**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to ensure physician notification occurred with a change in resident condition . This affected one (Resident#1) of three reviewed for change in condition. Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included paraplegia, morbid obesity, obstructive hydrocephalus, presence of cerebrospinal fluid drainage device, major depressive disorder, and abnormal posture. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition. The resident required physical assistance with activities of daily living. Review of the nursing progress note dated 12/25/24 at 11:30 A.M. revealed the resident received Zofran 4 mg (ordered 11/04/24) by mouth for nausea and vomiting. The administration was listed as effective. Review of the nursing progress note dated 12/26/24 at 8:55 A.M. revealed Resident #1 had frequent episodes of emesis for the last three days and was unable to keep medications, fluids, and food down. The physician was notified. Review of the nursing progress note dated 12/26/24 at 3:34 P.M. revealed a physician order was given for promethazine 12.5 mg intramuscularly (IM) injection to be given every six hours as needed for nausea and vomiting. Review of the Medication Administration Record, dated December 2024, revealed Resident #1 was administered promethazine 12.5 mg IM on 12/26/24 at 3:56 P.M. and 10:38 P.M. The medication administration was noted to be effective. Review of the nursing progress note dated 12/27/24 at 1:48 A.M. (authored by LPN #200) revealed brown colored emesis, varying from thick to watery. Vital signs: blood pressure 94/52, pulse 120, respirations 20, and oxygen saturation 90% on room air. Physician notified. (There was no information documented in regards to how the physician was notified or what information was provided to the physician during the notification). Review of the nursing progress note dated 12/27/24 at 1:54 A.M. (authored by LPN #200) revealed acetaminophen 325 mg, two tablets, were given for pain. Review of the nursing progress note dated 12/27/24 at 5:15 A.M. (authored by LPN #200) revealed this nurse went into resident's room to re-assess after Tylenol was given at 1:45 A.M. The resident stated she was not feeling right. This nurse observed the resident to have short, rapid respirations, her skin was cold and moist, pale in color. This nurse attempted to obtain another full set of vital signs; blood pressure was unable to be read, oxygen saturation was 76% on room air, and temperature was 96.2. Oxygen was applied via nasal cannula and the physician was notified. An order was given to send the resident to the ER. EMS was notified of the emergency need of transport. Second nurse arrived to assist this nurse (LPN #200), and the Director of Nursing (DON) was notified of the resident's rapid change in condition. This nurse grabbed the crash cart and automated external defibrillator (AED) from the wall. At 4:49 A.M. CPR was initiated by this nurse and second nurse. EMS arrive at 4:51 A.M. and stated they were unaware of need for an emergency and had to go back out to the ambulance to retrieve equipment. CPR was continued by nursing staff. Resident #1 was intubated. After 20 minutes, an emergency medical technician (EMT) told the nursing staff to stop CPR and called an ER doctor to get the time of death. The physician, DON, and power-of-attorney were notified. Interview on at 01/21/25 at 1:51 P.M. with LPN #200 revealed on 12/27/24, Resident #1 had complained of not feeling well and had vomited brown emesis. LPN #200 stated she administered Tylenol at this time. LPN#200 stated she went back to re-assess Resident #1 and the resident complained that she didn't feel well. LPN #200 stated she was unable to obtain a blood pressure reading and the resident's oxygen saturation was low, so she notified the physician, who ordered the resident to be sent to the ER. LPN #200 stated the resident continued to decline and coded about one minute prior to the arrival of EMS. LPN #200 stated she and LPN #290 began CPR while awaiting the arrival of EMS. Interview on 01/25/25 at 4:32 P.M. with Physician #400 revealed he had not been notified on 12/27/24 around 2:00 A.M. concerning Resident #1. Physician #400 stated Resident #1's vomiting and abnormal vitals were concerning and indicated the resident was on the edge, and he would have hoped the nursing staff would have called him. Physician #400 stated there should have been action beyond administering Tylenol. Review of the facility policy titled, Notification of Changes, dated 08/29/24, revealed the purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies the resident's representative when there is a change requiring notification. Circumstances requiring notification include significant change in the resident's physical, mental, or psychological condition such as deterioration in health, mental, or psychological status. This may include life threatening conditions or clinical complications. This deficiency represents non-compliance investigated under Complaint Number OH00161084.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and policy review the facility to maintain privacy during Resident 7's wound care and failed provide a covering to prevent Resident #51's urine from being visible related to his catheter. This affected two residents (#7 and #51) of two residents reviewed for dignity. The facility census was 69. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 04/21/17. Diagnoses included spina bifida, paraplegia, and stage three pressure ulcers to the resident's right and left ischial tuberosity. Review of Resident #7's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and had two stage three pressure areas. Observation on 08/21/24 at 1:06 P.M. through 1:20 P.M. revealed Licensed Practical Nurse (LPN) #216 and State Tested Nursing Assistant (STNA) #502 entered Resident #7's room to complete wound care. LPN #216 left the resident's door open and pulled the treatment cart up to the resident's door. She opened the resident's curtain and began to complete wound care while STNA #502 assisted with positioning. The resident was positioned on her left side, exposing the resident's buttocks, abdomen, perineal area, and pressure wounds, during the treatment. The resident could be seen, from the hallway by other residents visitors and staff. Interview on 08/21/24 at 1:35 P.M. with LPN #216 verified she did not provide privacy by shutting Resident #7's door or closing her curtain during wound care. She also confirmed the resident could be visualized from the hallway while she was providing Resident #7's wound care. Review of the facility policy, Clean Dressing Change dated 12/28/23 revealed the first step for compliance was to explain the procedure to the resident and screen for privacy. 2. Review of Resident #51's medical record revealed an admission date of 08/10/21 with diagnoses including type II diabetes, generalized anxiety, cognitive communication disorder, need for assistance with personal care, muscle weakness, obstructive and reflux uropathy. Review of the quarterly MDS assessment dated [DATE] revealed the resident was moderately impaired for daily decision making, no upper or lower extremity impairment, used a walker and wheelchair for mobility, substantiation/maximal assistance for personal hygiene, toileting, rolling, and sitting to standing and was always incontinent of bowel and has an indwelling catheter. Observation on 08/19/24 at 10:28 A.M. revealed the resident was seated in his wheelchair, waiting to go out to smoke. A urinary catheter drainage bag was observed, uncovered, hanging under the resident's wheelchair, exposing yellow urine in the drainage bag and tubing. On 08/19/24 at 12:22 P.M. the resident was observed in the dining room, eating lunch, with the exposed catheter bag under his wheelchair. He had yellow urine in the bag. On 08/19/24 at 1:35 P.M. the resident was observed outside smoking with other residents. The urine drainage bag was hanging from underneath his wheelchair, and yellow urine was observed in the drainage bag. Interview on 08/19/24 at 4:51 P.M. with the Director of Nursing and Administrator verified the resident's catheter bag was not covered and was exposing his urine. Review of the facility's Catheter Care Procedure Urinary policy revised 12/28/23 included provide catheter care in accordance with current clinical standards. Privacy bags are used to cover catheter drainage bags while in use.

Based on observation, medical record review, policy review and staff interview the facility failed to ensure the use of a geri chair was appropriate and not considered a restraint. This affected one (Resident #58) of one residents reviewed for restraints. The facility census was 69. Findings include: Observation of Resident #58 throughout the annual survey from 08/19/24 to 08/22/24 revealed the resident seated in a reclined geri chair (comfortable and supportive wheeled seating solution beyond typical wheelchairs and recliners). Review of Resident #58's medical record revealed an admission date of 10/20/23 with diagnosis that included cerebrovascular accident with hemiplegia, prostate cancer and vascular dementia. Review of Resident #58's Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 07/24/24 indicated the resident had a severely impaired cognition level and indicated no restraint use in place for the resident. Review of the resident assessments found no evidence of any type of assessment for the use of the geri chair to determine if the resident was able to release the chair from the reclining position independently. Additional review of the medical record revealed physician's orders from 02/21/24 to 05/06/24 for the use of a broda chair (wheeled, reclined and padded wheelchair). A safety device assessment for the use of the broda chair was completed on 05/02/24 which indicated the device was utilized for end of life care and comfort care. Review of Resident #58's care plans revealed no evidence of any use of a geri chair. On 08/21/24 at 10:30 A.M. interview with the Director of Nursing verified there was no order or assessment prior to the use of the geri chair for Resident #58. Review of the facility policy titled Use of Assistive Devices with a revision date of 10/26/23 indicated use of assistance devices will be based on the resident's comprehensive assessment. The policy did not indicate a physician's order was required for use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide comprehensive, resident centered activities for dependent residents. This affected two (Resident's #35 and #42) of three residents reviewed for activities. The census was 69. Findings include: 1. Review of Resident #35's medical record revealed an admission date of 06/22/24 with diagnoses including palliative care, Parkinson's disease, vascular dementia, psychotic disturbance, mood disturbance and anxiety, depression, and weakness. Review of an Activities Evaluation dated 06/24/24 revealed he finds strength in faith/religion, gardening/outdoors, movies/television, music/talk radio, pet visits, religious activities, and beauty and barber. Prefers activities in his room in the afternoon and evenings and 1:1 activities. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately impaired for daily decision making, no behaviors, has little interest or pleasure in doing things, feeling down, depressed or hopeless, and sometimes social isolation. It was very important to him to have snacks available between meals, chose a bedtime, have family involved, listen to music, somewhat important to be around pets, do favorite activities, participate in religious services, and go outside when the weather was good. His family provided the answers to the assessment. He had no upper or lower extremity impairment, partial moderate assist for eating, oral hygiene, substantial/maximum assistance for toileting, dressing, personal hygiene, and from rolling from left to right, sit to lying Review of an Activity plan of care dated 07/03/24 and revised 07/08/24 revealed Resident #35 was at risk for altered activity patterns/pursuits related to decline in health status. The resident will express satisfaction with the type of activities and level of activity involvement when asked, 1:1 visits from staff and volunteers as resident will allow, allow resident to make choices/decisions about their preferred activity pursuits, encourage to participate in leisure interests throughout the day, provide, when possible, based on interest (internet access, preferred radio programs, audio books, library books, word puzzles, magazines, etc.) for in-room use, provide resident with activity calendar, enjoys religious activities, and respect wishes to decline invitations into structured activity programs. Review of the State Tested Nursing Assistant (STNA) task list in the electronic documentation system included one 1:1 activity for music on 07/22/24, and an activity refusal on 07/27/24 for planned activities. The music 1:1 was the only activity documented in the electronic record in the last 30 days. Observation 08/19/24 at 10:00 A.M. revealed the resident was on an alternating air mattress while he was in bed. Additional observations at 10:15 A.M., 12:56 P.M. and 4:30 P.M. revealed the resident remained in bed. Interview 08/19/24 at 1:59 P.M. with the resident's wife revealed her husband does not get out of bed. He doesn't watch television and isn't interested in a whole lot. Activities does not come in and interact with him. Observation 08/20/24 at 9:37 A.M., 12;03 P.M., 1:57 P.M., 2:09 P.M., and 5:57 P.M. the resident was in bed. His television was not on and a radio was not playing in the room. Interview on 08/21/24 at 9:54 A.M. with Resident #35 revealed no one has brought a pet in for him to see and he doesn't think anyone has read scripture to him. The resident stated it hurts to move. Observation 08/21/24 at 9:54 A.M. and 12:36 P.M. and 08/22/24 at 9:06 A.M. the resident was more awake and did not get out of bed. His television was not on. There was not a radio playing in the room. There were no observations of activities interacting with the resident. Review of the activity 1:1 binder revealed there was not a 1:1 sheet for Resident #35. Review of the monthly calendar for August 2024 revealed the resident had on the television/movie in room, radio, reminisce, conversation, sermon on in room on television on Sundays. There were up to five refusals a day marked on the activity sheet, 50 refusals in the first 19 days of the month. Interview 08/20/24 at 2:43 P.M. with Activities Aide #267 verified she does not ask Resident #35 if he wants to attend activities because he stays in bed. She stated she was new to her position in the last few months and said she was taught if a resident did not come to an activity, to mark them as refused even if she did not ask them if they wanted to attend. She said she did not have a 1:1 activity sheet for the resident but had cleaned his fingernails a few times when his wife asked her to. Interview on 08/20/24 at 2:47 P.M. with Activities Director #200 revealed she missed putting a 1:1 sheet in the binder for Resident #35. She verified the 1:1's were not completed per the plan of care for a hospice resident who was bed bound. Activity Director #200 further verified refused should not be marked on activity sheets if the resident was not asked or did not refuse to attend an activity. 