resident over there, I woke up about 1:30 to 2:00 in the morning, he was on top of me, he had his pajama bottoms on humping me, I was scared to death, I kicked him, that's how I got him off of me. Resident #93 revealed after she got him off her, she ran screaming, and the nurse aid came, and she told her what happened. Resident #93 revealed she was very upset; the staff were standing over her after that and she was embarrassed. Resident #93 revealed they moved her room, and she missed her friends. Resident #93 revealed she was afraid to close her eyes, she saw a psychiatrist, and he gave her something to relax. Resident #93 revealed, If I think about it, I get so upset and scared but if I don't think about it, I am fine. Resident #93 revealed she never went around him before that, she never spoke more than in passing good morning or hi. Record review for Resident #70 revealed an admission date of 01/18/12. Diagnoses included dementia, respiratory disorders, morbid obesity, Alzheimer's disease, heart failure, kidney failure, paranoid schizophrenia, and anxiety disorder. Review of the annual MDS assessment dated [DATE] revealed Resident #70 was moderately cognitively impaired. Residents had no mood concerns, no hallucinations, and delusions with no physical or aggressive behavior towards others. Resident #70 had no impairment of upper or lower extremities, required partial or moderate assistants for bed mobility, transfers, and was independent with ambulation. Review of the care plan dated 02/23/24 for Resident #70 revealed Resident #70 had altered the though process, sometimes had a hard time being understood, understanding, inattentive, rarely initiated conversation. Difficulty making self-understood, difficulty getting words out. Review of the Social Service (SS) assessment dated [DATE] at 12:21 P.M., for Resident #70 completed by SS #311 revealed Resident and/or Responsible Party Offered Care Conference. Proceed to care plan. Monitor resident for Social Service needs. Other psychosocial assessments are completed for this period. Resident #70 is able to make needs known, is understood and understand others. Resident #70 shows no signs or symptoms of distress during assessment follow up from incident. Review of Resident #70's progress notes revealed no further documentation regarding the incident noted on 03/14/24 at 2:00 A.M. Interview on 03/25/24 at 3:54 P.M., with DON confirmed after the incident reported on 03/14/23, an immediate investigation was initiated, staff were interviewed, residents were interviewed, and head to toe skin assessments were completed on residents who were not interview able. DON confirmed an SRI was initiated. DON revealed Resident #70 had no history of inappropriate sexual behavior towards any staff or residents. There was no proof or witnesses Resident #70 went into Resident #90's room. DON revealed they placed Resident #70 on every 15-minute check but that would be stopped today. DON confirmed a police report was never made regarding the incident due to no sexual act occurred. DON revealed she consulted with the corporate team and the decision was made that it was not a crime, there was no crime committed even if he was on top of her humping because there was no penetration, so it was not rape. DON reiterated and confirmed that even if the allegation occurred, if there was no sexual penetration then it was not a crime so there was no need to make a police report and because sexual abuse did not occur, there was no need to report to state within two hours. Review of the policy titled Abuse, Neglect, Exploitation of Resident Property, dated 11/21/2016, included it is the facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property, including injuries of unknown source. Additionally, the facility should immediately report all such allegations to the Administrator and to the Ohio Department of Health. In cases where a crime is suspected, staff should also report the same to local law enforcement. Ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately but no later than two hours after the allegation is made, if the event that caused the allegation involve abuse or result in serious bodily injury. The policy included the definition of Sexual Abuse: Nonconsensual sexual contact of any type with a resident. This deficiency represents non-compliance investigated under Complaint Number OH00152220.

Based on record reviews and interviews the facility failed to report an allegation of abuse reported on 11/07/23 involving Resident #42. This affected one (Resident #42) of four residents reviewed for abuse. The census was 99. Findings included: Review of the medical record for Resident #42 revealed an admission date of 10/20/23. Diagnoses included neurocognitive disorder with lewy bodies, unspecified dementia, type 2 diabetes mellitus and hypo-osmolality and hyponatremia. Review of the admission Minimum Data Set (MDS) assessment, dated 10/27/23, revealed Resident #42 had impaired cognition. The resident was independent with locomotion on unit and room. Review of behaviors and moods revealed Resident #42 exhibited physical and verbal behaviors and other behaviors toward others one to three times a week. He exhibited rejection of care and wandering on a daily basis. It stated his behaviors had no impact on others. Interviews on 11/15/23 at 9:40 A.M. during the entrance conference with Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed there were no current self-reported incidents (SRIs). Interview on 11/15/23 from 12:00 P.M. to 5:11 P.M. with Licensed Practical Nurse (LPN) #208, State Tested Nursing Assistant (STNA) #206, STNA #207 and STNA #209 revealed they had concerns with Resident #42's behaviors. They stated they heard he had put a pillow over another resident's mouth but did not witness it. Interview on 11/15/23 at 4:00 P.M. with the DON revealed she heard various reports of alleged incidents with Resident #42 but no one said they saw anything particularly about alleged incident on 11/07/23. She stated she