Based on observation, staff and family interviews, record review and facility policy review, the facility didn't ensure indwelling urinary catheter bags were timely covered in a dignified manner. This affected one (Resident #8) out of two residents reviewed for dignity and had the potential to affect four additional (Residents #15, #37, #41, and #206) the facility identified as having indwelling urinary catheters. The facility census was 56. Findings include: Review of the medical record for Resident #8 revealed an admission date of 05/19/25 and a readmission date of 06/12/25. Pertinent diagnoses included retention of urine, obstructive and reflux uropathy (blockage in body which makes it difficult or impossible to urinate), disorder of kidney and ureter (small tubes of muscle that transport urine from kidneys to the urinary bladder), and chronic kidney disease. Review of the readmission Minimum Data Set (MDS) assessment revealed it was in process of being completed. Review of the 06/02/25 discharge MDS assessment revealed the staff had assessed Resident #8 as having modified cognitive status and an indwelling urinary catheter. Further review of Resident #8's medical record revealed physician orders dated 06/13/25 for a 16 French (F) Foley catheter with 10 cubic centimeters (cc) balloon (indwelling urinary catheter) to continuous drainage and to change the Foley drainage bag every 30 days and PRN (as needed). Observation on 06/16/25 at 9:04 A.M. revealed Resident #8 was lying in bed, and there was an uncovered indwelling urinary catheter collection bag of urine hanging on the left side of the bed, which was visible from the hallway and was one third full of urine. Interview on 06/16/25 at 9:17 A.M. with Therapy Manager #266 and Physical Therapy Assistant #267 confirmed Resident #8's indwelling urinary catheter bag wasn't covered, and they stated there was usually a privacy cover on the bag. Observation on 06/17/25 at 8:14 A.M. revealed Resident #8 was lying in his bed. His indwelling urinary catheter collection bag was hanging on the left side of the bed which was visible from the hallway, but the collection bag now had a blue privacy covering. Continued review of Resident #8's medical record revealed a progress note dated 06/17/25 and authored by Assistant Director of Nursing Registered Nurse (ADON/RN) #266 which indicated ADON/RN #266 had changed Resident #8's indwelling urinary catheter bag to a fig leaf privacy bag. Interview on 06/17/25 at 9:27 A.M. with ADON/RN #266 stated the indwelling urinary catheter collection bag which the resident had come back from the hospital with hadn't had a privacy covering attached. He stated normally the facility would change the collection bag to one with a privacy cover on it, but the facility hadn't gotten around to changing Resident #8's collection bag until he changed the collection bag on 06/17/25. Interview on 06/17/25 at 12:19 P.M. with family members of Resident #8 revealed the catheter collection bag hadn't been covered until 06/16/25 when it was covered with a pillowcase. They stated on 06/17/25 the indwelling urinary catheter collection bag had been changed to one with a privacy covering. Review of facility policy/procedure Foley Catheter Care Procedure, dated January 2025, revealed there was nothing in the policy/procedure indicating the indwelling urinary catheter drainage bag should have a privacy covering. Review of the undated facility policy Resident Rights revealed the resident had the right to be treated at all times with courtesy, respect, and full recognition of dignity and individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview and facility policy review, the facility failed to ensure residents' wishes regarding end-of-life measures were signed by the physician. This affected two (Residents #6 and #47) of three residents reviewed for Advanced Directives. The facility census was 56. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 01/08/24. Diagnoses included dementia, depression, diabetes and kidney failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was severely cognitively impaired. She required set up help for eating, oral and personal hygiene, partial assistance for showering and substantial assistance for toileting. Review of the physicians' orders for June 2025 for Resident #6 revealed an order for Do Not Resuscitate, Comfort Care only, comfort care will be provided, even before a cardiac or respiratory arrest occurs (DNRCC). Review of the Do Not Resuscitate (DNR) form dated 01/08/24 revealed no evidence that the required signature of the physician had been obtained. 2. Review of the medical record for Resident #47 revealed an admission date of 12/20/24. Diagnoses included cirrhosis of the liver, repeated falls, congestive heart failure and depression. Review of the quarterly MDS assessment dated [DATE] revealed Resident #46 was cognitively intact. She required set up help for eating, oral and personal hygiene, supervision for toileting and dressing and partial assistance for showering. Review of the physician' orders for June 2025 for Resident #47 revealed an order for a DNRCC. Review of the DNR form dated 12/20/24 revealed no evidence the required signature of the physician had been obtained. Interview on 06/17/25 at 8:50 A.M. with Certified Nurse Aide (CNA) #205 confirmed neither DNR form for Resident #6 or #47 had been signed by the physician. Review of the facility policy titled Advance Directives, dated 08/01/22, did not address the completion of the DNR form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, tray ticket and facility policy reviews, the facility failed to ensure fluid restrictions were followed as ordered for Residents #26 and #158. This affected two (Residents #26 and #158) out