2. Review of Resident #42's medical record revealed an initial admission date of 09/05/19 and re-admission date of 04/15/24 with diagnoses including traumatic subarachnoid hemorrhage contracture of muscle right forearm, left forearm, tracheostomy, seizures, dysphagia, cognitive communication disorder, and persistent vegetative state. Review of the activity plan of care dated 08/03/23 revealed the resident was at risk for altered activity patterns/pursuits related to being dependent on staff for meeting social needs. Resident is at risk for altered activity patterns/pursuits related to resident will accept and participate in 1:1 visits as evidenced by turning head, making eye contact one to two times a week from staff and volunteers. The resident's preferred activities are: offer aromatherapy, being read to, and music. Review of the Annual MDS dated [DATE] revealed the resident was severely impaired for daily decision making,, behaviors not present, little interest or pleasure in doing anything, feeling tired or having little energy, being short tempered and easily annoyed, rejection of care one to three days, it was somewhat important to take care of personal belongings, have animals around, keep up with the news, and to get fresh air when the weather is good. It was very important to chose between a tub bath, shower, bed bath or sponge bath, choose bedtime, have family involved, to listen to music, and do favorite activities. The resident had upper and lower extremity impairment on both sides, totally dependent for all care, always incontinent of bowel and bladder, received scheduled pain medication, tube feed (enteral nutrition), oxygen and tracheostomy. Review of the residents 1:1 activity sheet revealed 1:1 activities were not offered one to two times a week per the resident's plan of care. There was not a 1:1 activity between 06/03/24 and 06/16/23 (13 days) and between 07/25/24 and 08/09/24 (15 days). There was no aroma therapy, a preferred activity, since May 2024. Review of the monthly activity log for August 2024 revealed two to four refusals a day for activities, 54 refusals marked in the first 20 days of the month. The resident had movie/TV in his room, radio on and visitors as the only activities marked for the month. Observation of the resident on 08/19/24 at 10:00 A.M. revealed a sign on his wall that stated please have resident up in chair and taken to all in-house activities every day, No exceptions. Resident is to be up, dressed, and taken to the day room during the day to allow interaction with staff and residents. The resident was laying in bed, dressed in a t-shirt, sweatpants and socks. He was receiving oxygen per a tracheostomy mask, receiving enteral nutrition via a pump. The resident's eyes were open but made no eye contact when spoken to. The radio in his room was playing music. On 08/19/24 at 4:33 P.M., 08/20/24 at 9:30 A.M., 12:25 P.M., 1:59 P.M., 5:58 P.M. and 08/22/24 at 9:01 A.M the resident was observed either in his bed or in a wheelchair in his room. The radio was on during observations. There were no observations of the resident out of his room, with the television on or engaged with activity staff. Interview 08/20/24 at 2:43 P.M. with Activities Aide #267 revealed she does not ask Resident #42 if he wants to come to activities. She said she only asks the residents who usually come to activities. She stated she was new in the last few months and indicated she was taught if a resident did not come to an activity, to mark them as refused even if she did not ask them if they wanted to attend. She verified did not know he had a sign on his wall to attend all activities. Interview 08/20/24 at 02:49 P.M. with Activities Director #200 revealed she was short of staff so 1:1's were not completed one to two a week. Activity Director #200 further verified refused should not be marked on activity sheets if the resident was not asked or did not refuse to attend an activity. Interview 08/21/24 at 4:10 P.M. with the Director of Nursing DON revealed she called the resident's mother, who said the note on the wall to take to activities was an old note from when he first arrived at the facility and his mother does not expect him to be out at all activities. The DON verified the note should not be on the wall if it was outdated and it was not to be followed. Review of the facility's Activities policy revised 10/30/23 revealed activities will be designed with the intent to enhance the resident's sense of well-being , belonging, and usefulness, promote physical activity, cognition, emotional health, self esteem, dignity, pleasure, comfort, education, creativity, success and independence, reflect age and interest, cultural and religious interests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy and interview, the facility failed to ensure preventative skin care was provided to residents with pressure ulcers. This affected one (Resident #35) of three residents reviewed for pressure ulcers. The census was 69. Findings include: Review of Resident #35's medical record revealed an admission date of 06/22/24 with diagnoses including palliative care, Parkinson's disease, vascular dementia, psychotic disturbance, mood disturbance and anxiety, depression, weakness, chronic obstructive pulmonary disease, transient cerebral ischemic attack, and hypertension. Review of a Braden Scale for Predicting Pressure Sore Risk dated 06/23/24 revealed the resident had no sensory impairment, skin was occasionally moist, walks occasionally, very limited mobility, probably inadequate nutrition, potential problem with shear and friction, and was identified at risk for pressure ulcer development. Review of a resident plan of care for at Risk for Impaired Skin Integrity related to decline in mobility, and end of life/hospice care was initiated 06/24/24. The goal was the resident will have intact skin to the extent allowed by the resident's age, mobility status, continence status, nutritional status, medication and/or treatment compliance, medical condition and/or comorbidities, and compliance with wound prevention recommendations. Interventions included to apply protective barrier cream after each incontinence episode. Review of a wound evaluation dated 06/27/24 revealed the resident had a Kennedy terminal ulcer (dark sores that develop rapidly in the final stages of life), Stage 1 (the mildest and affects the upper layer of your skin. In this stage, the wound has not yet opened) measuring 5.39 centimeters (cm) length x 5.02 cm width. Review of the admission Minimum Data Set assessment dated [DATE] revealed the resident was moderately impaired (cognition) for daily decision making, He had no upper or lower upper extremity impairment, partial moderate assist for eating, oral hygiene, substantial/maximum assistance for toileting, dressing, personal hygiene, rolling from left to right, sit to lying, and was frequently incontinent of urine and always incontinent of bowel. Review of physician orders dated 08/01/24 revealed to cleanse the sacrum with generic wound cleanser, pat dry, apply medihoney and calcium alginate, cover with silicone foam dressing (four by four) daily and as needed. Observation of a dressing change on 08/21/24 at 12:42 P.M. with Licensed Practical Nurses #246 and #237 revealed the sacrum had several open areas. The resident was turned onto his right side. He had a small bowel movement contained between his gluteal folds. LPN #237 performed the dressing change. The open areas left spots of blood on the resident's brief and the periwound area was deep red. After cleansing the wound, calcium alginate, medihoney and a foam dressing was applied. LPN #237 then cleansed the bowel movement. The resident had deep red skin between his gluteal folds. The LPN's cleaned the bowel movement, and placed a clean brief on the resident. The staff did not apply barrier cream to the red periwound or red gluteal folds areas. Barrier cream was observed on the resident's chest of drawers in his room. Interview 08/21/24 at 1:00 P.M. with LPN's #246 and #237 verified between the resident's gluteal folds his skin was deep red and the periwound exposed outside of the resident's newly placed sacral dressing was red. Both nurses verified the resident had barrier cream available that should have been applied per his plan of care. Review of the facility's Pressure Injury Prevention Guidelines policy revised 03/20/24 included to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of the facility to implement evidence based interventions for residents who are assessed at risk or have a pressure injury present.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to adequately monitor enteral nutrition administration for Resident #42 which resulted in a significant weight loss. In addition, the facility did not notify the physician or Registered Dietitian of the significant weight loss in a timely manner. This affected one resident (#42) of one identified by the facility as receiving enteral nutrition. The facility census was 69. Findings include: Review of the medical record for Resident #42 revealed an admission date of 09/05/19 with diagnoses including traumatic brain injury, severe protein-calorie malnutrition, gastrostomy status, dysphagia, persistent vegetative state, aphasia, and tracheostomy status. Review of the physician's orders for June 2024 identified orders for Nutren 2.0 at 50 milliliters (ml) per hour for 24 hours and may substitute Jevity 1.5 if Nutren is unavailable (ordered 05/23/24). The order did not specify an administration rate for the substitution of Jevity 1.5. Review of the Medication Administration Record (MAR) for June 2024 revealed there was no documentation of Resident #42's enteral nutrition being held at any point from 06/01/24 to 06/30/24 and it was documented that Resident #42 received 400 ml of Nutren 2.0 on each of three shifts every day, which indicated Resident #42 received the full ordered amount of 1200 ml per day, every day. There were no variances in the amount of formula infused and every shift was documented as exactly 400 ml infused. Enteral feeding residuals were documented ranging from 0 ml to 60 ml and there was no documentation on the MAR of any residual greater than 60 ml. On 06/09/2024 Resident #42 weighed 161.2 pounds (lbs) and on 07/03/2024 Resident #42 weighed 150.7 lbs, which is a significant weight loss of 10.5 pounds (6.51%) in one month. On 07/04/24 Resident #42 weighed 150.7 pounds. There was no documentation in the medical record of the physician or Registered Dietitian (RD) #278 being notified of the weight loss. Review of the progress note dated 06/17/24 at 5:27 A.M. revealed Resident #42 had emesis, the physician was notified and stated to check residuals and report any further episodes of emesis, Resident #42 had further emesis and residuals greater than 100 ml during morning medication pass, and the tube feeding was turned off. Review of the progress note dated 06/17/24 at 4:29 P.M. revealed Resident #42 had no further emesis. Further review of the progress notes dated 06/17/24 through 07/09/24 revealed there were no additional nurses notes indicating the tube feeding was turned off or held, there was no note indicating how long the tube feeding was turned off on 06/17/24 or when it was turned back on, and there were no notes indicating Jevity 1.5 had to be used due to unavailability of Nutren 2.0. Review of the nutrition progress note dated 07/09/24 at 10:50 A.M. revealed Resident #42 had a 6.5% weight loss from 06/09/24 to 07/04/24. The note indicated Resident #42 had a period of intolerance as evidenced by emesis and Jevity 1.5 had to be used for a period of time as Nutren 2.0 was unavailable. The note did not specify a timeframe for the intolerance or use of Jevity 1.5, and the note did not specify an administration rate for Jevity 1.5. RD #278 recommended continuing the tube feeding as ordered and starting weekly weights. On 08/21/24 at 5:37 P.M., an interview with the Director of Nursing (DON) confirmed the MAR for June 2024 indicated Resident #42 received the same amount of formula on every shift, there was no indication on the MAR for when Jevity 1.5 had to be used, there was no specification in the order for an administration rate if Jevity 1.5 had to be substituted for Nutren 2.0, and the nurses note on 06/17/24 indicated Resident #42's tube feeding had to be turned off. She further stated that when the weight loss occurred, she told RD #278 that weight loss for a resident with tube feeding is the facility's fault. On 08/22/24 at 8:41 A.M., an interview with the DON stated RD #278 should have specified an administration rate for the use of Jevity 1.5. She also confirmed that although there was a nurses note indicating the tube feeding was held, the documentation on the MAR indicated the full amount of formula was provided and there was no indication on the MAR that the tube feeding was held at any point. The DON further stated that the nurse on duty that day verified to the DON that she did not document when the tube feeding was held or how long it was held. On 08/22/24 at 10:49 A.M., an interview with RD #278 stated Resident #42 was not tolerating his tube feed for a period of time and the tube feed had to be stopped for a period of time. He further stated the facility was short on Nutren 2.0 and Jevity 1.5 had to be used for a short period of time which could have contributed to the weight loss. RD #278 stated he did not know at what rate Jevity 1.5 was administered and he did not know how long Jevity 1.5 had to be used in place of Nutren 2.0. RD #278 said ideally, nursing should have contacted him when Jevity 1.5 had to be substituted so a rate adjustment could be made. He further stated when he reviewed the weight loss, he did not review the tube feed formula intake documentation on the MAR and he only used the information told to him by the nurses. RD #278 said he thought the main cause of the weight loss was inadequate nutrition provided via tube feed due to the tube feed being held and Jevity 1.5 being substituted for Nutren 2.0. On 08/22/24 at 12:22 P.M., an interview with the DON verified there was no documentation of the physician or RD #278 being notified of the weight loss on 07/03/24 (which was a Wednesday). The DON further stated that the interdisciplinary team (IDT) meets on Mondays and Tuesdays and the notification would not have occurred until the following Monday at the IDT meeting. Review of the facility's policy titled Feeding Tubes, revised 06/30/22, revealed feeding tubes would be used when medically necessary to maintain acceptable parameters of nutrition and hydration, the RD would estimate a resident's daily nutritional and hydration needs, staff would be directed on the types of enteral nutrition formulas available for use, the facility would collaborate with the RD to determine whether the tube feedings meet the resident's needs and when to adjust them accordingly, staff would ensure the administration of enteral nutrition was consistent with and followed the practitioner's orders, and the facility would notify and involve the physician or designated practitioner of any complications. Review of the facility's policy titled Weight Monitoring, revised 10/26/23, revealed the facility would ensure all residents maintained acceptable parameters of nutritional status, interventions would be identified and implemented with ongoing monitoring to maintain acceptable parameters of nutrition with intervention modifications made as appropriate, a significant change was defined as a 5% change in one month or a 7.5% change in three months or a 10% change in six months, the physician should be informed of a significant weight loss, meal consumption information should be recorded and may be referenced by the IDT as needed, the RD should be consulted to assist with interventions and actions should be recorded in the nutrition progress notes, and care instructions should be communicated to facility staff by the IDT.