started an investigation folder but felt like everything she heard staff saying was hearsay. The DON stated there was no documentation in the chart about alleged incidents though she said she asked staff to document if something occurred. She stated she spoke to LPN #200 who told the DON Resident #42 was climbing into bed with other resident but there was no physical aggression or harm. LPN #200 told her she redirected Resident #42 and he had not put a pillow over Resident #52's face. Phone interview on 11/15/23 at 4:31 P.M. with LPN #200 revealed she was told by STNA #203 on 11/07/23 that Resident #42 was forcefully holding a pillow over Resident #52's face. LPN #200 stated Resident #42 was coming out of the room and did not appear agitated. Resident #52 was not gasping for breath. She could not say if Resident #42 did or did not do it. LPN #200 did not get a statement from STNA #203. On a different note, LPN #200 stated Resident #42 was in an out of other resident's rooms on 11/10/23. She said Resident #40 complained of him pulling her arm then pulled her out of bed but LPN #200 did not believe she was pulled out of bed. She stated the arm was not reddened nor did they have to assist resident back up. She stated she hung a stop sign across the doorway which seemed to be effective in keeping Resident #42 out of her room. Phone interview on 11/15/23 at 5:03 P.M. with STNA #203 revealed she walked into Resident #52's room to see Resident #42 holding the pillow on her face and pushing it down. She stated she physically stopped him. He was a little agitated when she walked him out of the room. She stated Resident #52 looked scared during the ordeal. STNA #203 said she informed both LPN #200 and LPN #210 who said she would speak to the ADON and DON. She stated she was never asked or called to make a statement. Interview at 5:30 P.M. with Clinical Manager (CM) #204 and Regional LNHA (RLNHA) #205 stated the facility was not aware potential abuse happened because they only had the statement from the nurse stating she did not believe it was abuse. They stated they initiated an SRI for the incident on 11/07/23 after being informed during the complaint survey. They verified STNA #203 should have been interviewed as her name was in the statement by LPN #200. Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 11/21/16, revealed all incidents and allegations of Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation Resident Property and all Injuries of Unknown Source must be reported immediately to the Administrator or designee. The facility must have evidence that all alleged violations were thoroughly investigated. This deficiency represents non-compliance investigated under Complaint Number OH00148317.

Based on record reviews and interviews the facility failed to thoroughly investigate an allegation of abuse reported on 11/07/23 involving Resident #42. This affected one (Resident #42) of four residents reviewed for abuse. The census was 99. Findings included: Review of the medical record for Resident #42 revealed an admission date of 10/20/23. Diagnoses included neurocognitive disorder with lewy bodies, unspecified dementia, type 2 diabetes mellitus and hypo-osmolality and hyponatremia. Review of the admission Minimum Data Set (MDS) assessment, dated 10/27/23, revealed Resident #42 had impaired cognition. The resident was independent with locomotion on unit and room. Review of behaviors and moods revealed Resident #42 exhibited physical and verbal behaviors and other behaviors toward others one to three times a week. He exhibited rejection of care and wandering on a daily basis. It stated his behaviors had no impact on others. Interviews on 11/15/23 at 9:40 A.M. during the entrance conference with Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed there were no current self-reported incidents (SRIs). Interview on 11/15/23 from 12:00 P.M. to 5:11 P.M. with Licensed Practical Nurse (LPN) #208, State Tested Nursing Assistant (STNA) #206, STNA #207 and STNA #209 revealed they had concerns with Resident #42's behaviors. They stated they heard he had put a pillow over another resident's mouth but did not witness it. STNA #206 and STNA #207 stated they were not aware Resident #42 was on every 15-minute checks however LPN #208 and STNA #209 were aware and had documented it. Staff stated no one stopped them from charting any behaviors or reporting abuse. LPN #208 stated there was not anything documented in the chart about alleged incident of Resident #42 putting a pillow over Resident #52's face or of him pulling Resident #40 out of bed. She stated the night nurse (LPN #200) should have documented what she knew. Interviews with Housekeeper (HSKPR) #210, HSKPR #211 revealed they had no specific information. HSKPR #210 stated she worked that unit but stayed away from him. They stated none of the other housekeepers voiced concerns. Interview on 11/15/23 at 4:00 P.M. with the DON revealed she heard various reports of alleged incidents with Resident #42 but no one said they saw anything particularly about alleged incident on 11/07/23. She stated she started an investigation folder but felt like everything she heard staff saying was hearsay. The DON stated there was no documentation in the chart about alleged incidents though she said she asked staff to document if something occurred. She stated she spoke to LPN #200 who told the DON Resident #42 was climbing into bed with other resident but there was no physical aggression or harm. LPN #200 told her she redirected Resident #42 and he had not put a pillow over Resident #52's face. Surveyor asked DON to present investigation folder. The DON was gone for at least 30 minutes and returned with a folder with two statements about the alleged incident on 11/07/23. The statements, dated 11/07/23, were authored by the DON and ADON after interviewing LPN #200 together. Both stated LPN #200 did not believe Resident #42 was holding pillow over face of other resident (Resident #52) but rather was moving pillows around. The