of four residents reviewed for nutrition and had the potential to affect one additional (Resident #36) identified by the facility as being on a fluid restriction. Additionally, the facility failed to ensure weekly weights were obtained as ordered for Residents #26. This affected one (Residents #26) out of four residents reviewed for nutrition. The facility census was 56. Findings include: 1. Review of the medical record for Resident #158 revealed an admission date of 05/12/25 and a reentry date of 06/07/25. Diagnoses included acute on chronic combined systolic and diastolic heart failure (CHF), Non-ST elevation (NSTEM) myocardial infarction (heart attack), cardiomyopathies (disease of the heart muscle), hypertension (high blood pressure), and hyperlipidemia. Review of Resident #158's history and physical dated 05/13/25 revealed the resident was admitted to the facility after being hospitalized from [DATE] to 05/12/25 for new onset of CHF. During hospitalization, a CHF nurse was consulted and completed education with the resident. Due to new onset CHF, dyspnea (shortness of breath) on exertion, and lower extremity edema, the physician ordered a fluid restriction for the resident along with the resident being weighed three times a week. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #158 was cognitively intact, did not reject care, required setup or cleanup assistance from staff for eating, and was on a therapeutic diet. Review of the physician orders revealed an order dated 05/13/25 for an 1800 ml (milliliter)/day fluid restriction due to CHF with nursing giving 120 ml each medication pass (480ml/day) and dietary providing 1320 ml/day. The 1800 ml fluid restriction order was discontinued on 06/07/25, and a 2000 ml fluid restriction was started on 06/07/25 with nursing providing 250 ml each medication pass (1000 ml/day) and dietary providing 1000 ml/day. Review of Resident #158's care plan dated 05/13/25 revealed the resident was at risk for fluid volume excess due to CHF and edema. Interventions included fluid restriction as ordered, encourage fluids within fluid restriction, and observe for edema and report to physician as needed. Observation on 06/17/25 at 8:06 A.M. revealed there was one large white Styrofoam cup with a lid full of water and ice on Resident #158's over bed table. At the time of observation, Resident #158 stated she was not aware she was on any special diet or fluid restriction, and the Styrofoam cup was full of ice water, which had just been brought to her by a staff member. Interview on 06/17/25 at 8:25 A.M. with Activity Aide #325 and Activity Supervisor #277 revealed the activity department would pass water to residents every day. They stated they were made aware of who was on a fluid restriction via the dashboard of the electronic medical record (EMR), which would show any changes, or by the nurses verbally telling them. They stated they were unaware Resident #158 was on a fluid restriction and Activity Aide #325 confirmed she had given Resident #158 a full cup of ice water, which was a 20-ounce cup (591 ml). Interview on 06/17/25 at 11:06 A.M. with Dietary Supervisor #224 revealed for residents who were on a fluid restriction, nursing would let him know how much fluids dietary were allowed in a day, and he would divide that number by three and then put on the dietary ticket how much fluids a resident was allowed for each meal. He stated the tray tickets would go down with the beverage cart prior to the meal so the aides could take the meal orders and would know who was on a fluid restriction. After the beverages were passed and meal orders were taken, the aides would return the meal tickets with the meal orders written on them. Interview on 06/17/25 at 11:28 A.M. with Certified Nurse's Aide (CAN) #206, who normally worked the day shift on the unit where Resident #158 resided, revealed she believed there wasn't anyone on the unit who was on a fluid restriction, and if a resident was on a fluid restriction, the resident shouldn't have a water pitcher in the room. She indicated she wasn't always able to see in the EMR if a resident was on a fluid restriction, and if she had a question about a fluid restriction, she would ask the nurse. Interview on 06/17/25 at 2:37 P.M. with CNA #263, who normally worked afternoon shift on the unit where Resident #158 resided, revealed she was unaware Resident #158 was on a fluid restriction. Review of Resident #158's lunch meal ticket dated 06/17/25 revealed there was nothing noted on the meal ticket indicating the resident was on a fluid restriction. An additional interview on 06/18/25 at 8:07 A.M. with Dietary Supervisor #224 confirmed after reviewing Resident #158's lunch meal ticket dated 06/17/25 there was nothing noted on Resident #158's meal ticket to indicate the resident was on a fluid restriction. He stated normally he would note the fluid restriction at the bottom of the ticket, which he stated he hadn't done. He went on to state the CNAs used the tray tickets as a means of knowing who was on a fluid restriction. Interview on 06/12/25 at 9:05 A.M. with Dietitian #270 stated a fluid restriction should be noted on a resident's tray ticket. 