Based on observation, record review and interview, the facility failed to label the contents in a tube feeding/enteral nutrition bag. This affected one (Resident #42) of one residents reviewed for tube feeding. The census was 69. Findings include: Review of Resident #42's medical record revealed an admission date of 09/05/19 and readmission date of 04/15/24 with diagnoses including traumatic subarachnoid hemorrhage, severe protein calorie malnutrition, gastrostomy, tracheostomy, seizures, dysphagia, cognitive communication disorder, and persistent vegetative state. Physician orders included a 05/23/24 order for Nutren 2.0 calorie at 50 millimeters (ml) an hour. Review of the 07/16/24 Annual Minimum Data Set (MDS) Assessment revealed the resident was severely impaired for daily decision making and the resident received tube feeding. Observation of Resident #42 on 08/19/24 at 10:00 A.M. revealed the resident had tube feeding infusing at 50 milliliters an hour through a gastrostomy tube. The bag of tube feeding was labeled with the resident's last name and dated 08/19/24. The label did not identify what was poured into the bag or at what time. Interview and observation on 08/19/24 at 4:33 P.M. with the Director of Nursing and Administrator verified the tube feeding was placed into a bag and the contents were not identified. It was undetermined what type of tube feeding was in the bag infusing. Review of the facility's Tube Feeding policy last updated 06/30/22 included ensuring the administration of enteral nutrition is consistent with and follows the practitioners orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy and interview, the facility failed to ensure oxygen tubing was dated when changed. This affected two (Resident's #32 and #35) of two residents reviewed for oxygen therapy. The census was 69. Findings include: 1. Review of Resident #35's medical record revealed admission date of 06/22/24 with diagnoses including dysphagia, palliative care, Parkinson's disease, vascular dementia, psychotic disturbance, mood disturbance and anxiety, depression, chronic obstructive pulmonary disease, transient cerebral ischemic attack, and hypertension. Physician orders included an order dated 06/22/24 for oxygen tubing/filter to be changed every week. An order dated 07/29/24 to run the oxygen at 4.0 liters per minute continuous. Review of the admission Minimum Data Set assessment dated [DATE] included the resident was moderately impaired for daily decision making and he received oxygen. Observation on 08/19/24 at 10:00 A.M. revealed the resident was in bed, His nasal cannula was on the floor, The oxygen condenser was set at 3.5 Liters Per Minute (LPM). The nasal cannula equipment was not dated but bag hanging on the oxygen condenser said 08/01/24, A nebulizer mask was on the bedside table not in the bag. The nebulizer mask had white spots inside the mask and the mask was dated 08/01/24. Review of the August treatment sheet revealed the oxygen tubing was signed off as being changed on 08/08/24, and 08/14/24 but the tubing was dated 08/01/24. Observation and interview on 08/19/24 at 4:32 P.M. with the Director of Nursing (DON) and the Administrator verified the nasal cannula attached to the oxygen condenser was not dated but the bag said 08/01/24. Further interview verified the nebulizer mask was soiled and not replaced as per policy. Interview 08/20/24 at 11:49 A.M. with the DON verified the treatment to change oxygen tubing weekly was signed off as completed weekly when it had not been changed. 2. Review of Resident #32's medical record revealed an admission date of 01/31/24 with diagnoses including chronic obstructive pulmonary disease, cognitive communication deficit, muscle weakness, difficulty walking, anxiety disorder, need for assistance with personal care, and hypertension. A plan of care for pulmonary/respiratory status related to Chronic Obstructive Pulmonary Disease (COPD) initiated 01/31/24 included to administer oxygen as ordered. Physician orders included on 01/31/24 an order for oxygen tubing/filter change every week on Wednesday night shift. On 02/05/24 oxygen saturation every shift and as needed, and oxygen two to four liters per minute continuous via nasal cannula to keep oxygen saturation greater than 92 percent. The 08/06/24 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was moderately impaired for daily decision making, and received oxygen. Observation 08/19/24 at 11:13 A.M. the resident was in physical therapy. He had oxygen being delivered via canister at three liters per minute (LPM). The nasal cannula tubing was dated 07/07/24. Review of the treatment sheets revealed the treatment to change the oxygen tubing weekly was signed off as completed 08/07/24 and 08/14/24. The tubing was signed of as being changed weekly when it was dated 07/07/24. Observation and interview 08/19/24 at 4:37 P.M. with the Director of Nursing (DON) and the Administrator verified the nasal cannula attached to the oxygen canister on his wheelchair was dated 07/07/24 and was not changed per orders Interview 08/20/24 at 11:49 A.M. with the DON verified the treatment to change oxygen tubing weekly was signed off as completed weekly when it had not been changed.

Based on medical record review, review of pharmacy recommendations, and staff interview, the facility did not ensure pharmacy recommendations were reviewed and addressed by a physician in a timely manner. This affected three residents (#10, #51, and #58) of five reviewed for unnecessary medications. The facility census was 69. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 12/11/18 with diagnoses including major depressive disorder, hypertension, type two diabetes mellitus, morbid obesity, congestive heart failure, vitamin D deficiency, personal history of transient ischemic attack and cerebral infarction, and chronic obstructive pulmonary disorder. Review of the physician's orders for August 2024 identified orders for Mirtazapine tablet 15 milligrams (mg) one tablet once daily at bedtime (ordered 11/30/21), Rivaroxaban 20 mg one tablet once daily in the evening (ordered 11/01/22), Diltiazem HCl extended release 12 hour 120 mg one capsule once daily in the morning (ordered 12/08/23), and Vitamin D 1.25 mg (50,000 UT) one capsule once weekly on Thursday (ordered 08/02/22). Review of the pharmacy recommendation dated 03/06/24 revealed a recommendation was made to discontinue Mirtazapine. The physician/prescriber response section on the recommendation form was blank. Review of the pharmacy recommendation dated 03/06/24 revealed a recommendation was made to re-evaluate use of Rivaroxaban due to updated criteria which recommended to avoid using for long-term treatment of nonvalvular atrial fibrillation and venous thrombosis. The physician/prescriber response section on the recommendation form was blank. Review of the pharmacy recommendation dated 04/03/24 revealed a recommendation was made to change Diltiazem extended release 12 hour capsule from once daily to twice daily. The physician/prescriber response section on the recommendation form was blank. Review of the psychiatric provider note dated 05/31/24 revealed use of Mirtazapine was addressed, which was 86 days after the pharmacy recommendation was made. Review of the pharmacy recommendation dated 06/13/24 revealed a recommendation was made to change the order for Vitamin D from weekly to monthly. The physician/prescriber response section on the recommendation form was blank. On 08/20/24 at 4:29 P.M., an interview with the Director of Nursing (DON) verified the pharmacy recommendations forms did not have a provider response on the forms and she was unable to locate any evidence in the medical records that the recommendations were addressed by a physician. 2. Review of Resident #58's medical record revealed an admission date of 10/20/23 with diagnoses that included cerebrovascular accident with hemiplegia, prostate cancer and vascular dementia. Further review of the medical record including pharmacist recommendations revealed on 07/11/24 the pharmacist made a recommendation to evaluate continued use of Lipitor (cholesterol lowering medication) due to resident receiving end of life hospice services at this time. No evidence was found indicating the physician was notified and reviewed the pharmacist recommendation as of 08/21/24. On 08/21/24 at 1:30 P.M. interview with the Director of Nursing verified the pharmacy recommendation dated 07/11/24 had not been reviewed and addressed by Resident #58's physician. 3. Review of Resident #51's medical record revealed an admission date of 08/10/21 with diagnoses including type 2 diabetes, generalized anxiety, cognitive communication disorder, depression, need for assistance with personal care, metabolic encephalopathy, gastroesophageal reflux disease without esophagitis, bipolar disorder, peripheral vascular disease, nicotine dependence, difficulty walking, muscle weakness, fractured femur, obstructive and reflux uropathy, anemia, hypertension, acquired absence of left great toe, acute respiratory failure, anemia, acute embolism and thrombosis of unspecified vein, Parkinson's disease, chronic obstructive pulmonary disease, severe sepsis with septic shock and ventilator associated pneumonia. Review of the 08/30/23 pharmacy review recommendation included to make order read Miralax or polyethylene 17 Grams (gm) in six to eight ounces of liquid and give by mouth or gastrostomy tube. Review revealed the order was not updated until 01/09/24 to please update the Miralax order to include dissolve in 4-8 ounces of liquid and drink. Review of a 03/06/24 pharmacy recommendation included please update the Miralax order to include: dissolve in six to eight ounces of liquid and drink. The order was not updated until 06/24/24. Review of a 04/03/24 Note to Attending Physician from the Pharmacist included the resident has an order for Depakote Delayed Release (DR) 500 milligrams (mg) every morning. The DR formulation is twice daily, Extended release (ER) is once daily. Should this be Depakote ER 500 mg every morning? The order was not changed until 06/24/24 when the DR was discontinued and Depakote ER 500 mg was ordered every morning. The 07/11/24 pharmacy recommendation included the resident has been taking the antidepressant Zoloft 25 mg every bedtime and Depakote ER 500 mg every morning. Please evaluate the current dose and consider a reduction. The recommendation had not yet been addressed on 08/21/24. Interview 08/21/24 at 3:00 P.M. with the Director of Nursing verified the physician had not addressed pharmacy recommendations timely. Further verified several recommendations were for the same medication where the order was not clarified on readmission. Review of the facility's Addressing Medication Regimen Review Irregularities last revised 12/28/23 included facility nursing staff will notify attending physician of any recommendations and forward a copy to the medical director and Director of Nursing. If orders are received via telephone the nurse shall indicate in the nursing response portion of the form.

Based on observations, medical record review, staff interview, and review of the facility policy the facility failed to maintain a medication error rate of less than five percent (%). The medication error rate was calculated to be 7.69% which included two medication errors of 26 medication administration opportunities. This affected one resident (Resident #22) of six residents observed for medication administration. The facility census was 69. Findings include: Review of the medical record for Resident #22 revealed an admission date of 03/29/2024. Diagnoses included chronic obstructive pulmonary disease with acute exacerbation (COPD), myocardial infarction, Coronary artery disease (CAD), and cute respiratory failure with hypoxia. Review of Resident #22 physician orders dated August 2024 revealed an order for Amlodipine Besylate Oral Tablet 5 mg by mouth in the morning for CAD and Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG inhale one puff orally in the morning for COPD. Observation of medication administration on 08/20/24 08:42 A.M. revealed Registered Nurse (RN) #208 preparing medications to administer to Resident#22. The following medications were administered: Amlodipine Besylate 10 milligrams (mg) oral tablet, Plavix 75 mg, Gabapentin 600 mg, Hydroxyzine 75 mg, Omeprazole 20 mg, Carvedilol 6.25 mg, Isosorbide Mononitrate ER Tablet Extended Release 24 Hour 30 MG, Cozaar Tablet 25 MG, Iron 325 mg, and B 12 1000 micrograms (mcg), and Folic Acid 1 mg. Additionally RN #208 assisted with administering the residents Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 mcg inhaler by holding it to her mouth and activating the inhalant. RN #208 left the resident room without advising or assisting the resident with rinsing out her mouth after receiving her inhaler. Observation of the Trelegy Ellipta Inhalation storage box revealed to rinse mouth after use. Interview on 08/20/24 at 9:40 A.M. RN #208 confirmed she administered Amlodipine Besylate 10 mg when the order stated to administer 5 mgs. She revealed the order changed on 08/08/24 but the facility nurses had not replaced the 10 mg medication card with the 5 mg medication card. RN #208 was able to fine the correct card and dose in her medication cart unused. She also confirmed she did not advise or assist Resident #22 with rinsing her mouth after using her Trelegy inhaler. Review of the Trelegy Ellipta Inhalation Aerosol Powder Breath Activated insert revealed Candida albicans infection of the mouth and pharynx may occur. Monitor patients periodically. Advise the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce the risk. Review of the facility policy, Medication Administration, dated 01/17/23 revealed facility nurses should compare medication source with the medication administration record to verify resident name, medication name, form, dose, route, and time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the medical record for Resident #42 revealed an admission date of 09/05/19 with diagnoses including traumatic brain injury, severe protein-calorie malnutrition, gastrostomy status, dysphagia, persistent vegetative state, aphasia, and tracheostomy status. Review of the physician's orders for June 2024 identified orders for Nutren 2.0 at 50 milliliters (ml) per hour for 24 hours and may substitute Jevity 1.5 if Nutren unavailable (ordered 05/23/24). The order did not specify an administration rate for the substitution of Jevity 1.5. Review of the Medication Administration Record (MAR) for June 2024 revealed there was documentation of Resident #42's enteral nutrition being held at any point from 06/01/24 to 06/30/24 and it was documented that Resident #42 received 400 ml of Nutren 2.0 on each of three shifts every day, which indicated Resident #42 received the full ordered amount of 1200 ml per day every day. There were no variances in the amount of formula infused and every shift was documented as exactly 400 ml infused. Enteral feeding residuals were documented ranging from 0 ml to 60 ml and there was no documentation on the MAR of any residual greater than 60 ml. Review of the progress note dated 06/17/24 at 5:27 A.M. revealed Resident #42 had emesis, the physician was notified and stated to check residuals and report any further episodes of emesis, Resident #42 had further emesis and residuals greater than 100 ml during morning medication pass, and the tube feed was turned off. Further review of the progress notes dated 06/17/24 through 07/09/24 revealed there were no additional nurses notes indicating the tube feed was turned off or held, there was no note indicating how long the tube feed was turned off on 06/17/24 or when it was turned back on, and there were no notes indicating Jevity 1.5 had to be used due to unavailability of Nutren 2.0. Review of the nutrition progress note dated 07/09/24 at 10:50 A.M. revealed Resident #42 had a 6.5% weight loss from 06/09/24 to 07/04/24. The note indicated Resident #42 had a period of intolerance as evidenced by emesis and Jevity 1.5 had to be used for a period of time as Nutren 2.0 was unavailable. The note did not specify a timeframe for the intolerance or use of Jevity 1.5, and the note did not specify an administration rate for Jevity 1.5. RD #278 recommended continuing the tube feeding as ordered and starting weekly weights. On 