one statement added that an STNA (STNA #203) may have been a witness. Continued interview with DON revealed she said she left two voicemails for STNA #203 to obtain a statement but did not receive a return phone call. When asked if STNA #203 was disciplined for not following protocol, she said no. She verified she did not pursue further investigation based on LPN #200's interview. The DON stated she was completing an SRI for the incident that happened on this date (11/15/23) between Resident #42 and Resident #41. Phone interview on 11/15/23 at 4:31 P.M. with LPN #200 revealed she was told by STNA #203 on 11/07/23 that Resident #42 was forcefully holding a pillow over Resident #52's face. LPN #200 stated Resident #42 was coming out of the room and did not appear agitated. Resident #52 was not gasping for breath. She could not say if Resident #42 did or did not do it. LPN #200 did not get a statement from STNA #203. On a different note, LPN #200 stated Resident #42 was in an out of other resident's rooms on 11/10/23. She said Resident #40 complained of him pulling her arm then pulled her out of bed but LPN #200 did not believe she was pulled out of bed. She stated the arm was not reddened nor did they have to assist resident back up. She stated she hung a stop sign across the doorway which seemed to be effective in keeping Resident #42 out of her room. Phone interview on 11/15/23 at 5:03 P.M. with STNA #203 revealed she walked into Resident #52's room to see Resident #42 holding the pillow on her face and pushing it down. She stated she physically stopped him. He was a little agitated when she walked him out of the room. She stated Resident #52 looked scared during the ordeal. STNA #203 said she informed both LPN #200 and LPN #210 who said she would speak to the ADON and DON. She stated she was never asked or called to make a statement. A subsequent interview on 11/15/23 at 5:15 P.M. with DON revealed the DON continued to state she left a voicemail but did not pursue investigation because she had the nurse's statement saying the nurse did not believe the situation happened. Interview at 5:30 P.M. with Clinical Manager (CM) #204 and Regional LNHA (RLNHA) #205 stated the facility was not aware potential abuse happened because they only had the statement from the nurse stating she did not believe it was abuse. They stated they initiated an SRI for the incident on 11/07/23 after being informed during the complaint survey. They verified STNA #203 should have been interviewed as her name was in the statement by LPN #200. Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 11/21/16, revealed all incidents and allegations of Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation Resident Property and all Injuries of Unknown Source must be reported immediately to the Administrator or designee. The facility must have evidence that all alleged violations were thoroughly investigated This deficiency represents non-compliance investigated under Complaint Number OH00148317.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of medication administration times form, review of pharmacy contract, review of pharmacy delivery invoices, review of the swing kit (emergency box) replacement forms, review of the swing kit contents, review of medication and treatment errors and omissions reports, review of 12/25/22 census sheet, review of the Quality Improvement Plan, review of MapQuest, review of policies, observation, and interviews the pharmacy failed to ensure the facility maintained an adequate plan and supply of scheduled oral prescription medications during holidays and inclement weather to prevent the interruption of routine medication administration. This affected all 96-resident residing in the building on 12/25/22 and four (Resident #18, #20, #59, and #69) of four resident records reviewed. Findings included: 1. Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including pruritus, depression, hypothyroidism, hypertension, and neuropathy. Review of Resident #18's orders and medication administration records (MAR) dated 12/2022 revealed Resident #18 did not receive Hydroxyzine 25 milligrams (mg) at 9:00 A.M. for pruritus, Fluoxetine 40 mg upon rise for depression, Levothyroxine 88 micrograms (mcg) early for hypothyroidism, Lisinopril 40 mg upon rise for hypertension, and Neurontin 300 mg at 9:00 A.M. for neuropathy per physician orders on 12/25/22. 2. Record review revealed Resident #20 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including rheumatoid arthritis (RA), atherosclerotic heart disease, hypothyroidism, hypertension, and gastric reflux disease. Review of Resident #20's orders and MAR dated 12/2022 revealed Resident #20 did not receive Prednisone 12.5 mg upon rise for RA, Clopidogrel 75 mg upon rise for atherosclerotic heart disease, Hydroxychloroquine Sulfate 200 mg upon rise for RA, Levothyroxine 125 mcg early for hypothyroidism, Metoprolol 50 mg upon rise for hypertension, and Pantoprazole 40 mg for gastric reflux disease per physician orders on 12/25/22. 3. Record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including hypothyroidism and hypertension. Review of Resident #59's orders and MAR dated 12/2022 revealed Resident #59 did not receive Levothyroxine 25 mcg early for hypothyroidism and Metoprolol 12.5 mg upon rise per physician order on 12/25/22. 