2. Review of the medical record for Resident #26 revealed a date of admission of 09/26/24 with diagnoses including cerebral infarction due to embolism of an unspecified cerebral artery, hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side, congestive heart failure and prediabetes. Significant orders included reduced concentrated sweets diet, mechanical soft texture, thin liquid consistency, weights three times a week on Monday, Wednesday, and Friday for CHF dated 02/17/25, 1800 ml in 24 hours fluid restriction, 480 ml nursing (120 ml each medication pass) and 1320 ml dietary dated 04/17/25, and Bumex (a diuretic to remove excess water from the body) one milligram (mg), one tablet daily for CHF dated 02/13/25. Review of the nurse practitioner note dated 02/12/25 revealed Resident #26 was noted to have a weight gain. The assessment and plan within the note revealed a diagnosis of CHF with weight gain. The plan was to continue weights three times a week as well as adding a fluid restriction of 1800 ml daily. Review of the quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating Resident #26 was cognitively intact. The MDS further revealed a weight gain of 5% or more while not on a physician prescribed weight gain regimen. Review of the care plan dated 05/09/25 revealed Resident #26 had the potential for fluid volume excess or decreased fluid volume related to diet and medicine use. Interventions included, dietary to review meal intakes, weights, and fluid needs as needed, fluid restrictions as ordered, weights as ordered, observe for edema and report to the physician as needed. The care plan further revealed Resident #26 was at risk for altered nutrition related to medical diagnosis including diabetes mellitus type two, risks and weight fluctuations associated with diuretic use, daily fluid restriction, variable meal intakes and significant weight variances. Interventions included providing and serving diet as ordered, obtaining weights as ordered, and providing fluid restrictions as ordered. Review of the medication administration records (MARs) dated 02/01/25 through 06/17/25 revealed no orders on the record for the nursing staff for weights three times weekly on Monday, Wednesday and Friday. A review of the MARs dated 04/01/25 through 06/17/25 revealed no orders on the records for 1800 ml fluid restrictions. Review of the dietician progress note dated 06/05/25 revealed a current weight of 175 pounds reflecting a continued weight gain. Significant weight gain noted for three and six months. The note further revealed potential for weight fluctuations related to the history of edema and diuretic therapy. Recommendations were to continue weights on Monday, Wednesday, and Friday per order, and 1800 ml daily fluid restriction. A review of documented weights for Resident #26 revealed the following: • 02/14/25: 166.0 pounds • 02/17/25: 165.0 pounds • 02/21/25: 166.1 pounds • 02/28/25: 162.0 pounds • 03/03/25: 158.4 pounds • 04/01/25: 171.6 pounds • 04/16/25: 176.0 pounds • 04/21/25: 178.2 pounds • 05/02/25: 173.4 pounds • 06/03/25: 175.0 pounds The weights were documented as being taken on a seated scale. A review of the facility diet list dated 06/17/25 revealed Resident #26 was not listed for a dietary fluid restriction. On 06/17/25 at 4:00 P.M. an interview with the Director of Nursing (DON) verified the MARs dated 02/01/25 through 06/17/25 had no orders for weights three times weekly on Monday, Wednesday and Friday. The DON further verified the MARs dated 04/01/25 through 06/17/25 had no orders for the 1800 ml fluid restrictions. The DON stated the orders were entered incorrectly and therefore not carried out resulting in Resident #26 not having weights three times weekly on Monday, Wednesday and Friday and no fluid restriction of 1800ml. A review of the policy titled; Weight Management Program and Weight Loss Policy, revised 11/29/24, revealed all residents will be weighed monthly and as ordered. The policy further revealed weights will be reviewed by the dietitian and designated nurse monthly and as needed. The DON or designee will maintain a list of residents in the weekly weight program and the dietitian weekly reports. The DON or designee will review the dashboard for high-risk weight changes progress notes daily and address accordingly. The dietitian will review all residents' monthly weight reports during the weight committee meeting. Any issues or trends in resident weights will be discussed and documented. The interdisciplinary team will meet weekly to discuss all resident weight issues, including dietitian recommendations. The team will ensure all recommendations have been implemented. A review of the policy titled; Nutrition/Hydration, revised 06/17/25, revealed a resident's diet will be recorded on the physician orders and dietary communication form to the kitchen. Any changes must be reflected in a physician order and written communication to the dietary department. The policy further revealed upon admission the residents baseline weight and height will be obtained and recorded in point click care period new residents and readmitted residents will be weighed weekly for four weeks. Weekly weights may be continued according to the recommendation of the dietician. Nutritional meetings will be held weekly with the dietitian. All recommendations will be communicated as soon as possible to the physician and new orders will be implemented. The policy also stated all residents will be reviewed at least quarterly by the facility dietitian and more often as needed based on skin changes, changing condition, changing intakes, weight concerns or other clinical changes. Recommendations may be generated and will be communicated as soon as possible to the physician and new orders will be implemented. A review of the policy titled Policies and Procedures Manual Policy/Procedure Dietary, dated 01/22/25, revealed the purpose of the policy is to manage fluid overload in the body, particularly when there is an issue with the heart, kidney or liver. The procedure to divide fluids was stated as follows: • Count the number of medication passes the resident has. • Decide the least amount of fluid the resident needs at each medication pass. If possible try to use only 120 ml at each medication pass. • Add the milliliters from each medication pass to get the total