08/21/24 at 5:37 P.M., an interview with the Director of Nursing (DON) confirmed the MAR for June 2024 indicated Resident #42 received the same amount of formula on every shift, there was no indication on the MAR for when Jevity 1.5 had to be used, there was no specification in the order for an administration rate if Jevity 1.5 had to be substituted for Nutren 2.0, and the nurses note on 06/17/24 indicated Resident #42's tube feed had to be turned off. On 08/22/24 at 8:41 A.M., an interview with the DON stated RD #278 should have specified an administration rate for the use of Jevity 1.5. She also confirmed that although there was a nurses note indicating the tube feed was held, the documentation on the MAR indicated the full amount of formula was provided and there was no indication on the MAR that the tube feeding was held at any point. The DON further stated that the nurse on duty that day verified to the DON that she did not document when the tube feed was held or how long it was held. 4. Review of the medical record for Resident #49 revealed an admission date for 10/18/22. Diagnoses included unspecified dementia, mood disturbance, and chronic atrial fibrillation. Review of Resident #49's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a severe cognitive impairment. Review of Resident #49's Physician orders dated physician order dated 08/08/24, revealed Resident to be up in wheelchair for meals. Resident to be in dining room for meals. Observations of Resident #49 on 08/19/24 at 12:34 P.M., 08/20/24 at 9:56 A.M., 08/20/24 at 12:35 PM , and 08/21/24 at 11:01 A.M. revealed the resident was eating his in breakfast and lunch meals while in his bed. Review of Resident #49's medication administration record from 08/19.24 through 08/21/24 reveled the facility nurses were initialing that the resident was up in his chair at mealtimes. Interview on 08/21/24 at 9:31 A.M. with STNA #502 revealed the resident frequently refused to get out of bed but is offered to get up at each meal. Interview on 08/21/24 at 11:49 A.M. Interview with Registered Nurse (RN) #503 reported she has been documenting that Resident #49 is getting up for meals when he is actually refusing. She stated she thought that she was supposed to documented he was up for meals as long as the staff offered to get him up even if he refused. Interview on 08/21/24 at 12:38 P.M. the facility's Director of Nursing verified the facility's nurses are incorrectly documenting that Resident #49 is getting up out of bed for meals when he is refusing to do so. 6. Review of Resident #4's medical record revealed an admission date of 07/26/23 with diagnoses that included end staff renal disease with hemodialysis, atrial fibrillation and diabetes mellitus. Further review of the medical record revealed Resident #4 currently received hemodialysis three times weekly. Review of a quarterly nutritional assessment completed on 07/19/24 indicated the facility dietician (RD #278) communicated with Resident #4's hemodialysis dietician who recommended to continue a regular diet, oral nutritional supplements and to add protein. Further review of the nutritional assessment indicated a recommendation to add 30 milliliters (ml) of liquid protein daily to provide an additional 100 kilocalories and 15 grams of protein. Further review of the medical record for Resident #4 found no evidence of any type of liquid protein supplement ordered or provided. A dietary progress note from 08/20/24 completed by RD #278 indicated a regular diet and four ounces of oral nutritional supplement three times daily. No evidence of any type of liquid protein supplement was noted. On 08/21/24 at 10:30 A.M. interview with the Director of Nursing indicated a she had communicated with RD #278 who indicated the recommendation of adding a liquid protein supplement was a documentation error as he and the dialysis RD had discussed the resident's current diet, oral nutritional supplement and weights and determined a liquid protein supplement was not indicated at this time. Based on observation, record review, and interview, the facility failed to maintain accurate medical records. This affected five (Resident's #4, #35, #37, #42, and #49) of 19 records reviewed. The census was 69. Findings include: 1. Review of Resident #35's medical record revealed an admission date of 06/22/24 with diagnoses including dysphagia, palliative care, Parkinson's disease, vascular dementia, psychotic disturbance, mood disturbance and anxiety, depression, gastroesophageal reflux disease, weakness, chronic obstructive pulmonary disease, transient cerebral ischemic attack, and hypertension. Interview 08/19/24 at 01:59 P.M. with the resident's wife included her husband does not get out of bed. He doesn't watch television and isn't interested in a whole lot. Activities does not come in and interact with him. Review of the monthly calendar for August 2024 revealed the resident had on the television/movie in room, radio, reminisce, conversation, sermon on in room on television on Sundays. There were up to five refusals a day marked on the activity sheet, 50 refusals in the first 19 days of the month. Interview 08/20/24 at 2:43 P.M. with Activities Aide #267 revealed she does not ask Resident #35 if he wants to come to activities because he stays in bed. She stated she was new in the last few months. She indicated she was taught if a resident did not come to an activity to mark them as refused even if she did not ask them if they wanted to attend. Interview 08/20/24 02:47 P.M. with Activity Director #200 verified refused should not be marked on activity sheets if the resident was not asked or did not refuse to to attend an activity. Activity #200 verified it would be misleading to say a resident had refused to attend an activity when they had not been asked if they want to attend. 2. Review of Resident #42's medical record revealed an admission date of 09/05/19 and re-admission date of 04/15/24 with diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours, severe protein calorie malnutrition, hyperosmolality and hypernatremia, contracture of muscle right forearm, left forearm, chronic respiratory failure with hypoxemia, gastrostomy, tracheostomy, seizures, dysphagia, cognitive communication disorder, wedge compression fracture of fourth lumbar vertebra, hypertension, esophageal reflux disease, post traumatic hydrocephalus, persistent vegetative state, and metabolic encephalopathy. The resident had a sign on his wall to please have the resident up in the chair and taken to all in-house activities every day, No exceptions. Resident is to be up, dressed, and taken to the day room during the day to allow interaction with staff and residents. Observation 08/19/24 at 10:00 A.M. of Resident #42 was lying in bed. His eyes were open but made no eye contact. He was dressed in a t shirt, sweat pants and socks. On 08/19/24 at 04:33 P.M., 08/20/24 at 9:30 A.M., 12:25 P.M., 1:59 P.M., 5:58 P.M. and 08/27/24 at 9:50 A.M. 08/22/24 at 9:01 A.M the resident was either in bed or in a wheelchair his room. The radio was on during observations. There were no observations of the resident out of his room, with the television on or engaged with activity staff. Review of the monthly activity log revealed in August two to four refusals a day for activities, 54 refusals marked in the first 20 days of the month. The resident had movie/TV in room, radio on and visitors as the only activities marked for the month. Interview 08/20/24 at 2:43 P.M. with Activities Aide #267 revealed she does not ask Resident #42 if he wants to come to activities. She said she only ask the residents who usually come to activities. She stated she was new in the last few months. She indicated she was taught if a patient did not come to an activity to mark them as refused even if she did not ask them if they wanted to attend. Interview 08/20/24 at 02:49 P.M. with Activities Director #200 revealed refused should not be marked on activity sheets if the resident was not asked or did not refuse to attend an activity. 3. Review of Resident #37 revealed a 09/23/23 admission with diagnoses including acute and chronic respiratory failure with hypoxia, COPD, congestive heart failure, osteoarthritis, type 2 diabetes, muscle weakness, morbid severe obesity, depression, asthma, hypertension, hypolipidemia, hypothyroidism, edema, insomnia, obstructive sleep apnea, and transient ischemic attack. Review of cut letters revealed the resident received Medicare Part A skilled services from 02/06/24 till 04/05/24. A facility initiated cut when days were not exhausted was signed 04/03/24 by the resident. A 10055 and 10123 were provided. The 10055 was marked the resident wanted to appeal. There was no evidence of the appeal being made. Interview 08/21/24 at 11:10 A.M. with Business Office Manager (BOM) #229 revealed she was with the resident when she signed the cut letter and she did not ask for an appeal. BOM #229 said she did not realize the resident filled in the square Option 1 indicating she wanted an appeal. Option 1: I want the care listed above. I want Medicare to be billed for an official decision on payment, which will be sent to me on a Medicare Summary Notice (MSN). I understand if Medicare doesn't pay I'm responsible for paying, but I can appeal to Medicare by following the directions on MSN. BOM #229 did not file an appeal because the resident did not say she wanted one and must of marked that she did by mistake and she did not notice what was marked. Interview 08/21/24 at 11:19 A.M. with Resident #37 revealed she did not remember if she asked for an appeal or not. She was not upset about how services ended.

Based on observation and interview the facility failed to maintain a clean environment. This affected residents but had the potential to affect all residents residing in the facility. The census was 69. Findings include: On 08/22/24 fro 9:00 A.M. through 9:20 A.M. the following observations were made: 1. Torn wallpaper border was noted between resident rooms, above the medical and storage room on the 100 hall; 300 hall resident rooms as well as above the 300 hall shower room and nurses' station; and 400 hall resident rooms. 2. Black marks from adhesive tape where noted on the ceiling near Resident #20's room and the ceiling above the medical and storage rooms on 100/200 halls. 3. Repaired drywall with unfinished/untextured drywall compound was observed outside the women's bathroom in the front lobby, inside and outside the private dining room, at the 300/400 nurses' station and fire doors, 100/200 hall nurses' station and fire doors. 4. Scraped and damaged drywall from resident beds was noted in the following resident rooms: Resident #7, Resident #20, Resident #33, Resident #42, Resident #62 and Resident #20. On 08/22/24 at 9:20 A.M. interview with the Administrator and Maintenance Director verified the observations.

Based on employee file review, staff interview and review of facility policy, the facility failed to ensure State Tested Nursing Assistants (STNAs) had evaluations completed as required. This had the potential to affect all 69 residents residing in the facility. Findings Include: Review of the employee file for State Tested Nursing Assistant (STNA) #274 revealed a hire date of 06/14/23. No annual performance evaluation was found. Review of the employee file for STNA #219 revealed a hire date of 08/17/22. No annual performance evaluation was found. Review of the employee file for STNA #501 revealed a hire date of 02/2024. A 90-day performance evaluation was not found. Interview on 08/22/24 at 12:30 P.M. the facility Administrator verified the evaluations for STNAs #274, STNA #219, and STNA #501 were not completed. Review of the facility policy Performance Appraisals dated 01/01/22 revealed it is the facility policy to evaluate performance of employees at least annually.

4. Review of the facility's Annual tuberculosis (TB) Risk Assessment for 2024 revealed health care workers (HCW) will receive a baseline skin testing performed with two-step Tuberculin Skin Test. The assessment stated HCW are tested for TB at hire and annually. Review of the facility's policy, Employee Health Records dated 12/13/23 revealed, a health record for each employee should be maintain (with) a document (of a) TB screening record including the evidence of the most recent TB test as well as sign and symptom risk assessment screening. Review of the employee files revealed State Tested Nursing Assistant (STNA) #219 was hired on 08/17/22 but did not receive annual TB test or screening. Review of the employee files revealed STNA #501 was hired on 07/16/24 but did not receive an initial TB two step test. Review of the employee files revealed STNA #504 was hired on 07/16/24 but did not receive an initial TB two step test. Review of the employee files revealed Licensed Practical Nurse (LPN) #265 was hired on 10/01/22 but did not receive annual TB test or screening. Review of the employee files revealed STNA #274 was hired on 06/14/23 but did not receive an annual TB test or screening. Review of the employee files revealed Director if Nursing was hired on 06/25/24 but did not receive an initial TB two step test. Review of the employee files revealed Registered Nurse #207 was hired 06/21/23 but did not receive an annual TB test or screening. Interview on 08/22/24 at 1:10 P.M. the facility Administer confirmed she was unable to find the above employees initial and annual TB test and screenings. Based on record review, policy and interview, the facility failed to ensure Enhanced Barrier Precautions were in place, indwelling catheters were not dragging on the floor, handwashing met professional standards and tuberculin testing of staff was conducted on hire and annually. This affected Resident's #35 and #51 and had the potential to affect all the residents in the facility. The census was 69. Findings include: 1. Review of Resident #51's medical record revealed an admission date of 08/10/21 with diagnoses including type 2 diabetes, generalized anxiety, cognitive communication disorder, depression, need for assistance with personal care, metabolic encephalopathy, gastroesophageal reflux disease without esophagitis, bipolar disorder, peripheral vascular disease, nicotine dependence, difficulty walking, muscle weakness, fractured femur, obstructive and reflux uropathy, anemia, hypertension, acquired absence of left great toe, acute respiratory failure, anemia, acute embolism and thrombosis of unspecified vein, Parkinson's disease, chronic obstructive pulmonary disease, severe sepsis with septic shock and ventilator associated pneumonia. Review of the 06/17/24 quarterly Minimum Data Set Assessment (MDS) included the resident was moderately impaired for daily decision making, behaviors not present, no upper or lower extremity impairment, uses a walker and wheelchair, substantiation/maximal assistance for personal hygiene, toileting, rolling, and sitting to standing, always incontinent of bowel and has an indwelling catheter. Observation 08/19/24 at 10:28 A.M. revealed the resident had a urinary drainage bag hanging under his wheelchair. He was in a wheelchair in the hall waiting to smoke. The urine drainage bag was not covered and exposed yellow urine in the bag and tubing. [NAME] urine was visible in the bag and tubing. Observation on 08/20/24 at 11:57 A.M. revealed the resident was in the dining room. His indwelling urinary catheter bag was now a privacy bag colored blue. The catheter bag was hanging under the seat of the wheelchair. The bag was resting on the floor. Observation on 08/20/24 at 12:21 P.M. the resident went to his room with the catheter bag dragging on the floor hooked under the wheelchair. Observation on 08/20/24 at 2:02 P.M. the resident was sitting in the dining room at an activity. The indwelling catheter bag was resting on the floor. Interview 08/20/24 at 2:04 P.M. with the Administrator verified the indwelling catheter bag was not positioned to remain off the floor and was resting on the floor. 