4. Record review revealed Resident #69 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including infection, diabetes, hyperlipidemia, hypothyroidism, hypertension, heartburn, hypokalemia, and heart transplant. Review of Resident #69's orders and MAR dated 12/2022 revealed Resident #69 did not receive Fluconazole 200 mg upon rise for infection, Prednisone (steroid) 2.5 mg upon rise, Acyclovir 400 mg upon rise prophylactic, Dapagliflozin 10 mg upon rise for diabetes, Fenofibrate 120 mg upon rise for hyperlipidemia, Levothyroxine 150 mcg early for hypothyroidism, Metoprolol 25 mg upon rise for hyperlipidemia, Omeprazole 40 mg early for heartburn, Potassium 40 milliequivalent upon rise for hypokalemia, Sirolimus 0.5 mg early for heart transplant, and Sitagliptin 25 mg upon rise for diabetes. Review of medication administration time form undated revealed early administration time was 5:00 A.M. to 7:00 A.M. and upon rise was 7:00 A.M. to 11:00 A.M. Review of census sheet dated 12/25/22 revealed there was 96 residents residing in the building on 12/25/22. Review of the Pharmacy delivery invoice dated 12/23/22 to 12/25/22 revealed the pharmacy made a delivery on 12/23/22 at 5:44 AM and next delivery date was not until 12/25/22 at 12:16 P.M. There was no evidence the pharmacy delivered medication on 12/24/22. Review of the pharmacy contract dated 09/29/2017 revealed pharmacy would provide delivery services to the facility at least once daily Monday through Saturday, and as other wised agreed to by the parties, except for circumstances and conditions beyond Pharmacy's control. Pharmacy shall make arrangements with another Pharmacy supplier to provide such products and services to facilities, in the event the at Pharmacy cannot furnish a product or service on a prompt and timely basis, Pharmacy shall immediately notify the facility. Review of the Quality Improvement Plan dated 12/26/22 revealed the problem was due to inclement weather medication were not delivered. The goal was to limit the numbers of delays related to inclement weather. The action plan and evaluation included to contact physician for guidance when lack of availability of medication, utilize contingency medication on hand, monitor residents, and stay in contact with pharmacy to determine delivery schedules. There was no plan to use alternative pharmacy locally or who the pharmacy contracted with per the contract, or plan ahead when inclement weather was anticipated. Review of swing (emergency) replacement forms dated 12/25/22 revealed two Lasix 20 mg was removed for Resident #91 at 6:24 A.M., two Lasix 20 mg for Resident #25 (time not legible) leaving four Lasix 20 mg remaining and one Norvasc 5 mg for Resident #10 leaving one additional Norvasc 5 mg remaining. Review of swing kit contents undated revealed the following medication would have been available in the swing kit to be administered to the above four residents (Resident #18, #20, #59, and #69), however they were never pulled. The medications included Hydroxyzine 25 mg, Lisinopril, Metoprolol, Ondansetron, Potassium, Prednisone, Acyclovir, and Fluconazole. Review of physician blanket order dated 12/26/22 revealed due to inclement weather, okay to give medication when available from pharmacy on 12/25/22. There was no resident name specified on the order. Review of medication and treatment errors and omissions dated 11/2022 to 02/05/23 revealed no evidence of medication omissions/errors that occurred on 12/25/22. Review of MapQuest revealed the distance from the facility to the contracted pharmacy was 73 miles and 93 minutes. Review of the medication administration policy (dated 06/21/17) revealed medications would be administered by legally-authorized and trained persons in accordance to applicable state, local, and federal laws, and consistent with accepted of practice. All medication dispensed in Paxil bags are intended for oral administration. Evening sift or the night shift staff are responsible for off-loading the next day's medication pass bundles/bags into the resident organizer in the cart. If the administration bag doesn't contain a needed medication the following should occur. If the medication is not available obtain the necessary medication form an alternate preferred medication source per pharmacy. If a STAT delivery see policy for ordering and procuring a STAT med or ordering a procuring extra dose of medication of medication was taken from another package. Review of the medication ordering and receipt policy (dated 06/21/17) revealed there may be a STAT delivery fee assessed for non-urgent mediation and medication not re-ordered timely. The pharmacist would determine if the medication will be dispensed from the pharmacy directly or sent form a local back-up pharmacy. STAT delivered are made within four hours of being requested after a complete order was received. Observation on 02/05/23 at 12:02 P.M., of A hall medication cart with the DON revealed the cart had individualized time packets in the drawer for today (02/05/23) and in the bottom drawer was unpackaged individualized medication packets for 02/06/23. There was no evidence of medication for more then 02/05/23 and 02/06/23 in packets. The DON confirmed pharmacy delivers 24 hours' worth of medication for the following day seven days a week. Over the counter medication, controlled substances, inhalers, and insulin's were available more than two days. The DON reported the pharmacy did not show up in the early morning of 12/24/22 due to inclement weather, nor did they come later in the day to deliver medication for 12/25/22. The residents did not have medications for the early and upon rise medication pass. There was no negative effects due to the medication omission, however she doesn't have records of what medications were not administered. She had received a verbal order on 12/25/22 and signed by the physician on 12/26/22 stating due to inclement weather it was okay to give medication when available from pharmacy. The pharmacy did finally deliver medication for 12/25/22 around noon or 1:00 PM that day. Interviews on 02/05/23 from 9:18 A.M. to 1:46 P.M., with Licensed Practical Nurses (LPN) #176, #180, LPN #180, LPN #226, Registered Nurse (RN) #142, State Tested Nurse's Aide (STNA) #108 and #204 verified resident's did not receive most of their early and upon rise medication on 12/25/22 due to the medication packets did not arrive on 12/24/22 from the pharmacy. The pharmacy delivers 24 hours' worth of medication the prior day around 3:00 A.M. The staff reported they were not aware of any contracts with local pharmacy they could utilize if they could not obtain medication from their contracted pharmacy. One nurse reported she had