amount of fluid allotted to nursing. • Subtract the amount of nursing milliliters from the total fluid restriction amount to get the amount dietary can use for meals. • Notify the dietary department of the amount of fluid allotted for meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and facility policy review, the facility failed to ensure respiratory equipment was dated and monitored for routine replacement. This affected two (Residents #41 and #48) of four residents reviewed for respiratory care but had the potential to affect an additional 10 (Residents #2, #7, #9, #12, #20, #33, #34, #43, #157, and #158) the facility identified as using oxygen. The facility census was 56. Findings include: 1. Review of Resident #41's medical record revealed an admission date of 01/29/25 with diagnoses including pneumonia, atrial fibrillation (irregular heart rhythm), anxiety disorder, vascular dementia, acidosis (too much acid in the body fluids), bradycardia (heart beats more slowly than expected), atherosclerotic heart disease, hypertension (high blood pressure), right bundle branch block (an obstacle in the right bundle branch of the heart that makes the heartbeat late and creates an irregular heart beat), and old myocardial infarction (heart attack). Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was severely impaired cognitively, was dependent on staff for all activities of daily living (ADL) and mobility, was under Hospice services, and used oxygen. Review of Resident #41's physician orders dated 06/06/25 revealed an order for oxygen at three liters via nasal cannula and may titrate to maintain SPO2 (blood oxygen level) greater than 90 percent and an order to change oxygen tubing every week and PRN (as needed). Observation on 06/16/25 at 9:38 A.M. revealed Resident #41's oxygen tubing was not dated. Observation on 06/16/25 at 9:53 A.M. of Resident #41's oxygen tubing and interview with Assistant Director of Nursing Registered Nurse (ADON/RN) #265 revealed ADON/RN #265 confirmed no date was present and should have been dated when oxygen tubing was changed. ADON/RN #265 stated he was just getting ready to go around and date the oxygen tubing. Observation of ADON/RN #265 at time of interview revealed he had a roll of white surgical tape and black marker in hand. 2. Review of Resident #48's medical record revealed an admission date of 06/01/25 with diagnoses including atherosclerotic heart disease, cerebral ischemia (a condition that occurs when there isn't enough blood flow to the brain), chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and dependence on supplemental oxygen. Review of the admission MDS assessment revealed Resident #48 was moderately impaired cognitively, required substantial/maximum assistance from staff for toileting hygiene, bathing, and to transfer from bed/chair to chair, and used oxygen. Review of Resident #48's physician orders dated 06/02/25 revealed an order for continuous oxygen at two liters per minute and an order to change the nasal canula every Thursday. Observation on 06/16/25 at 8:44 A.M. revealed Resident #48's oxygen tubing was not dated. Interview on 06/16/25 at 9:31 A.M. with Registered Nurse (RN) #220 revealed oxygen tubing was to be changed weekly during the night shift, and the tubing should be dated when changed. Observation of Resident #48's oxygen tubing at the time of interview with RN #220 revealed RN #220 confirmed no date was present and should have been dated when the oxygen tubing was changed. Review of the facility policy Oxygen Therapy, revised 08/07/14, revealed oxygen tubing must be dated/initialed and changed weekly.

**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 ensure pharmacy recommendations were reviewed and responded to timely by the physician and/or practitioner. This affected two (Residents #17 and #20) of five residents reviewed for unnecessary medications. The facility census was 56. Findings include: 1. Record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, chronic atrial fibrillation, type two diabetes, hypertension, peripheral vascular disease, lymphedema, benign prostatic hyperplasia, osteoarthritis, hypothyroid, hypomagnesemia, ulcerative colitis, post traumatic disorder, metabolic encephalopathy, major depressive disorder, heart failure, and dementia. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #17 had intact cognition and was receiving antidepressant medication, anticoagulant medication, diuretic medication, antiplatelet medication and hypoglycemic medication during the assessment period. Review of the medication orders revealed on 03/29/25 Resident #17 received an order to administer Remeron oral tablet 15 milligram (mg) (antidepressant) one time a day for sleep. Review of facility document titled Note to Attending Physician/Prescriber dated 04/27/25 revealed a pharmacy recommendation made to the physician to clarify the supporting diagnosis for the medication Aricept so that nursing could update the orders in Point Click Care (PCC), the electronic medical record (EMR). Further review of the physician/prescriber response revealed a prescriber agreed with and wrote changed diagnosis to dementia. A prescriber signature and date were missing from the response. Review of Resident #17 medication records, treatment records, progress notes, physician response documentation and physician orders revealed there was no documentation of a response from the physician to the pharmacy of facility staff regarding the recommendations made by pharmacy on 04/27/25 and 05/29/25. Review of facility document titled Note to Attending Physician/Prescriber dated 05/29/25 revealed the pharmacy stated hypnotic drug have a Gradual Dose Reduction (GDR) attempt quarterly when used routinely. The pharmacy requested an attempt for a dose reduction or trial as needed use to verify the resident was on the lowest possible dose. The pharmacy also stated if a GDR was not appropriate at this time, please document a clinical rational for continuing therapy. Further review of the undated Physician/Prescriber Response revealed a note that Resident #17 would be seen by psych team on next scheduled visit 06/26/25. The document was not signed or dated by the practitioner. Review of Resident #17 medication orders revealed an updated order on 06/17/25 for Aricept oral tablet five mg (improves mental function) one tablet by mouth daily. 