2. Review of Resident #35's medical record revealed an admission date of 06/22/24 with diagnoses including dysphagia, palliative care, Parkinson's disease, vascular dementia, psychotic disturbance, mood disturbance and anxiety, depression, gastroesophageal reflux disease, weakness, chronic obstructive pulmonary disease, transient cerebral ischemic attack, and hypertension. A resident plan of care for at Risk for Impaired Skin Integrity related to decline in mobility, and end of life/hospice care was initiated 06/24/24. The goal was resident will have intact skin to the extent allowed by the resident's age, mobility status, continence status, nutritional status, medication and/or treatment compliance, medical condition and/or comorbidities, and compliance with wound prevention recommendations. Interventions included a 06/24/24 intervention to apply protective barrier cream after incontinence episode. A 06/27/24, wound evaluation documented a Kennedy terminal ulcer (dark sores that develop rapidly in the final stages of life), Stage 1 (the mildest and affects the upper layer of your skin. In this stage, the wound has not yet opened) measuring 5.39 centimeters (cm) length x 5.02 cm width. There was not an order for Enhanced Barrier Precautions. A 08/01/24 physician order included Sacrum- cleanse with generic wound cleanse, pat dry, apply medihoney and calcium alginate, cover with silicone foam dressing (4x 4) daily and as needed. Observation of dressing change 08/21/24 at 12:42 P.M. with Licensed Practical Nurses #246 and #237 revealed the sacrum had several open areas. The LPN's wore gloves. There was no other personal protective equipment (PPE) used. Review of the facility's Enhanced Barrier Precautions revised 03/26/24 included even if the resident is not known to be infected or colonized with Multi Drug Resistant Organism (MDRO), an order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (chronic wounds such as pressure injuries, diabetic foot ulcers, unhealed surgical wounds and chronic venous stasis ulcers. Note:wounds generally include chronic wounds, not shorter-lasting wounds such as skin breaks or skin tears coverers with an adhesive bandage (e.g. Band-Aid) or similar dressing. Interview 08/21/24 at 01:00 P.M. with LPN's #246 and #237 verified the resident was in hospice care, bedridden, with an open wound terminal ulcer , on a pureed diet with weight loss. Neither nurse knew why the resident was not in enhanced barrier precautions. Interview 08/21/24 at 01:16 P.M. with the Director of Nursing verified the resident should of been on EBP with an open wound. 3. Review of Resident #35's medical record revealed an admission date of 06/22/24 with diagnoses including dysphagia, palliative care, Parkinson's disease, vascular dementia, psychotic disturbance, mood disturbance and anxiety, depression, gastroesophageal reflux disease, weakness, chronic obstructive pulmonary disease, transient cerebral ischemic attack, and hypertension. A 08/15/24, wound evaluation documented a Kennedy terminal ulcer (dark sores that develop rapidly in the final stages of life), Unstageable (slough and/or eschar) measuring 1.38 centimeters (cm) length x 0.84 cm width and 0.3 cm depth. The 08/15/24 Wound Evaluation photo revealed the wound was open. Observation of the sacrum dressing change 08/21/24 at 12:42 P.M. with Licensed Practical Nurses #246 and #237 revealed the sacrum had several open areas. Both washed their hands and gloved. The resident was turned onto his right side for the dressing change. He had a small bowel movement contained between his gluteal folds. LPN #237 performed the dressing change. After cleansing the wound calcium alginate, medihoney and a foam dressing was applied all with technique meeting professional standards,. LPN #237 then cleansed the bowel movement. She wore the gloves she had changed into prior to applying the clean foam dressing. Perifresh was applied to a cloth and she wiped from back to front to remove the bowel movement, taking care not to touch the new dressing. There was deep red skin between the gluteal folds. She wiped with different parts of the cloth six times to remove the bowel movement until the cloth came out clean when wiped. With the same gloves on both LPN's turned the resident to his left side, pulled the soiled brief through and placed a new brief. LPN #246 threw the brief in the trash. Without removing their gloves they had on while cleaning the bowel movement LPN #237 who cleansed the bowel movement grabbed the pillow on each side of his face and pulled it down further to his shoulders. Her left hand was on the pillow near his mouth. She put a brown printed pillow between his knees and a pillow under his heels. She placed a pillow under his right arm. He stayed positioned to his left. She used the remote control on the bed to adjust the height of the bed. Then touched his overbed table moving it with her gloved hand, handed the resident his call light with his right hand, pulled a blue banket up to his chin along with LPN #246's help. Neither nurse had removed their gloves used for cleaning the bowel movement until after they made him comfortable in bed. Interview 08/21/24 at 01:00 P.M. with LPN's #246 and #237 verified between they did not remove their gloves after cleaning a bowel movement and touched the resident's pillows, bedding, call light, bed control and overbed table.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility Self-Reported Incident, interviews and policy review, the facility failed to prevent an incident of resident to resident sexual abuse. This affected one resident (Resident #44) of four residents reviewed for abuse. The facility census was 74. Findings Include: Review of the facility self reported incident (SRI) tracking number 248709 dated 06/17/24 at 9:54 A.M. revealed an allegation or suspicion of sexual abuse. Local Law enforcement was contacted , and an officer came out to complete a report, #24-0212. Resident #7 was placed on one to one supervision. The facility investigation was completed on 06/24/24 at 12:35 P.M. with the allegation of sexual abuse being substantiated. An interview on 06/24/24 with State Tested Nurse Aide (STNA) #505 revealed witnessing inappropriate touching between Resident # 7 and Resident #44. STNA #505 indicated that Resident #7 was sitting next to Resident# 44 in the common dining area at approximately 9:51 A.M. on 06/16/24. Resident #7 reached over and touched Resident #44's breast over the clothing. Resident #7 was immediately instructed to keep his hands to himself, and Resident #7 and Resident #44 were immediately separated. STNA #505 revealed the total incident lasted less than 30 seconds. a. Review of the medical record for Resident #44 revealed an admission date of 02/05/24. Diagnoses included dementia, atrial fibrillation (abnormal heart rhythm), hypertension, sick sinus syndrome (abnormal heart rhythms), osteoarthritis, chronic kidney disease, and cognitive communication deficit. Review of the Resident #44's quarterly Minimum Data Set (MDS) assessment, dated 05/10/24, revealed the resident had severely impaired cognition. Review of Resident #44's skin assessment dated [DATE] revealed no abnormal skin areas. An interview was attempted on 06/24/24 at 8:50 A.M., with Resident #44, but she was unable to recall the incident occurring on 06/16/24. b. Review of Resident #7's medical records revealed admission date of 09/29/23. Diagnoses included degeneration of the nervous system, major depressive disorder, alcohol abuse, mild cognitive impairment, transient cerebral infarction, hemiplegia (paralysis) and hemiparesis (muscle weakness) of right side of the body Review of the Resident #7 quarterly Minimum Data Set (MDS) assessment, dated 04/03/24 revealed mild cognitive impairment. An interview on 06/24/24 at 9:11 A.M., with Resident #7, revealed he didn't understand why this was a big deal. Resident #7 indicated that Resident #44 was a friend and before he touched her breast, he asked permission and permission was granted by Resident #44. Review of Resident #7's care plan dated 04/03/24 revealed Resident #7 demonstrated verbally aggressive behaviors usually directed at staff. Review of the Resident #7's nursing progress note dated 06/16/24 revealed Resident #7 was placed on one-to-one supervision following the allegation of inappropriate touching. Review of Resident # 7's nursing progress notes from 03/01/24 through 06/24/24 revealed sporadic documentation of verbal aggression primarily directed toward staff when redirecting the resident. Review of The Psychiatry Progress notes signed by Nurse Practitioner #510 on 03/13/24 and 04/11/24 revealed no indication of sexually inappropriate behaviors and Resident #7 was psychiatrically stable. An interview with the Administrator on 06/25/24 at 12:07 P.M. verified the incident of inappropriate touching by Resident #7 of Resident #44 clothed breast area occurred on 06/16/24 at 9:51 A.M. Review of facility policy titled Abuse, Neglect and Exploitation dated 01/10/24, revealed the facility will implement policies and procedures to prevent and prohibit all types of sexual abuse, neglect, and misappropriation of resident property that establishes a safe environment This deficiency represent non-compliance investigated under Complaint Number OH00154973.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review , review of a facility self-reported incident, policy review and interviews the facility failed to timely report an allegation of resident to resident sexual abuse to the administrator and state survey agency. This affected one resident (Resident #44) of four residents reviewed for abuse. The facility census was 74. Findings Include: Review of the facility self reported incident (SRI) tracking number 248709 dated 06/17/24 at 9:54 A.M. revealed an allegation or suspicion of sexual abuse. Local Law enforcement was contacted , and an officer came out to complete a report, #24-0212. Resident #7 was placed on one to one supervision. The facility investigation was completed on 06/24/24 at 12:35 P.M. with the allegation of sexual abuse being substantiated. An interview on 06/24/24 with State Tested Nurse's Aide (STNA) #505 revealed they witnessed inappropriate touching between Resident #7 and Resident #44. STNA #505 indicated that Resident #7 was sitting next to Resident #44, in the common dining area at approximately 9:51 A.M. on 06/16/24, and Resident #7 reached over and touched Resident #44's breast, over the clothing. Resident #7 was immediately instructed to keep his hands to himself, and Resident #7 and Resident #44 were immediately separated. STNA #505 revealed the incident lasted less than 30 seconds. STNA #505 revealed they completed a witness statement on 06/16/24 and placed it under the door of the Administrator's office. a. Review of the medical record for Resident #44 revealed an admission date of 02/05/24. Diagnoses included dementia, atrial fibrillation (abnormal heart rhythm), hypertension, sick sinus syndrome (abnormal heart rhythms), osteoarthritis, chronic kidney disease, and cognitive communication deficit. Review of the Resident #44's quarterly Minimum Data Set (MDS) assessment, dated 05/10/24, revealed the resident had severely impaired cognition. b. Review of Resident #7's medical record revealed an admission date of 09/29/23. Diagnoses included degeneration of the nervous system, major depressive disorder, alcohol abuse, mild cognitive impairment, transient cerebral infarction, hemiplegia (paralysis) and hemiparesis (muscle weakness) of right side of the body Review of Resident #7's quarterly MDS assessment, dated 04/03/24, revealed the resident had mild cognitive impairment. An interview with the Administrator on 06/25/24 at 12:07 P.M. verified the incident of inappropriate touching by Resident #7 to Resident #44's clothed breast area, occurred on 06/16/24 at 9:51 A.M. The Administrator was made aware of the situation on 06/17/24 upon arrival to the facility on [DATE] at approximately 8:35 A.M. when a witness statement was found in their office. The witness statement had been slipped under their door and was signed by STNA # 505. A Self-Reported Incident (SRI) was started on 06/17/24 at 9:54 A.M. and a facility investigation was initiated and completed on 06/24/24 at 12:35 P.M. Lastly, the Administrator verified the allegation was not reported to the Administrator and the state survey agency within two hours of the incident, as required. Review of the facility Abuse, Neglect, and Exploitation Policy dated 01/10/24 revealed an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur and the reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agencies immediately, but no later than two hours after the allegation involving abuse or result in serious bodily harm. This deficiency represents non-compliance investigated under Complaint Number OH00154973.

Based on observation, medical record review, resident and staff interviews and policy review, the facility failed to ensure wound care was completed as ordered by the physician. This affected two (Residents #35 and #64) of three residents reviewed for wound care. The facility census was 67. Findings include: 1. Review of Resident #35's medical record revealed an admission date of 11/09/23 with diagnoses that included cerebrovascular accident, diabetes mellitus and hypertension. Review of Resident #35's Minimum Data Set (MDS) 3.0 admission assessment with a reference date of 11/30/23 revealed Resident #35 had intact cognition Review of Resident #35's admission wound assessments revealed Resident #35 was admitted to the facility with bilateral stage two pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) to the bilateral heels. Review of Resident #35's physician's orders revealed on 12/01/23 wound care orders to clean the bilateral heels with wound cleanser, apply skin prep (protectant barrier), cover with an ABD (large gauze) pad and wrap with kerlix (gauze wrap) every day and as needed. Review of the Treatment Administration Record (TAR) revealed no evidence the wound care was completed as ordered by the physician on 12/02/23 and 12/12/23. The TAR indicated wound care was completed on 12/15/23, 12/16/23 and 12/17/23. Observation on 12/18/23 at 9:40 A.M. of Resident #35's bilateral heel bandages with Licensed Practical Nurse (LPN) #71 revealed bandages were in place to the bilateral heels. The left heel dressing was dated 12/14/23 and the right heel dressing was undated. Interview with LPN #71 at 9:40 A.M. revealed bilateral bandage changes are to be completed to Resident #35's heels every day. LPN #71 further verified the left heel bandage was dated 12/14/23, the right heel bandage was not dated. The LPN verified the left heel bandage had not been changed as ordered daily on 12/15/23, 12/16/23 and 12/17/23 and there was no date on the right heel dressing to indicate when the dressing had been changed. Interview with Resident #35 at 9:45 A.M. verified no wound care had been provided to his bilateral heels since 12/14/23. Interview with the Director of Nursing (DON) on 12/18/23 at 10:55 A.M. verified wound care for Resident #35 were documented as completed on 12/15/23, 12/16/23 and 12/17/23, but the observation of the dressing revealed no wound care had been provided since 12/14/23. Further interview with the DON also verified there was no documented evidence of bilateral heel wound care was provided on 12/02/23 and 12/12/23. 2. Review of Resident #64's medical records revealed an admission date of 10/11/23 with admission diagnoses that included right femur fracture, chronic obstructive pulmonary disease and hypertension. Review of Resident #64's physician's orders revealed wound care orders on 12/06/23 for care of treatment of the right lateral malleolus and bilateral heels with wound cleanser, pat dry, apply skin prep, cover with ABD pad and wrap with kerlix every day and as needed. Review of Resident #64's wound assessments revealed Resident #64 was admitted to the facility with unstageable pressure wounds (known but unstageable due to coverage of wound bed by slough or eschar) to the bilateral heels and right lateral malleolus. Review of Resident #64's TAR revealed no evidence of wound care for the right lateral malleolus and bilateral heels completed as ordered by the physician on 12/15/23 and 12/16/23. Interview with the DON on 12/18/23 at 10:55 A.M. verified wound care was not documented as provided for Resident #64's bilateral heels and right lateral malleolus on 12/15/23 and 12/16/23. Review of the facility policy Wound Treatment Management with a revision date of 10/26/23 indicated wound treatments will be provided in accordance with physician orders. This deficiency represents non-compliance investigated under Complaint Number OH00149087.