pulled one or two medication out of the swing box, but the other nurses reported they were told not to administer the early and upon rise medication per the physician. The physician told the nurses there was too many resident records to review and just to omit medication until they arrived from pharmacy. The facility had all day on the 24th to attempt to make other arrangement to obtain medication for the residents, since the pharmacy courier usually comes between 3:00 A.M. to 5:00 A.M., to bring medication for the following day, however no arrangement was made. There was no plan for emergencies and the swing box was one of the worst swing boxes they have seen. The licensed nurses reported getting medication from the pharmacy had been a struggle for some time. Interview on 02/05/23 at 10:51 A.M., with the Administrator revealed the facility had been using the same pharmacy since 2017, however the individual packets were newer and only sending one day of medication at a time was newer. Residents were monitored on 12/25/22 when medication were not available and was only charged on by exceptions. The residents that were alert and oriented were notified of the medication concern, however the Administrator doesn't believe resident representatives were notified. The facility did not have a contract with a local pharmacy to utilize in an emergency situation. Interview on 02/05/23 at 11:15 A.M., with the local Walmart Pharmacy revealed the pharmacy was open on 12/24/22, however was closed on 12/25/22. Interview on 02/05/23 at 11:42 A.M., with the Administrator revealed the facility didn't complete medication omission/errors forms on 12/25/22 to determine what medication were omitted for each resident. The Administrator confirmed the 96 resident residing in the building on 12/25/22 would have been affected by the pharmacy not delivering medication the morning of 12/24/22 resulting in omission of some medication administration to the residents. Interview on 02/05/23 at 1:21 P.M., with the Administrator and Director of Nursing (DON) confirmed they did not know who the emergency pharmacy supplier was if the contracted pharmacy was not available per the contract. The Administrator reported Walmart was close, however she did not think the Walmart pharmacy was open on 12/25/22. Interview on 02/05/23 at 2:21 P.M., with the DON verified the above four residents (Residents #18, #20, #59, and #69) did not receive the medication documented above. This deficiency represents non-compliance investigated under Complaint Number OH00139604 and OH00138920.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and resident and staff interviews, the facility failed to ensure Resident #37 had access to her call light at all times. This affected one resident (Resident #37) of 19 residents reviewed for accommodation of needs. Finding include: Review of Resident #37's medical record identified admission to the facility occurred on 08/11/14 with medical diagnosis including obstructive hydrocephalus, convulsions, COPD, malignant neoplasm of breast, neoplasm of bone, schizoaffective disorder, dysphasia, panic disorder and low back pain. The [AGE] year old was identified to be wheelchair dependent. Review of the 10/10/22 Quarterly Minimum Data Set (MDS) Assessment identified Resident #37 was dependent on staff for all Activates of daily living. Review of the plan of care for Resident #37 identified Clip to call light to bed and encourage resident to use for help. Interview with Resident #37 occurred on 12/04/22 at 10:02 A.M. in her room. Resident #37 was observed at that time without her call light. Resident #37's tilt-in-space wheelchair was positioned near the bathroom door. The call light was located under Resident #37 and not in reach. Resident #37 identified she could not access the call system from where she is located. Observation on 12/04/22 at 1:19 P.M. revealed the call light remained in the same position and was not accessible to Resident #37. Observation of Resident #37 occurred on 12/07/22 at 7:39 A.M. Resident #37 was positioned in her wheelchair near the bathroom without access to her call light. Interview with Licensed Practical Nurse (LPN #102) occurred on 12/07/22 at 7:39 A.M. LPN #102 confirmed Resident #37 was positioned near the bathroom door and not near her bed. The interview confirmed Resident #37 does not have access to her call light in this position.

Based on medical record review, facility policy review, and staff interview, the facility failed to report an alleged incident of misappropriated narcotics to the State Survey Agency within five working days of the incident. This affects one resident (Resident #37) of six residents reviewed for controlled narcotic medication. Findings include: Review of the medical record for Resident #37 revealed an admission date of 08/11/14. Resident #37's diagnoses included malignant neoplasm of breast, neoplasm of bone and low back pain. Review of Resident #37's physician orders revealed orders for oxycodone 5 milligrams (mg) give 1 tablet by mouth every four hours as needed for pain to low back and may have two tablets every four hours for pain. Review of the missing medications investigation dated 06/22/22 revealed on 06/22/22 during the narcotic reconciliation count with Licensed Practical Nurse (LPN) #102 and LPN #218 there was a discrepancy with Resident #37's oxycodone tablet 5 milligrams (mg) cards in the narcotic drawer. Resident #37 had three cards of oxycodone 5 mg in the narcotic drawer. Card #1 identified with Rx# 26937782 revealed there were 53 pills in the bubble pack. The Controlled Drug Receipt/Record/Disposition Form revealed Card #1 should have had #54 pills. Card #2 identified with Rx# 27335479 revealed there were 59 pills in bubble pack card. The controlled drug receipt/record/disposition form revealed there should have been 60 pills in Card #2. Card #3 identified with Rx# 27684929 revealed there were 58 pills in the bubble pack card. The Controlled Drug Receipt/Record/Disposition Form revealed the