2. Record review for Resident #20 revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia, chronic obstructive pulmonary disease, protein calorie malnutrition, hypertension, insomnia, chronic pain syndrome, anxiety, atrial fibrillation, hypotension, syncope, hyperlipidemia, Vitamin D deficiency, Vitamin B12 deficiency, history of falling, changes in retinal vascular appearance, drug induced constipation, major depressive disorder, other symptoms and signs concerning food and fluid intake, gastro esophageal reflux, pain in hand, partial intestinal obstruction, muscle weakness, abnormal posture, abnormal gait. Review of the quarterly MDS assessment dated [DATE] revealed Resident #20 had moderately impaired cognition. The resident received antidepressant medication and anticoagulation medication during the seven-day assessment reference period. Review of the physician orders revealed on 11/25/24 Resident #20 was ordered to receive Reglan oral tablet five mg (antiemetic). (Reglan has a black box warning for the serious side effect of tardive dyskinesia, which is a potentially irreversible movement disorder). Review of the facility document the pharmacy monthly medication review dated 04/27/25 for Resident #20 revealed the pharmacy recommended Abnormal Involuntary Movement Scale (AIMS) testing completed upon initiation of Reglan and every six months thereafter. The pharmacy wrote at the time of the review that an AIMS test was not available in PCC and suggested nursing complete an AIMS test at their earliest convenience. It was noted that a boxed warning for Reglan chronic or high dose use had been linked to tardive dyskinesia which continues even after discontinuation of the drug. Those at greatest risk were the elderly and recommended Reglan treatment not to exceed three months. Further review of the document revealed the physician/prescriber did not respond, sign or date the recommendation but a written statement from the Director of Nursing (DON) dated 06/17/25 revealed an AIMS test was performed on 06/17/25. Further review of the medical records for Resident #20 including progress notes, medication orders, and physician progress notes revealed no evidence the physician responded to the pharmacy recommendation dated 04/27/25. Interview on 06/18/25 at 8:36 A.M. with the DON revealed the facility utilized Wellness Director #271 to direct all the pharmacy recommendations and GDR to the physician or practitioner through email, or a folder was given to the practitioner to review upon visits to the facility. Wellness Director #217 ensured the pharmacy recommendations were signed and dated by the practitioner. Interview on 06/18/25 at 9:00 A.M with the DON verified there was not a physician signature or date regarding the pharmacy recommendation dated 04/27/25 for a supporting diagnosis of dementia, additionally the DON verified a practitioner did not sign or date they received the pharmacy recommendation dated 05/29/25 for Resident #17 GDR recommendation. The DON verified she wrote the response Resident #17 would be seen by the psych team on the next scheduled visit with her signature. Lastly, the DON verified the practitioner did not sign or date that they received the pharmacy recommendation dated 04/27/24 regarding Resident #20's recommendation for an AIMS test and the boxed warning regarding long term use of Reglan. The DON verified she wrote an AIMS test was done 06/17/25, and the nurse practitioner assessed Resident #20 on 04/11/25 and 06/04/25. Interview on 06/18/25 at 9:07 A.M. with Wellness Director #271 revealed her responsibility was to email the pharmacy recommendations to the DON and to put the recommendation in a folder to be provided to the practitioner upon their visits to review and sign. Wellness Director #271 stated she did not know why the recommendations for Resident #17 and Resident #20 were missed and not addressed until 06/17/25. Review of the facility policy titled Documentation and Communication of Consultant Pharmacist Recommendation, dated 07/01/21, revealed the consultant pharmacist worked with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies were communicated to those with authority or responsibility to implement the recommendations , and were responded to in an appropriate timely fashion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure medications had the appropriate diagnosis for administration. This affected one (Resident #28) out of five residents reviewed for unnecessary medications. The facility census was 56. Findings include: Review of the medical record for Resident #28 revealed an admission date of 11/21/22. Diagnoses included Parkinson's disease, delusions, kidney disease, diabetes, paranoid schizophrenia and high cholesterol. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact. He required set up help for eating and personal hygiene, supervision for oral hygiene and toileting and partial assistance for showering. Review of the gradual dose reduction (GDR) form dated 02/28/25 revealed a recommendation by Pharmacist #268 to clarify the diagnosis for Namenda, which had been prescribed for paranoid schizophrenia. The recommendation was made to correct the diagnosis to dementia, which was signed by Nurse Practitioner #269 on 03/05/25. Review of the physician's orders for June 2024 revealed an order for Namenda (used to treat dementia) five milligrams (mg) by mouth two times per day for paranoid schizophrenia. Interview on 06/18/25 at 9:15 A.M. with Licensed Practical Nurse (LPN) #271 confirmed Resident #28 was prescribed Namenda and did not have the appropriate diagnosis for the medication. Review of the facility policy titled Consultant Pharmacist Reports, dated 07/01/21, revealed pharmacy recommendations would be acted upon and documented by the facility staff and/or prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility to ensure Turbersol serum was dated upon opening per manufacturers instruction for efficacy. This had the potential to affect 15 (Residents #15, #19, #21, #51, #52, #106, #107, #156, #157, #206, #207, #208, #209, #256 and #257) identified as new admissions on the 100 unit in the last 30 days. The facility also did not ensure pills were not left at the bedside for Resident #35. This had the potential to affect seven (Residents #11, #24, #43, #106, #157, #208, and #257) who were identified as cognitively impaired and independently mobile on the 100 unit. The facility census was 56. Findings include: 1. On 06/16/25 at 8:20 A.M. an inspection of the medication storage room on the 100 unit revealed a one milliliter vial of Turbersol (a serum used to aid in the diagnosis of tuberculosis) that was opened and undated. The Director of Nursing (DON) verified the opened vial of Tubersol as being undated at the time of the observation. A review of the package inserts for Tubersol revealed a vial of Tubersol which has been opened and in use for 30 days should be discarded. A review of the facility policy titled; Medication Storage in the Facility, dated of 07/01/21, revealed medications and biologicals are stored safely, securely and properly following manufacturers recommendations. The policy further stated certain medications, once opened, require an expiration date shorter than the manufacturers expiration date to ensure medication purity and potency. When the original seal of a manufacturer's container or vial is initially broken, the container or vial shall be dated. 2. A review of medical records for Resident #35 revealed a date of admission of 08/27/24. Significant diagnosis included personal history of malignant melanoma. A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS of 15 (cognitively intact). A review of a care plan dated 05/05/25 revealed Resident #15 could keep artificial tears at bedside for self-administration. The care plan did not include antibiotic medication to be left at the bedside for self-administration. The care plan also revealed Resident #35 to have inappropriate behaviors at times related to refusal of medications. Interventions included to administer medications as ordered. A review of assessments within the medical record did not reveal a completed self-medication administration assessment (an assessment completed to ensure a resident can safely self-administer medications). Review of the physician's orders for Resident #15 included an order dated 06/12/25 for Cephalexin (an antibiotic used for infection) 500 milligrams (mg), give one by mouth one time a day for infection for seven days. A review of the medication administration record (MAR) for June 2025 the Cephalexin was signed off as administered at bedtime on 06/15/25. On 06/16/25 at 8:52 A.M. an observation of the bedside table for Resident #35 revealed a pink capsule in a medication cup. Resident #35 stated they got the pill last night and did not take it as she thought she was to take it in the morning. An interview with Registered Nurse (RN) #239 at the time of the observation revealed the capsule to be the Cephalexin. Resident #35 stated the capsule was given last night, and she did not take it as she thought it was to be taken in the morning. RN #239 then instructed Resident #35 that the Cephalexin was ordered once a day at bedtime. RN #239 removed the pink capsule from the room. On 06/16/25 at 3:32 P.M. an interview with the Director of Nursing (DON) verified the lack of a self-administration assessment within the medical record of Resident #35. There were seven (Residents #11, #24, #43, #106, #157, #208, and #257) who were identified as cognitively impaired and independently mobile on the 100 unit. A review of the facility policy titled; Specific Medication Administration Procedures, dated 07/01/21, revealed once removed from the package or container, unused or partial doses of medication should be disposed of in accordance with the medication destruction policy.

Based on observation, staff interviews and facility policy review, the facility failed to ensure the garbage and refuse was maintained in a sanitary condition. This had the potential to affect all 56 residents residing in the facility. Findings include: Observation of the facilities outside dumpster area with Dietary Supervisor (DS) #224 on 06/16/25 at 7:26 A.M. revealed there were two dumpsters in the area. The dumpster on the right-hand side had both lids closed on top and both sliding doors on each side were closed. The dumpster on the left side had both lids closed and the sliding door on the right side of the unit was closed. On the left side of the dumpster, there was an opening in the dumpster where the sliding door should have been with the black sliding door located on the ground under the back left-hand corner of the dumpster. Located on the ground around the dumpsters was a buildup of debris which included five white plastic surgical gloves, one clear plastic cup, one empty pudding cup container, two medicine cups, multiple pieces