Based on self-reported incident review, record review, policy review and interview the facility failed to ensure residents were free from financial exploitation by staff members. This affected one (Resident #10) of one residents reviewed for misappropriation of resident funds. The facility census was 66. Findings include: Review of Self-Reported Incident (SRI) #239326 revealed on 09/13/23 Resident #10 informed a therapy staff member that he loaned a staff member $100 to purchase school supplies. Further review of the SRI revealed the therapy staff member advised the facility abuse coordinator (Administrator) of the incident at this time. The facility initiated an investigation of the incident. Facility investigation identified State Tested Nurse Aide (STNA) #105 as the staff member who received money from Resident #10. STNA #105 indicated she borrowed $40 from Resident #10 on 08/14/23 and advised the resident she would pay him back. STNA #105 stated she reimbursed Resident #10 on 08/19/23 the full amount of $40. Facility staff attempted interview with Resident #10, but the resident refused to provide information and indicated it was his money and he could do what he wanted with it. Staff educated the resident that it is against facility policy for staff members to accept cash from residents. Facility was unable to determine if the amount was $40 or $100 as Resident #10 was uncooperative and refused to answer questions or provide additional information. Review of Resident #10's medical record revealed an admission date of 11/02/22 with diagnoses that included diabetes mellitus, right below the knee amputation, peripheral vascular disease and chronic kidney disease. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 07/11/23 indicated Resident #10 had an intact and independent cognition level. Review of the facility policy titled Abuse, Neglect and Exploitation dated 10/24/22 revealed; It is the policy of this facility to provide protections for the health, welfare and rights of each resident be developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Interview with the Director of Nursing on 10/24/23 at 11:05 A.M. verified STNA #105 accepted cash from Resident #10 as indicated in SRI #239326.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility Self-Reported Incident (SRI) review, medical record review, interview, and facility policy review, the facility failed to ensure staff immediately reported staff to resident abuse.This affected two residents (#35 and #50) of three residents reviewed for abuse. Findings include: 1. Review of Resident #35's medical record revealed an admission date of 08/21/20 with admission diagnoses that included impulse disorder, shizoaffective disorder, bipolar, anxiety disorder, chronic obstructive pulmonary disease, congestive heart failure, morbid obesity, mood affect disorder and hypertension. Further review of the medical record including the Minimum Data Set (MDS) 3.0 annual assessment with a reference date of 06/15/23 indicated Resident #35 was independent for daily decision making. The resident required extensive assist for bed mobility, transfers, personal hygiene and toileting. Review of the facility SRI #237972 with a created date of 08/10/23 revealed on 08/10/23 the Administrator was notified of an allegation of verbal abuse of Resident #35 by State Tested Nurse Aide (STNA) #76. The accused staff member was interviewed and immediately placed on administrative leave. The allegation was substantiated and STNA #76 was terminated 08/15/23. Review of a 08/10/23 untimed statement from Resident #35 confirmed verbal abuse by STNA #76. He stated she told him to scoot your fat a$ back in the chair, move your fu##### legs. He stated he got upset and cursed back at her. Review of staff statements included a 08/10/23 untimed statement by STNA #100 who witnessed STNA #76 verbally abuse Resident #35 in the shower room. STNA #76 was telling Resident #35 to scoot his fat a$ back in the chair and to move his fu##### legs. STNA #76 totally was humiliating him (Resident #35). STNA #100 started to hear things from her (STNA #76) the beginning of August (2023) and was afraid of retaliation. Review of a 08/09/23 (came in on the 08/09/23 night shift) untimed statement by STNA #98 included she had witnessed STNA #76 being very condescending, making inappropriate comments and being aggressive with multiple residents including Resident #35. Per STNA #98, STNA #76 has made numerous comments in regards to her employment stating she can't be fired: she will use the race card and threatened to call the The National Advancement of Colored People (NWACP). Review of a 08/10/23 untimed STNA #99 statement revealed she was out in the hall on the 300 hall, by room [ROOM NUMBER], and overheard STNA #76 tell Resident #35 he was lazy and to do what she was asking him to do, by himself instead of begging her because he could. Review of an undated STNA #101 statement revealed she witnessed STNA #76 yell at Resident #35 after having to completely change him for a second time when he refused his shower. STNA #101 stated she reported it to a nurse who no longer works at the facility who said she would see what she could do. Review of a 08/10/23 untimed STNA #102 statement revealed she witnessed STNA #76 belittle Resident #35 on numerous occasions. Review of a 08/10/23 statement from Registered Nurse (RN) #97 included she asked Resident #35 about allegations of verbal abuse from STNA #76 and he confirmed verbal abuse and stated she said scoot your fat a$ back in the chair, move your fu##### legs. Resident #35 stated he got upset when STNA #76 said that and cursed back at her. Interview on 08/17/23 at 3:09 P.M. with the Director of Nursing (DON) verified they walked STNA #76 out of the building on 08/10/23 and terminated her 08/15/23. STNA #76 would not give a statement. STNA #76 would not give the police a statement. During the course of the interviews, they identified several staff who had heard or seen something but had not reported it due to fear of retaliation. Staff also identified two other residents (#50 and #51) they saw or heard STNA #76 be inappropriate with so they were also added to the SRI and investigated. The DON verified those staff who heard or witnessed potential abuse and did not report it timely will receive discipline. Interview on 08/17/23 at 4:06 P.M. with Resident #35 revealed STNA #76 flung his legs into the bed. She stretched his legs out and flung them in the bed. Resident #35 told her it hurt. STNA #76 said you're not hurt. Resident #35 told her it hurt. Resident #35 said he gave a statement to the police. 2. Review of Resident #50's medical record revealed a 01/05/23 admission with diagnoses including quadriplegia, traumatic brain injury, major depressive disorder, anxiety disorder, and abnormal posture. Further review of the medical record including the Minimum Data Set (MDS) 3.0 annual assessment with a reference date of 07/27/23 indicated Resident #50 was independent for daily decision making. The resident required total assist of two for bed mobility, transfers, personal hygiene, toileting and extensive assist for eating. Resident #50 had upper and lower extremity functional limitation bilaterally. Review of the facility SRI #237972 with a created date of 08/10/23 revealed on 08/10/23 the Administrator was notified of an allegation of verbal abuse of residents by State Tested Nurse Aide (STNA) #76. During the course of the investigation, Resident #50's name was given by staff with knowledge of inappropriate behaviors toward him by STNA #76. Behaviors of STNA #76 included flicking Resident #50's left nipple ring and penis, resulting in an allegation of sexual abuse. Resident #50 reported he was not affected by these acts and believed STNA #76 was just joking around. Review of a 08/10/23 untimed statement from Resident #50 included he answered yes when asked if anyone flipped his nipple ring. He said STNA #76 was joking with him. He denied she left a hoyer pad under him or cussed at him about changing his shirt. Review of staff statements included a 08/10/23 statement from STNA #100 as she witnessed STNA #76 cuss at Resident #50 about changing his shirt when he didn't want to. He swore at her so she got in his face. STNA #76 then hoyered him in bed and then left the pad under him and went to lunch. Another aide went in and finished providing care to Resident #50. STNA #100 started to hear things from STNA #76 last month/the beginning of month and was afraid of retaliation. There was a note at the bottom of the statement that stated STNA #100 was educated on the abuse policy at the bottom of the statement. Review of a 08/09/23 (night shift on 08/09/23) STNA #98's statement included she had witnessed STNA #76 being very condescending, making inappropriate comments and being aggressive with multiple residents including Resident #50. STNA #98 has made numerous comments in regards to her employment stating she can't be fired: she will use the race card and threatened to call the The National Advancement of Colored People (NWACP). Review of a 08/09/23 (night shift on 08/09/23) statement by Licensed Practical Nurse (LPN) #81 included STNA #76 had been verbally aggressive with the resident and was visually seen flicking Resident #50's nipple ring. LPN #81 and another nurse attempted to deescalate a situation with an aggressive resident and when STNA #76 came to the situation with an aggressive demeanor, the resident (#50) became more aggressive. Review of a 08/10/23 untimed statement from STNA #93 included STNA #76 would flick Resident #50's nipple ring when he would take a shower and would also do it in front of the 300/400 nurses station where the resident sits and would curse and scream at her and yell for someone to get her away from him. Review of an undated statement from STNA #94 included she heard STNA #76 swear at Resident #50. Two aides were putting the resident to bed and he swung at STNA #76. STNA #94 thought maybe he got hurt or was uncomfortable. STNA #76 grabbed Resident #50's right arm to stop him from hitting her and then stated something along the lines of you're not going to ever fu#### hit me again. STNA #94 reported she told a nurse, but doesn't know which one. STNA #94 couldn't remember the day it happened but thought it was a weekend. Review of a 08/10/23 untimed STNA #99 statement revealed she witnessed STNA #76 refusing to give care to Resident #50 because she wanted to eat. STNA #99 helped another aide use the mechanical lift to get Resident #50 into bed and left him there on the lift pad flat in his bed soiled without a call bell. Review of a 08/10/23 untimed statement by STNA #102 revealed she witnessed STNA #76 have an aggressive tone toward Resident #50 and inappropriate behavior including flicking Resident #50's nipple ring, on numerous occasions. Review of a 08/15/23 statement from Resident #50's sister included she asked him about the incident and he did tell her STNA #76 flicked his penis and nipple. Review of a statement revealed Registered Nurse (RN) #97 on 08/16/23 asked Resident #50 if STNA #76 flicked his bare penis or did he have a brief on. He stated it was his bare penis. Review of a 08/16/23 statement from the DON included Resident #50 refused to speak with the police and doesn't want to press charges. Interview on 08/17/23 at 3:09 P.M. with the DON included on 08/16/23 she spoke to Resident #50 because the police were at the facility to take a report. The resident did not want to talk about it and refused to give the police a statement and did not want to press charges. He did not want to get STNA #76 in trouble and said she was just joking but the facility substantiated sexual abuse based on witness statements. The DON further stated the third resident mentioned by name (Resident #51) did not have any concerns of abuse when she interviewed him. Interview on 08/17/23 at 4:10 P.M. with Resident #50 revealed he did not want to talk about STNA #76. He did not want her to get in trouble. Review of the facility's Abuse, Neglect, and Exploitation policy (revised 10/24/22) included verbal abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Sexual abuse is non-consensual sexual contact of any type with a resident. The facility will implement policies and procedures providing residents, representatives, and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed. Identification of abuse includes resident, staff or family report of abuse. Verbal abuse of resident overheard. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The facility will have written procedures that include reporting of all alleged violations to the Administrator. This deficiency is cited as an incidental finding to Complaint Number OH00145527.