card should have had 60 pills in total Resident #37 had five missing oxycodone 5 mg in total. Interview on 12/04/22 at 1:46 P.M. with LPN #102 stated on 06/22/22 she was coming on shift at 7:00 A.M. and was doing narcotic count with LPN #218. LPN #102 stated when she pulled Resident #37 oxycodone card out, she noticed there was a missing pill at the bottom of the card. During the whole narcotic count, it was identified Resident #37 had three cards of oxycodone 5 mg with four pills missing and not accounted for. LPN #102 notified the supervisor. Interview on 12/05/22 at 4:12 P.M. with the Director of Nursing (DON) and Administrator revealed LPN #102 identified a discrepancy in the narcotic count with LPN #218. There were four missing oxycodone not accounted for. The Administrator verified there was a breakdown in documenting medications. The Administrator and DON verified they were not able to physically account for the four missing pills but felt the missing medications were actually a documentation and system breakdown. The Administrator verified she did not feel any misappropriation or diversion had occurred, so she did not report to appropriate authority of the incident. Review of the facility policy Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 11/21/16 revealed all investigations should be reported to the administrator, other officialism accordance with state law, including to the State Survey Agency, within five working days of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and resident and staff interviews, the facility failed to ensure Resident #37 and Resident #148 received assistance with activities of daily living (ADL). This affected two residents (Resident #37 and Resident #148) of three residents reviewed for ADL. Findings include: 1. Review of Resident #37's medical record identified admission to the facility occurred on 08/11/14 with medical diagnosis including obstructive hydrocephalus, convulsions, malignant neoplasm of Breast and bone, schizoaffective disorder, dysphasia, panic disorder, and low back pain. Review of Resident #37's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed #37 was dependant on staff for ADL, including hygiene and bathing. Interview and observation with Resident #37 on 12/04/22 at 10:02 A.M. revealed she had multiple long hairs across her chin. Resident #37 was asked if the hair on her chin bothered her. Resident #37 confirmed the long hairs on her chin did bother her and she would like it removed. Resident #37 had long fingernails which she confirmed did not bother her. Observation with State Tested Nursing Assistant (STNA #213) occurred on 12/04/22 at 1:19 P.M. The observation confirmed Resident #37 had long chin hairs covering the bottom of her chin. The interview confirmed Resident #37 was dependant on staff for ADL's. 2. Review of Resident #148's medical record identified admission to the facility occurred on 11/16/22 with medical diagnosis which included Alzheimer's disease, need assistance with personal care, high blood pressure, hearing loss, dementia and anxiety. Review of the MDS dated [DATE] revealed Resident #148 was dependent on staff for activities of daily living and was severely cognitively impaired. The assessment identified Resident #148 was totally dependent on staff for bathing/grooming. Review of Resident #148's written plan of care identified Resident #148 required total assistance with grooming including fingernails, shaving and hair. Observations of Resident #148 occurred on 12/04/22 at 9:40 A.M. The observation identified Resident #148 had a significant amount of facial hair and quite long fingernails with brown dirty substance under them. Resident #148 revealed they should be clipped. Observation of Resident #148 occurred with the facility Administrator on 12/05/22 at 1:30 P.M. The Administrator confirmed Resident #148's chin hair and fingernails needed attention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure new pressure ulcer treatment orders were transcribed and completed per physician orders. This affected one resident (Resident #91) of one resident reviewed for pressure ulcers. Findings Include: Review of the medical record for Resident #91 revealed an admission dated 10/04/22. Resident #91's diagnoses included non-pressure ulcer left foot, atrial fibrillation, and pressure ulcer. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #91 had intact cognition. The resident required extensive assistance of two staff for bed mobility, transfers, ambulation. Review of the physician orders for November 2022 revealed orders to cleanse bilateral buttocks with normal saline, pat dry, apply calcium alginate to excoriated area and cover with foam dressing, change everyday on dayshift and as needed. Review of the wound care nurse practitioner note dated 11/18/22 revealed new order for a buttock pressure wound, to apply medihoney ointment first, pack wound with alginate cover with foam dressing. The order continued to change dressing daily and as needed. Review of the wound assessment dated [DATE], revealed the coccyx (earlier identified as buttock) wound was a stage four pressure ulcer and the area was now a butterfly shaped with characteristic of Kennedy terminal ulcer, which was unavoidable. Review of the November and December 2022 Treatment Administration Reports (TAR) revealed no orders for medihoney, alginate and cover with foam dressing to coccyx. There was an order for calcium alginate and foam dressing to coccyx. Interview on 12/06/22 at 12:12 P.M. with Licensed Practical Nurse (LPN) #116 stated she was the wound nurse for the facility. LPN #116 verified a new order for Resident #91's coccyx was not put into the computer and there was no documentation of order being completed daily. LPN #116 verified the wound order was not transcribed and not completed. Interview on 12/06/22 at 12:30 P.M. with the Director of Nursing (DON) verified the new orders received on 11/18/22 had not been put into the computer and had not been completed per treatment orders.