of plastic wrap of various sizes, one brown cardboard box approximately 12 inches wide by nine inches tall and two-inches deep which was labeled fabric softener sheets, three blue surgical gloves, one straw, and numerous plastic spoons. Interview with DS #224 at the time of observation on 06/16/25 verified the above findings. Interview on 06/17/25 at 5:16 P.M. with Maintenance Supervisor #202 revealed he was made aware of the dumpster situation when he got to work on 06/16/25. He stated the door to the dumpster would slide off and people didn't want to pick up the door on the ground after it had slid off the dumpster. He confirmed the area had debris which he helped clean up, and it was the responsibility of the maintenance and housekeeping departments to keep the dumpster area clean. Review of the facility policy Trash/Dumpster Receptacle, dated 08/27/19, revealed all trash dumpsters and receptacles would be kept covered at all times. Employees who took trash and garbage to dumpsters were to close the lids after refuse was deposited, and trash was not to be deposited on the ground for any reason. If for any reason the receptacle lids could not be closed, maintenance would be notified right away for assistance, and maintenance would notify the trash pickup vendor if any problems occurred which impeded the facility's ability to store trash.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, facility self-reported incident (SRI) review, and facility policy review, the facility failed to ensure Resident #55 was free from staff-to-resident physical abuse. This affected one resident (#55) of three residents reviewed for abuse. The facility census was 54. Findings include: Review of the medical record for Resident #55 revealed an admission date of 01/26/24 and a discharge date of 10/11/24. Diagnoses included sepsis, muscle weakness, epilepsy, bipolar disorder, anxiety, and paraplegia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed resident #55 was cognitively intact. He was completely dependent on staff for eating, oral care, personal hygiene, showering, toileting, and dressing. Review of the care plan dated 08/06/24 revealed Resident #55 had inappropriate behaviors such as agitation and combativeness, aggression with staff, cursing at staff, and refusing to lie down. Interventions included approaching the resident in a slow, calm manner, bringing the resident to a quiet environment as needed, and observing for possible environmental causes of behaviors. Review of SRI tracking number 252677 dated 10/06/24 at 10:41 A.M. revealed Resident #55 reported a facility nurse slapped him. The perpetrator was identified as Registered Nurse (RN) #205 who was suspended pending an investigation. Review of the facility investigation for SRI tracking number 252677 revealed Resident #55 reported RN #205 was providing care when he became verbally aggressive with RN #205. He alleged RN #205 slapped his mouth. Resident #55 reported RN# 205 left his room after the occurrence. Interview with RN #205 confirmed Resident #55's report, stating she utilized the back of her hand to slap Resident #55's mouth, then exited the room. An interview with Certified Nurse Aide (CNA) #206 revealed she was present in the room and confirmed both Resident #55 and RN #205's reports of what occurred. Like residents were interviewed as well as all staff working at the time of the incident, and no further issues were noted. Resident #55 was assessed, and no injuries were noted, vital signs were obtained and reported blood pressure was 110/75, pulse 88, respirations 16, temperature 97.5 degrees Fahrenheit (F) and oxygen saturation was 98%. Review of the progress note dated 10/07/24 at 11:59 P.M. written by Advanced Practice Registered Nurse (APRN) #203 revealed Resident #55 had an altercation with another person (RN #205) and was struck in the face. An examination was completed, and the resident had no bruising swelling or redness noted to either side of the face. The resident was noted to be in good spirits. Interview on 11/03/24 at 9:44 A.M. revealed the facility was aware of the abuse of Resident #55 by RN #205. The facility had completed the investigation and substantiated the allegation of abuse. RN #205 was terminated as a result of the incident. Interview on 11/03/24 at 9:52 A.M. with RN #205 revealed she reported the incident of abuse to her immediate supervisor within an hour of the occurrence. She would provide no further information regarding the incident. Interview on 11/03/24 at 10:02 A.M. with CNA #200 revealed she came in to work at approximately 4:30 A.M. on 10/06/24. RN #205 told her she had called the on-call manager and was being sent home. CNA #200 revealed talking to Resident #55 who asked to speak with the Administrator, whom she called immediately. She had no knowledge of any other concerns regarding any incidences or suspicions of resident abuse. Interview on 11/03/25 at 10:35 A.M. with Licensed Practical Nurse (LPN) #204 revealed she was the manager on duty on 10/06/24 when she received a call at approximately 4:30 A.M. from RN #205. RN #205 admitted she slapped a resident. LPN #204 instructed RN #205 to write a witness statement, clock out, and go home. LPN #204 revealed she notified the Director of Nursing (DON) and Administrator, came to work and immediately started collecting witness statements and performing skin checks on residents. Review of the personnel file for RN #205 revealed her last shift worked was 10/05/24 from 7:00 P.M. to 10/06/24 at 4:30 A.M. She was terminated on 10/11/24 for poor work performance. Review of the facility policy titled Abuse, dated 01/31/20, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. The facility would not tolerate abuse, neglect or exploitation, and