Based on observation, medical record review, facility policy review and staff interview the facility failed to ensure residents in reclined wheelchairs had physician's orders in place for use and were appropriately assessed to determine appropriate indication for use. This affected one resident (Resident #4) of one resident reviewed for possible physical restraint use. The facility identified no current residents utilizing physical restraints. The facility census was 70. Findings include: Observations of Resident #4 from 03/27/23 to 03/30/23 revealed the resident utilized a reclining tilt in space wheelchair (a wheelchair with a tilt feature permitting the whole chair to tilt 30 to 60 degrees while maintaining knees at a 90 degree angle). Review of Resident #4's medical record revealed an admission date of 08/01/18 with diagnoses that included chronic obstructive pulmonary disease, peripheral vascular disease and hypertension. Review of Resident #4's Minimum Data Set (MDS) 3.0 quarterly assessment with a reference date of 02/27/23 identified no use of any type of physical restraint. The resident had a severely impaired cognition level and required extensive to total assistance with all activities of daily living. Further review of the medical record for Resident #4 found no evidence of any physician's order for use of a reclining tilt in space wheelchair. Review of Resident #4's assessments including the Safety Device Data Collection and Evaluation completed on 03/12/23 identified the only device evaluated was the use of assist grab bars to the bed. No assessment for the use of the reclining tilt in space wheelchair was found. Review of Resident #4's plan of care found no care plan or intervention in place regarding the use of a tilt in space wheelchair. Interview with the Director of Nursing on 03/29/23 at 3:50 P.M. revealed Resident #4 uses the reclined tilt in space wheelchair for comfort and positioning as an enabling device, not a physical restraint. She also verified no physician's order for use of the reclined tilt in space wheelchair or assessment to determine if the device is a restraint or an enabling device. Review of the facility policy Restraints with a review/revise date of 01/02/22 revealed restraints shall only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. An evaluation will be completed to determine the medical symptom requiring the device and to determine the least restrictive device to treat the symptom. Care plans which include the use of the physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used and the time limit for the use of the method.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure a behavioral care plan was in place. This affected one (Resident #21) of one resident reviewed for behaviors. The facility census was 70. Findings Include: Review of medical record of Resident #21 revealed an admission date of 02/022/23 and diagnoses included acute and chronic respiratory failure with hypoxia (low blood oxygen), recurrent unspecified major depressive disorder, altered mental status, and cognitive communication deficit. Review of the admission [DATE] Minimum Data Set (MDS) assessment revealed Resident #21 was cognitively intact, required supervision of one person for locomotion, limited assistance of one person for walking and dressing, limited assistance of two persons for bed mobility, and extensive assistance of two persons for transfers. Review of the 02/27/23 progress note revealed Resident #21 was very agitated and was shouting and calling staff names. Review of the 03/06/23 progress note revealed Resident #21 was visibly soiled, and when the nurse and state tested nursing assistant (STNA) offered to toilet and clean up Resident #21, he refused and stated, using profanities, he knew when he needed changed. Review of 03/08/23 progress note revealed Resident #21 was demanding with staff and other residents, yelling in room or hallway demanding his requests be fulfilled at that moment, and impatient with staff regarding various things. Review of the 03/13/23 psychiatry note revealed Resident #21 was very irritable, uncooperative, and used profanities. His affect was angry. Review of the 03/14/23 progress note revealed Resident #21 was verbally aggressive, impulsive and was using profanity. Review of the care plan for Resident #21 revealed there was no behavioral care plan. Observation on 03/27/23 around 9:00 A.M. during the screening process, revealed Resident #21 appeared agitated and short tempered when he answered the surveyor's questions. Interview conducted on 03/28/23 at 1:44 P.M. with Social Services #453 confirmed Resident #21 did have behaviors and all behaviors should be in the care plan. Social Services #453 stated not having a behavioral care plan for Resident #21 might have been an oversight. Review of facility policy Behavior Management Program, revised 01/01/22, revealed for residents exhibiting behaviors negatively affecting self or other residents, the Behavioral Management team would explore the root cause of behaviors/mood, would identify target behaviors, and develop an individualized plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure thorough weekly skin assessments were completed on the open area to the right palm of Resident #39. This affected one resident (Resident #39) of two residents reviewed for non-pressure skin condition. Findings included: Review of the medical record revealed Resident #39 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, persistent vegetative state, COVID-19, cognitive communication deficit, right and left forearm contracture, traumatic brain injury, traumatic subarachnoid hemorrhage, aphasia, epilepsy, pneumonia, deformity of the head, gastrostomy, tracheostomy, and seizures. Review of the physician's orders revealed Resident #39 had an order to cleanse his right palm with normal saline (NS), apply an abdominal dressing, wrap with Kerlix, change daily and as needed dated for 03/20/23. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #39 had severely impaired cognition and required total assist with all activities of daily living. Review of the Pertinent Charting for skin dated 02/01/23 revealed Resident #39 had an open area to the right palm with maceration tissues to surrounding area measuring 0.2 cm in depth and 0.2 circular in size. Intervention was to trim the resident's nails. Review of the weekly Skin Assessments from 02/09/23 to 03/25/23 revealed no measurement or assessment of the open area to the resident's right palm. Observation on 03/28/23 at 10:02 A.M. revealed Licensed Practical Nurse (LPN) #475 opened the hands of Resident #39 and verified the resident's fingernails needed trimmed. At the time of the observation, the open area to the resident's right palm was healed but the area remained reddened. On 03/29/23 at 2:41 P.M. an interview with the Director of Nursing (DON) revealed Resident #39 had an open area to his right hand that was from his fingernail digging in to his hand. The DON verified the lack of skin assessment of Resident #39's open area to his right palm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation,and staff interview the facility failed to ensure bilateral hand splints were applied to the hands of a resident. This affected one resident (Resident #39) of three residents reviewed for mobility. Findings included. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, persistent vegetative state, COVID-19, cognitive communication deficit, right and left forearm contracture, traumatic brain injury, traumatic subarachnoid hemorrhage, aphasia, epilepsy, pneumonia, deformity of the head, gastrostomy, tracheostomy, and seizures. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #39 had severely impaired cognition and required total assistance with all activities of daily living. Review of the plan of care dated 05/08/20 revealed Resident #39 needed activities of daily living assistance related to a traumatic brain injury, comatose, and requiring total dependence on staff for all needs. Interventions included to check nail length, trim and clean on bath day as resident would allow and as necessary. Report any changes to the nurse. Review of the physician's orders revealed Resident #39 had an order (dated 03/20/23) to cleanse his right palm with normal saline (NS), apply an abdominal dressing, wrap with Kerlix, change daily and as needed. The resident also had an order (dated 07/29/22) to wear bilateral hand splints following evening care and removed with morning care per the resident's tolerance and to wear a left upper extremity resting hand splint and right upper therapeutic carrot up to eight hours at a time per the resident's tolerance to maintain upper extremity range of motion. Review of the medical record, including the medication administration record, the treatment administration record and Point Click Care Nurse Assistant Task section revealed no documentation of the bilateral hand splints being applied following evening care and removed with morning care. Review of Resident #39's progress notes from 01/01/23 to 03/29/23 revealed no documentation Resident #39 had refused to allow the staff to put his bilateral hand splints on after evening care. Observation on 03/28/23 at 10:02 A.M. revealed Licensed Practical Nurse (LPN) #475 opened the hands of Resident #39. A interview at this time, LPN #475 verified the resident's fingernails needed trimmed. On 03/30/23 at 11:10 A.M. an interview with the Director or Nursing (DON) verified there was no documentation of the bilateral hand splints being applied in the evening and removed in the morning for Resident #39.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and facility policy review the facility failed to maintain a sterile field during tracheostomy care for Resident #39. This affected one resident (Resident #39) of one resident reviewed for tracheostomy care and treatment. Findings included: Review of the medical record revealed Resident #39 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, persistent vegetative state, COVID-19, cognitive communication deficit, right and left forearm contracture, traumatic brain injury, traumatic subarachnoid hemorrhage, aphasia, epilepsy, pneumonia, deformity of the head, gastrostomy, tracheostomy, and seizures. Review of the physician's orders revealed Resident #39 had an order (dated 07/16/22) for tracheostomy care every shift and as needed. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #39 had severely impaired cognition. The resident required total assist with all activities of daily living and had a tracheostomy. Observation on 03/28/23 at 10:06 A.M. of Licensed Practical Nurse (LPN) #475 providing tracheostomy care to Resident #39 revealed she washed her hands and put on a pair of clean gloves from the box of gloves in the room, and placed a barrier down on the over the bed table. LPN #475 unfastened the resident's tracheostomy oxygen mask with her gloved hands then proceeded to open the sterile tracheostomy kit with her nonsterile gloved hands. LPN #475 took the fluid container/box out of the sterile kit and opened it, placed it on the barrier with her nonsterile gloved hands. LPN #475 then opened the nonsterile container of normal saline (not from the sterile kit but one she had brought into the room from the treatment cart) and poured it into the fluid container. She removed the sterile gloves from the kit with her nonsterile gloved hands and placed them on the barrier then took her nonsterile gloves off and went to wash her hands. LPN #475 verified (during interview) at this time she broke the sterile field by touching the items in the sterile tracheostomy kit with her nonsterile gloved hands and threw everything away and started over. Review of the facility policy titled, Tracheostomy Care, dated 10/30/20 revealed the facility would ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. In Step 6 the procedure indicated to open and set up the sterile tracheostomy care kit and apply sterile gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide ongoing communication with the dialysis center for Resident #7. This affected one resident (Resident #7) of one resident reviewed for dialysis. The facility census was 70. Findings include: Review of the medical record revealed Resident #7 was admitted on [DATE]. Diagnoses included but not limited to end stage renal disease and type 2 diabetes mellitus. Review of the plan of care date dated 02/09/23 revealed Resident #7 required dialysis related to renal failure. Interventions included dialysis on Monday, Wednesday, and Friday, obtain and monitor laboratory/diagnostic work as ordered, and report results to physician and follow up as indicated. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #7 was cognitively intact. Physician orders included dialysis every Monday, Wednesday, and Friday. Review of the medical record for Resident #7 revealed the only dialysis communication was a nutritional profile and pre and post weights dated 03/20/23. Interview on 03/28/23 at 9:12 A.M. with facility Registered Dietician (RD) #480 revealed the facility currently had one dialysis resident, Resident #7. RD #480 contacted the dialysis center to speak with the renal RD when he needed to document on Resident #7. RD #480 revealed he had contacted the dialysis center and left multiple message for a return phone call. RD #480 stated they did speak with someone at the dialysis center and obtained laboratory information. Interview on 03/28/23 at 10:45 A.M. Resident #7 revealed the dialysis center sent paperwork back to the facility with the driver and she was not aware of what information was sent between the facility and the dialysis center. Interview on 03/29/23 at 9:08 A.M. the Director of Nursing (DON) verified the only communication from dialysis was nutritional profile and pre and post weights dated 03/20/23. Interview on 03/29/23 at 9:12 A.M. dialysis Patient Care Technician (PCT) #485 revealed the facility needed to send forms/booklet for the dialysis center for information to be put in to be sent back to the facility. Interview on 03/29/23 at 10:15 A.M. dialysis Administrator #490 revealed Resident #7's current facility did not send a communication book or forms to be filled out and sent back. Administrator #490 stated if there were any changes or problems, the dialysis center would call the facility where Resident #7 resided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #60 had appropriate indications for the use of as needed anti-anxiety medication, and non-pharmalogical interventions were attempted before the as needed anti-anxiety medication was administered. This affected one resident (Resident #60) of five residents reviewed for unnecessary medications. Facility census was 70. Findings include: Review of medical record revealed Resident #60 was admitted on [DATE]. Diagnoses included dementia, major depressive disorder, anxiety, and acute kidney failure. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #60 had cognitive impairment. The MDS also revealed Resident #60 received anti-anxiety medication. Plan of care dated 01/09/23 revealed Resident #60 used anti-anxiety medications related to anxiety disorder. Interventions included to administer medications as ordered and monitor for side effects and effectiveness every shift. Targeted behaviors included obsession over bowel and bladder and fixation on object or person. Review of documentation by State Tested Nursing Assistants (STNA) revealed Resident #60 frequently obsessed over bowel and bladder and was fixated on an object or person. Review of physician orders revealed Resident #60 was ordered lorazepam (anti-anxiety) one milligram (mg) every morning and bedtime and lorazepam 0.5 mg every six hours as needed. The medication administration record (MAR) for February 2023 revealed Resident #60 was administered 44 doses of as needed lorazepam 0.5 mg without documentation of behaviors or non-pharmalogical interventions being attempted before medication was administered. The MAR for March 2023 revealed Resident #60 was administered 21 doses of as needed lorazepam 0.5 mg without documentation of behaviors or non-pharmalogical interventions being attempted before medication was administered. Interview on 03/28/23 at 2:50 P.M. Registered Nurse (RN) #405 revealed Resident #60 would sometimes yell out for staff. RN #405 stated Resident #60 had not been having behaviors recently that she was aware of. RN #405 verified there was no documentation of Resident #60 having behaviors in the last 30 days. Interview on 03/29/23 at 9:46 A.M. Director of Nursing (DON) verified there was no documentation of behaviors or non-pharmalogical interventions being attempted before Resident #60 was administered as needed lorazepam in February and March 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview revealed the facility failed to provide adaptive feeding utensils for Resident #41 at meal time. This affected one resident (Resident #41) of five residents reviewed for nutrition. Findings included: Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, traumatic brain injury, COVID-19, congestive heart failure, chronic kidney disease, muscle weakness, gastroesophageal reflux disease, major depressive disorder, hypothyroidism, generalized anxiety disorder, dysphagia, iron deficiency anemia, hypertension, transient ischemic attack, feeding difficulties, cognitive communication deficit, aphasia, peripheral vascular disease, non-rheumatic mitral valve disorder, and hypomagnesemia. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #41 had moderately impaired cognation, required supervision with eating. Resident #41 had a weight loss and was not on a prescribed weight loss regimen. Review of the physician's orders dated 02/10/23 revealed Resident #41 had an order for curved utensils and a divided plate with meals. Review of the meal ticket dated 03/27/23 revealed Resident #41 was to have a divided plate and right curved utensils. Observation on 03/27/23 at 9:09 A.M. revealed Resident #41 was eating breakfast in her room. She had eaten her cereal, however she had not touched the sausage gravy and biscuits. The resident's meal ticket indicated she was to have curved utensils, however she received regulars silverware from the kitchen on her breakfast tray. On 03/27/23 at 9:10 A.M. an interview with State Tested Nursing Assistant #410 verified Resident #41 had not received curved utensils. She indicated the kitchen could not find them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review the facility failed to notify residents, their representatives and families of a single occurrence COVID-19 in the facility. This affected five residents (Residents #15, #26, #41, #47, and #61) of five residents reviewed for infection control with the potential to affect all 70 residents in the facility. The facility census was 70. Findings included: Review of the facility's COVID-19 positive list for the last four weeks revealed Physical Therapist #505 tested positive on 03/02/23 and Dietary Aide # 403 tested positive on 03/14/23. On 03/30/23 at 11:34 A.M. an interview with Registered Nurse (RN) #420 revealed all families were notified the facility would update the facility website if there was any positive cases of COVID-19 in the facility, RN #420 indicated they did not call families individually unless their family member was affected and positive. RN #420 further indicated the facility residents were not notified unless they were to ask specifically. On 03/30/23 at 12:35 P.M. an interview with Resident #15 revealed the facility used to notify the residents of positive COVID-19 in the facility but not anymore. She indicated she heard through staff gossip. On 03/30/23 at 12:38 P.M. an interview with Family Member #500 revealed the facility used to notify family of positive COVID-19 in the facility but not anymore. He stated he only knows of an outbreak now when he sees the testing cart going around the facility testing the residents. Review of the facility policy titled, COVID-19 Surveillance, dated 10/17/22 revealed the facility would implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness. Residents and representative would be kept up to date on conditions inside the facility related to COVID-19. The minimum information would be reported within 12 hours and subsequently an occurrence of a single confirmed infection of COVID-19 or 3 or more residents or staff with new onset of respiratory symptoms that occur within 72 hours. 1. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included spina bifida, paraplegia, obstructive hyrdrocephalus, edema, obstructive and reflux uropathy, and cervicalgia. Review of the progress notes dated from 03/01/23 to 03/27/23 revealed no documentation Resident #15 was notified of any occurence of COVID-19 positive residents or staff. 2. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses included osteoarthritis, COVID-19, gout, cognitive communication deficit, peripheral vascular disease, and dysphagia. Review of the progress notes dated from 03/01/23 to 03/27/23 revealed no documentation Resident #26 was notified of any occurence of COVID-19 positive residents or staff. 3. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, traumatic brain injury, COVID-19, congestive heart failure, chronic kidney disease, muscle weakness, gastroesophageal reflux disease, major depressive disorder, hypothyroidism, generalized anxiety disorder, dysphagia, iron deficiency anemia, hypertension, transient ischemic attack, feeding difficulties, cognitive communication deficit, aphasia, peripheral vascular disease, nonrheumatic mitral valve disorder, and hypomagnesemia. Review of the progress notes dated from 03/01/23 to 03/27/23 revealed no documentation Resident #41 was notified of any occurence of COVID-19 positive residents or staff. 4. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE]. Diagnoses included sepsis, metabolic encephalopathy, COVID-19, dementia, atrial fibrillation, hypertension, benign prostatic hyperplasia, pacemaker, repeated falls, pleural effusion and cognitive communication deficit. Review of the progress notes dated from 03/01/23 to 03/27/23 revealed no documentation Resident #47 was notified of any occurence of COVID-19 positive residents or staff. 5. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, anxiety disorder, COVID-19, diabetes, pneumonitis, subarachnoid hemorrhage, osteoarthritis, chronic kidney disease, cognitive communication deficit, atrial fibrillation cardiomyopathy, hypertension, acute respiratory failure, aphasia, gout, insomnia, obstructive sleep apnea, and dementia. Review of the progress notes dated from 03/01/23 to 03/27/23 revealed no documentation Resident #61 was notified of any occurence of COVID-19 positive residents or staff.