Based on medical record review, facility policy and staff interview the facility failed to maintain an accurate reconciliation of narcotic medication for Resident #37. This affected one resident (Resident #37) of six residents reviewed for controlled narcotic medication. Findings include: Review of the medical record for Resident #37 revealed an admission date of 08/11/14. Resident #37's diagnoses included malignant neoplasm of breast, neoplasm of bone and low back pain. Review of Resident #37's physician orders revealed orders for oxycodone 5 milligrams (mg) give 1 tablet by mouth every four hours as needed for pain to low back and may have two tablets every four hours for pain. Review of the missing medications investigation dated 06/22/22 revealed on 06/22/22 during the narcotic reconciliation count with Licensed Practical Nurse (LPN) #102 and LPN #218 there was a discrepancy with Resident #37's oxycodone tablet 5 milligrams (mg) cards in the narcotic drawer. Resident #37 had three cards of oxycodone 5 mg in the narcotic drawer. Card #1 identified with Rx# 26937782 revealed there were 53 pills in the bubble pack. The Controlled Drug Receipt/Record/Disposition Form revealed Card #1 should have had #54 pills. Card #2 identified with Rx# 27335479 revealed there were 59 pills in bubble pack card. The controlled drug receipt/record/disposition form revealed there should have been 60 pills in Card #2. Card #3 identified with Rx# 27684929 revealed there were 58 pills in the bubble pack card. The Controlled Drug Receipt/Record/Disposition Form revealed the card should have had 60 pills in total Resident #37 had five missing oxycodone 5 mg in total. Review of the interview with LPN #102 during investigation dated 06/22/22 revealed on 06/19/22 she worked and had done a thorough narcotic count and all pills were accounted for. On 06/22/22 during the narcotic count, it was identified there were four missing pills. Review of the interview with LPN #116 during the investigation revealed she worked on 06/20/22 and counted narcotics with LPN #218 and at the end of my shift with LPN #147, she pulled the narcotic cards forward to count and the count was correct both times. Review of the interview with LPN #218 during the investigation revealed when doing the narcotic count when she counts narcotic cards, they just flip through the cards to see the last full spot, they do not pull out the card out of the drawer. On 06/22/22 LPN #102 pulled out the cards and noticed a spot with a pill missing and she notified the supervisor. Interview on 12/04/22 at 1:46 P.M. with LPN #102 stated on 06/22/22 she was coming on shift at 7:00 A.M. and was doing narcotic count with LPN #218. LPN #102 stated she pulled the narcotic cards out of the drawer due to the cards being very tight together. When she pulled Resident #37 oxycodone card out, she noticed there was a missing pill at the bottom of the card. During the whole narcotic count, it was identified Resident #37 had three cards of oxycodone 5 mg with four pills missing and not accounted for. LPN #102 stated the supervisor was notified and a full investigation was completed. Interview on 12/05/22 at 4:12 P.M. with the Director of Nursing (DON) and Administrator revealed LPN #102 identified a discrepancy in the narcotic count with LPN #218. A full investigation was started. There were four missing oxycodone not accounted for. The Administrator verified there was a breakdown in documenting medications. The Administrator and DON verified they were not able to physically account for the four missing pills. Review of the facility policy Administration of Scheduled 2 Controlled Medications, dated 06/21/17 revealed any discrepancies in the individual resident's Controlled Drug Receipt/Record/Disposition Form must be immediately reported to the DON and or per facility policy. This deficiency represents non-compliance investigated under Complaint Number OH00133877.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident #57 was assessed quarterly for the use of alarming devices. This affected one (Resident #57) of six residents reviewed for restraints. Findings include: Resident #57 was admitted on [DATE] with diagnoses including hydrocephalus, epilepsy, anxiety disorder, unspecified dementia with behavioral disturbance, lack of coordination, and a history of traumatic brain injury. Resident #57's physician orders dated 12/29/16 revealed he was ordered a personal alarm while in bed to alert staff of transfers and on 04/11/18 he was ordered a motion sensor alarm to alert staff of unassisted transfers. Resident #57's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had short and long term memory problems. The Restraint section of the MDS indicated a bed alarm and motion sensor alarm were used daily. Review of Resident #57's medical record revealed no evidence the resident was assessed quarterly for the use of a motion alarm or personal alarm. Observation on 10/22/19 at 3:55 P.M. revealed Resident #57 was lying in a low positioned bed, with a personal alarm clipped to his shirt and a motion sensor alarm on a floor mat next to his bed. Interview on 10/23/19 at 9:49 A.M. with the Assistant Director of Nursing (ADON) revealed the facility assessed residents for alarm use quarterly. Interview on 10/23/19 at 10:06 A.M. with the ADON revealed residents were assessed to determine need for a reduction or discontinuation of alarms. The ADON confirmed there was no evidence Resident #57 had been assessed quarterly for the use of the personal or motion sensor alarms. Review of the facility policy, titled Restraint Use, dated 06/20/15, revealed the facility creates and maintains an environment that fosters minimal use of restraints. The interdisciplinary team regularly evaluates restraint reduction for each resident and a restraint assessment shall be used for initial and ongoing assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #57 was admitted on [DATE] with diagnoses including hydrocephalus, epilepsy, anxiety disorder, unspecified dementia with behavioral disturbance, lack of coordination, and a history of traumatic brain injury. Resident #57's quarterly MDS assessment dated [DATE] revealed