Based on review of the Self Reported Incident (SRI), policy review and staff interview, the facility failed to follow their abuse policy to complete a thorough investigation for an allegation of neglect. This affected one of one SRI reviewed and Resident #56. Findings include: Review of the SRI tracking number 186533 revealed on 01/07/20 an allegation of neglect. Resident #56's son voiced complaints to the Administrator of the facility being neglectful because the resident had a wound on her bottom and went to the hospital looking dirty. Review of the SRI folder revealed the investigation included five resident interviews that answered the questions How is your care? and Do you feel you are getting the care you need? The SRI included the wound was reoccurring and the dressing changed on 01/05/20. There was no evidence of a statement from the resident who was verbal with moderately impaired cognition. The investigation did not include investigating the allegation of the resident looking dirty. There was no evidence of asking the staff on duty when the resident went to the hospital, when incontinence care was last provided or if she had been bathed. The investigation did not include reviewing bathing documentation to investigate when the resident was last bathed. The SRI did not include how long the resident had the wound, where the wound was or what the wound was classified as. The investigation did not include whether the treatment was consistently being provided as ordered. The investigation did not address whether preventative measures had been in place prior to the development of the wound. Interview on 02/19/20 at 1:47 P.M. of the Administrator verified the abuse policy was not followed to conduct a complete investigation for an allegation of abuse, including interviewing the resident and staff and reviewing bathing, treatment and care documentation. Review of the facility's Abuse Prevention Program, revised 02/22/18, included interview staff members who have had contact with the resident during the period of the alleged incident and interview the resident as medically appropriate.

Based on review of the Self Reported Incident (SRI), policy review and staff interview, the facility failed to ensure an allegation of neglect was thoroughly investigated. This affected one of one SRI reviewed and Resident #56. Findings include: Review of the SRI tracking number 186533 revealed on 01/07/20 an allegation of neglect. Resident #56's son voiced complaints to the Administrator of the facility being neglectful because the resident had a wound on her bottom and went to the hospital looking dirty. Review of Resident #56 revealed she was moderately impaired for daily decision making with diagnoses of quadriplegia, chronic obstructive pulmonary disease, pseudobulbar affect, history of traumatic brain injury, schizophrenia, anxiety, bipolar disorder, personality disorder and contracture of knee. Review of the SRI folder revealed the investigation included five resident interviews that answered the questions How is your care? and Do you feel you are getting the care you need? The SRI included the wound was reoccurring and the dressing changed on 01/05/20. There was no evidence of a statement from the resident who was verbal with moderately impaired cognition. The investigation did not include investigating the allegation of the resident looking dirty. There was no evidence of asking the staff on duty when the resident went to the hospital, when incontinence care was last provided or if she had been bathed. The investigation did not include reviewing bathing documentation to investigate when the resident was last bathed. The SRI did not include how long the resident had the wound, where the wound was or what the wound was classified as. The investigation did not include whether the treatment was consistently being provided as ordered. The investigation did not address whether preventative measures had been in place prior to the development of the wound. Interview on 02/19/20 at 01:47 P.M. of the Administrator verified she did not address the allegation of being dirty in the SRI investigation. The Administrator did not determine the last time she had pericare or been bathed. The Administrator did not get statements from staff to determine how she looked prior to leaving, if she had incontinence care and when the last bath was provided. Review of the facility's Abuse Prevention Program revised 02/22/18 included interview staff members who have had contact with the resident during the period of the alleged incident and interview the resident as medically appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to ensure a dependent resident received baths and nail care. This affected one (Resident #56) of one resident reviewed for activities of daily living. Findings include: Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including quadriplegia, chronic obstructive pulmonary disease, pseudobulbar affect, history of traumatic brain injury, schizophrenia, anxiety, bipolar disorder, personality disorder and contracture of knee. Review of the 01/27/16 Activities of Daily Living plan of care revealed a 01/27/16 intervention to check nail length and trim and clean on bath day as resident allows and as necessary. A 01/27/16 intervention included resident preferring showers and being totally dependent of staff for showers. Review of the 01/19/20 five-day Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for daily decision making, had no behaviors, was totally dependent of two staff for bed mobility, transfers, personal hygiene, toilet use, and extensive assist of one staff for dressing, eating, bathing, with upper and lower extremity impairment on both sides. Observation 02/18/20 at 12:09 P.M. of Resident #56 revealed she was in a tilt-in-space wheelchair in the dining room. The resident had a Hoyer lift pad under her and was being fed by State Tested Nurse Aide (STNA) #11. The resident's left hand, wrist and fingers were contracted. Fingernails were long bilaterally approximately 1/4th to 3/8th's inches long. The nails of the second and third fingers of the left hand were curled into palm of her hand. There was no splint device present. The resident's forehead was beaded with moisture. Her eyes had yellow/brown dried debris in the corners and on the lashes. Interview of STNA #11 at the time of the observation revealed the resident was being transferred to another facility later in the day. STNA #11 verified her fingernails were long. STNA #11 verified the contracted fingers were positioned where the nails were touching the palm of her hand. STNA #11 was asked if the resident was being bathed prior to transfer. STNA #11 stated she was an afternoon shower. Interview on 02/18/20 at 2:32 P.M. with Resident #56 revealed they cut her fingernails after I pointed out how long they were to the staff. The resident included they said her left palm was calloused. Resident #56 revealed they had not bathed her that day. Observation revealed her eyes remained crusted. There were two aides in the hall with the resident. When asked if she received a bath or shower prior to transfer, they did not respond. Review of the bathing task revealed the resident was to be bathed every Monday, Wednesday and Friday. Review of the documentation revealed the last bath was given 02/14/20. There was no evidence of the resident being bathed on Monday 02/17/20 or Tuesday 02/18/20 the day of transfer. Interview on 02/19/20 at 12:20 P.M. with the Director of Nursing (DON) verified there was no evidence of the resident being bathed since 02/14/20. The DON verified the resident had not been bathed prior to being transferred to another facility. The DON verified she saw the resident's fingernails on 02/18/20 and they were long and could damage the palm of her contracted hand. Review of the facility Care of Fingernails/Toenails policy revised 01/16/11 included nail care included daily cleaning and regular trimming. Review of the facility Shower/Tub Bath policy revised 01/16/11 included notify the supervisor if the resident refuses the shower/tub bath.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure pressure relieving measures were provided to a resident with pressure ulcers. This affected one (Resident #23) of two residents reviewed for pressure ulcers. The facility identified six residents with pressure ulcers. Findings include: Review of Resident #23 revealed the resident was admitted [DATE] with diagnoses including spina bifida, paraplegia, obstructive hydrocephalus, obstructive and reflux uropathy and muscle weakness. The Activity of Daily Living plan of care initiated 04/21/17 included the resident required extensive assist of one staff to turn and reposition in bed and as necessary. A 10/23/19 Pressure Ulcer plan of care included the resident needed to turn/reposition at least every two hours, more often as needed or requested. Physician orders included a 03/21/18 order for a mechanical lift for all transfers related to Spina Bifida and a 09/10/19 order to encourage resident to turn and reposition in bed as tolerated. Review of the 12/11/19 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was independent for daily decision making, with no mood or behaviors, extensive assist of two staff for bed mobility and personal hygiene, totally dependent of two staff for transfers, toileting and bathing, and lower extremity impairment on both sides. The resident was at risk of pressure ulcers and had two Stage II (partial-thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguineous filled blister), one Stage IV (full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often include undermining and tunnel) and two unstageable (full-thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed) pressure ulcers. The resident had a pressure reducing bed, turning and repositioning program, pressure ulcer care and nutrition/hydration program. Review revealed four current pressure ulcers. A Stage IV to the right posterior skin fold measuring 6.5 centimeters (cm) x 4.0 cm x 1.8 cm, a Stage IV to the left gluteal fold measuring 3.5 cm x 3.0 cm x 0.5 cm, a Stage II to the right buttock measuring 4.7 cm x 6.5 cm x 0.1 cm and a Stage II to the right posterior upper thigh measuring 6.8 cm x 4cm x 0.1 cm. All measurements were from 02/18/20. Interview on 02/18/20 at 3:07 P.M. with Resident #23 revealed they don't always turn her every two hours. She had no feeling in her lower body, doesn't get pain or recognize she needs to turn. Observation on 02/19/20 at 2:54 P.M. revealed a pillow to the right side turning her to the left. Observation and interview on 02/19/20 at 4:37 P.M. revealed the resident remained on the left side. The resident said she had not been turned since I was in last. The resident said she doesn't pay attention to what time she is turned and doesn't ring the bell to be turned. Observation and interview on 02/19/20 at 6:31 P.M. resident remained on left side. She said she had not been turned since her dressing were changed that morning. The resident said day shift doesn't come and do it and 2:00-10:00 P.M. shift does more, but they had not been in yet. Interview on 02/19/20 at 6:33 P.M. of State Tested Nurse Aide (STNA) #80 revealed she arrived at 2:00 P.M STNA #80 revealed she had not turned her since she arrived for her shift. She said she usually waits until after supper then changes her and turns her. STNA #80 did not know the last time day shift turned her. Interview of STNA #13 revealed she had not turned her yet since she arrived at 2:00 P.M., and she did not know the last time day shift turned her. Interview of STNA #83 revealed she was in training and did not know the last time the resident was turned. She had not turned her. Observation on 02/19/20 at 6:36 P.M. of STNA #13 and STNA #83 revealed they turned the resident onto her right side. The aides did not pull down the lift pad to observe if the resident's skin was red or if she was soiled and needed changed. When asked to check if her skin was red, the spine was observed to be greatly deformed folding onto itself and short deformed lower extremities. The fold was wet. STNA #13 said they usually put powder in the fold and lotion; however, initially they just turned her without looking to see if she required more care. Untaped dressings were observed. The staff said the nurses don't tape them on due to the skin being fragile. Interview on 02/19/20 at 7:22 P.M. with the Director of Nursing (DON) revealed STNA #39 said she went into the room after she arrived at 2:00 P.M. and asked her if she wanted turned, and she refused. Interview on 02/20/20 at 7:51 A.M. revealed the resident was on her right side working on her laptop computer. She denied STNA #39 coming in her room the previous afternoon and asking her if she wanted turned. Interview on 02/20/20 at 12:35 P.M. with STNA #40 revealed she had the 100 hall on day shift the previous day. STNA #40 revealed she gave her a bedbath before breakfast the previous morning. She helped the nurse turn her around 6:30 A.M. for her dressing change and bathed her at that time. She said the resident doesn't ring often. She took her roommate to the bathroom and put her roommate in and out of bed. She asked her if she needed anything, and she said no. STNA #40 revealed she did not ask the resident if she wanted turned because she figured she would refuse. STNA #40 verified she repositioned the resident approximately 6:30 A.M. and she was not repositioned the remainder of the dayshift which ended at 2:00 P.M.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure monthly medication reviews identified when a gradual dose reduction (GDR) recommendation for a psychoactive drug was not properly addressed by the physician. This affected one resident (Resident #32) of five residents reviewed for unnecessary medications. Findings include: Review of medical records revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, major depressive disorder and muscle weakness. Review of the pharmacy recommendations dated 08/27/19 revealed the pharmacist made the recommendation for a GDR for Klonopin (sedative used to treat anxiety) 2 milligrams (mg), which was initially ordered on 03/19/19. The physician addressed the recommendation by referring the resident to the psychiatrist. The resident was seen by psychiatry on 09/12/19; however, the pharmacy recommendation was not addressed. There was no documented evidence of a GDR within the last year for the Klonopin and no evidence that the pharmacist addressed the need for a GDR during monthly pharmacy reviews after August 2019. Review of Resident #32's Medication Administration Record (MAR), dated February 2020, revealed the order for Klonopin 2 mg by mouth every day. The resident had received the medication since 03/19/19. During interview on 02/20/20 at 1:30 P.M., the Director of Nursing (DON) verified Resident #32's monthly medication review failed to properly identify why the pharmacist's recommendation on 08/27/19 was not completely addressed to ensure the medication was at its lowest dosage and why no subsequent pharmacy recommendation for a GDR of Klonopin was documented.

Based on observation, interview and policy review, the facility failed to store and prepare food under sanitary conditions. This affected all but Residents #15 and #21 who do not receive nutrition from the kitchen. The census was 63. Findings include: Observation of the kitchen during initial tour 02/18/20 from 8:45 AM through 9:10 A.M. revealed the ansul system above the cooktop, grill, steamer and ovens had a large amount of dust. Six spray heads had dust covering their surface. The dust in areas protruded 1/4th inch from the surface with a puffy appearance. The water pipe extending the length of the hood connecting the six spray heads had dust accumulated along the circumference and more heavily across the top. The pipe had dust protruding from the surface. The four lights illuminating the cooktop, grill area under the hood had dust from the surface of the bulb connecting to the metal webbing surrounding the bulb. The light bulbs and the metal safety bulb protector surrounding the bulb were dusty. The walk in refrigerator had 40 individual bowls of mandarin oranges on trays uncovered and five individual servings of applesauce on a tray uncovered, both undated. There was an open container of cottage cheese with a 02/04/20 open date written on the surface. The best used by date was 01/31/20. Review of the cleaning schedule revealed dusting of the piping, ansul system and lights was not on the cleaning schedule. Interview on 02/18/20 at 9:10 A.M. with Dietitian #63 verified the dust over food prep areas, outdated and uncovered food. Review of the Food Receiving and Storage Policy revised 06/23/16 included all foods stored in the refrigerator or freezer will be covered, labeled and dated with the use by date.