no falls were identified in his fall history since his last MDS dated [DATE]. Review of Resident #57's medical record from 05/22/19 through 08/22/19 revealed the resident had one fall on 07/30/19 that resulted in a small laceration and hematoma to his forehead. On 10/23/19 at 7:34 A.M. LPN #202 confirmed Resident #57's MDS dated [DATE] was inaccurately coded, and should have been coded one fall with an injury that was not major. Based on medical record review and staff interview the facility failed to ensure comprehensive assessments were accurate regarding prognosis for Resident #56 and falls for Resident #57. This affected two (Residents #56 and #57) of 26 reviewed for plans of care. The facility census was 108. Finding include: 1. Resident #56 was admitted to the facility on [DATE] with diagnoses including dementia, acute embolism and thrombosis, diabetes, hypokalemia, hypertension, dysphagia, right bundle block, hyperlipidemia, absence of kidney, Alzheimer's disease, syncope and collapse, cataract, insomnia, anxiety disorder, major depressive disorder, macular degeneration, acute myocardial infarction, and intervertebral disc degeneration. Review of the October 2019 Physicians orders revealed Resident #56 had an order dated 12/07/18 to be discharged from hospice services due to a prognosis of greater than six months. Review of the quarterly Minimum Data Set (MDS) 3.0 dated 03/16/19 revealed Resident #56 had a life expectancy of less than six months. Review of the quarterly MDS 3.0 dated 05/16/19 revealed Resident #56 had a life expectancy of less than six months. Review of the quarterly MDS 3.0 dated 08/16/19 revealed Resident #56 had a life expectancy of less than six months. On 10/24/19 at 9:01 A.M. Licensed Practical Nurse (LPN) #213 verified section J of the MDS assessments dated 03/16/19, 05/18/19 and 08/18/19 were coded incorrectly to indicate the resident had a prognosis of less than six months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure two residents (Residents #56 and #79) had care plans in place to address the use of positioning devices. This affected two of 25 residents reviewed for care plans. The facility census was 108. Findings include: 1. Resident #79 was admitted to the facility on [DATE] with diagnoses including vascular dementia, major depressive disorder, and inflammatory disease of the prostate. Review of Resident #79's care plans dated 01/02/19 did not reveal any care plan which addressed the use of a pommel cushion (a cushion used to prevent sliding or forward movement) only a care plan which stated Resident #79 slid down in his wheelchair with interventions for therapy to evaluate and treat. Review of Resident #79's Restraint-Enabler Decision Tree dated 09/12/19 revealed the pommel cushion did not restrict any movement, assisted in the improvement of Resident #79's functional status, and provided optimal positioning and safety while in the wheelchair. Observations of Resident #79 on 10/21/19 at 3:31 P.M., on 10/22/19 at 11:09 A.M., on 10/23/19 at 8:30 A.M. and 11:00 A.M., and on 10/24/19 at 8:00 A.M. revealed Resident #79 had a pommel cushion in place. Registered Nurse (RN) #104 verified on 10/21/19 at 3:31 P.M. Resident #79 had a pommel cushion to his wheel chair. On 10/24/19 at 8:27 A.M. RN #104 verified Resident #79's care plans did not address the use of a pommel cushion. 2. Resident #56 was admitted to the facility on [DATE] with diagnoses of dementia, acute embolism and thrombosis, diabetes, hypokalemia, hypertension, dysphagia, right bundle block, hyperlipidemia, absence of kidney, Alzheimer's disease, syncope and collapse, cataract, insomnia, anxiety disorder, major depression disorder, macular degeneration, acute myocardial infarction, and intervertebral disc degeneration. Review of the plan of care dated 05/23/14 revealed no plan of care that addressed the use of a pommel cushion for Resident #56. Observation on 10/21/19 at 8:50 A.M., on 10/22/19 at 9:01 A.M., and on 10/23/19 at 10:07 A.M. revealed Resident #56 was seated in a tilt and space wheelchair with a permanently affixed pommel cushion. On 10/24/19 at 9:01 A.M. Licensed Practical Nurse #213 verified The lack of a care plan to address the use of a pommel cushion for Resident #56.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure CPAP (continuous positive airway pressure) equipment for Resident #81 was cleaned regularly to reduce the risk for infection. This affected one (Resident #81) of one resident reviewed for the use of a CPAP machine. The facility census was 108. Findings include: Resident #81 was admitted on [DATE] with diagnoses including obstructive sleep apnea. Review of physician's orders dated 09/18/19 revealed she was to utilize a CPAP machine at 14 centimeters of water and to be set at two liters of oxygen during sleep. Interview on 10/21/19 at 2:37 P.M. with Resident #81 revealed she had asked the aides and nurses to clean her CPAP equipment regularly but she had never seen them clean it nor did they tell her they cleaned it. She cleaned it monthly with vinegar according to the manufacturer guidelines when she was at home. Resident #81 stated she could tell the mask had not even been wiped. Observation on 10/22/19 at 2:19 P.M. of Resident #81's CPAP machine and equipment revealed the hose was on the floor and the mask surface had smudges and small bits of debris on it. This was verified at the time of observation by Licensed Practical Nurse (LPN) #173. Interview on 10/22/19 at 2:21 P.M. with LPN #173 revealed CPAP equipment should be cleaned by staff and signed off on the (Treatment Administration Record TAR) after every use. LPN #173 verified staff were not cleaning the resident's CPAP equipment. Review of the policy dated 01/26/06 and revised on 09/14/18 regarding Respiratory Equipment Cleaning and Disinfecting revealed the facility must maintain respiratory equipment in a manner that would prevent the spread of disease and infections. For CPAP machines the external surfaces should be cleaned as needed, the mask cleaned weekly or as needed, the circuit and the filter should be changed per manufacturer's guidelines and the non-disposable filter changed monthly or as needed.