residents had the right to be free from abuse including corporal punishment, involuntary seclusion, and physical or chemical restraint. The deficient practice was corrected on 10/08/24 when the facility implemented the following corrective actions: • RN #205 was suspended on 10/06/24 immediately after reporting the abuse. Her employment was terminated on 10/11/24. • On 10/06/24, Resident #55 was assessed and interviewed regarding the abuse; no injuries were noted or reported. • On 10/06/24 all staff working at the time of the incident were interviewed, and residents were either assessed for injuries or interviewed. • On 10/07/24, Resident #55 was assessed by APRN #203. There were no new orders. • On 10/06/24, all staff education regarding abuse identification, prevention and requirements of reporting began, and was completed on 10/07/24. • On 10/06/24, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the occurrence and perform a root cause analysis. • On 10/07/24, RN #205 was reported to the Board of Nursing. • On 10/08/24 at approximately 11:45 A.M. a police report was filed by the facility, incident #24-14722. Resident #55 was adamant a police report was not necessary. Resident #55 was his own responsible party. • On 10/08/24 a follow-up psychosocial assessment was completed for Resident #55 with no changes noted. • One 10/08/24, the facility began weekly audits of staff's understanding of abuse prevention, identification and requirements of reporting for a period of four weeks. This deficiency represents non-compliance investigated under Master Complaint Number OH00159222 and Complaint Number OH00158827.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, review of the medication error report review, facility policy review, the facility failed to ensure the proper route of medication administration for Resident #51. This affected one resident (#51) of eight residents reviewed for proper medication administration. The facility census was 50. Findings include: Review of the medical records revealed Resident #51 was admitted to the facility on [DATE] and discharged on 05/20/24. Significant diagnoses included paraplegia, bacteremia, stage IV pressure ulcers (Full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling.) to the right and left buttocks, diabetes mellitus type II, and infection and inflammatory reaction due to cardiac valve prothesis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was cognitively intact. Review of the physician's orders revealed an order dated 04/18/24 through 05/17/24 for ceftriaxone sodium (an antibiotic) intravenous (IV) use 2000 milligrams (mg) IV two times a day and an order dated 04/18/24 through 05/17/24 ampicillin sodium injection solution (an antibiotic), use 2000 mg IV every four hours. On 05/17/24 a new order was obtained for ampicillin sodium injection solution use 2000 mg IV every four hours for two weeks. A review of a progress note dated 05/03/24 at 6:26 A.M. revealed LPN #177 misread the order for ampicillin and gave the 05/02/24, 8:00 P.M. dose intramuscularly (IM) instead of intravenously. The resident's wife was notified. The nurse practitioner was notified and stated the medication was okay to be given IM and no adverse reaction was expected. The nurse spoke with the pharmacist who said the medication was okay to be given IM. No redness or swelling was noted to the injection site. The resident stated he was not having pain. A review of the document titled, Country Club Retirement Center Medication and Treatment Errors and Omissions dated 05/03/24 signed by LPN #177 and the Director of Nursing (DON) revealed ampicillin 2000 mg was administered IM instead of IV as ordered on 05/02/24 at 8:00 P.M. by LPN #177. On 06/17/24 at 1:45 P.M. an interview with the DON verified that LPN #177 gave ampicillin 2000mg IM instead of IV as ordered and corrective actions were taken immediately. The nurse practitioner and the spouse were notified. A review of the policy titled, Specific Medication Administration Procedures, dated 07/01/21, stated the nurse is to review the five rights of medication administration three times before administering medication. The deficient practice was corrected on 05/04/24 when the facility implemented the following actions: • On 05/03/24 LPN #177 received a verbal warning regarding the medication error. • On 05/03/24 LPN #177 was educated on the Five Rights of Medication Administration: Right Patient, Right medication, Right dose, Right route and Right time by the DON. • On 05/03/24 an ad hoc quality assurance and performance improvement (QAPI) meeting was held. Random medication administration competencies would be done by the DON for two weeks. • Resident #51 was assessed on 05/03/24 by the DON and found to have no ill effects. • On 05/03/24 all nursing staff were educated the DON on the Five Rights of Medication Administration: Right Patient, Right medication, Right dose, Right route and Right time. Nurses who were not present in the facility were in-served via phone by Wellness Director #126. The sign in sheets were verified on 06/18/24. • On 05/03/24 medication administration competencies were conducted by the DON for LPN #126 and Registered Nurse (RN) #121 with no negative findings. • On 05/09/24 medication administration competencies were conducted by the DON for LPN #177 and RNs #173 and #168 with no negative findings. • On 05/14/24 medication administration competencies were conducted by the DON for LPN #133 with no negative findings. This deficiency represents non-compliance investigated under Complaint Number OH00154138.

Based on record review, observation, review of Centers for Medicare and Medicaid (CMS) Quality, Safety, and Oversight (QSO) Memo 24-08-NH, staff interview, and policy review, the facility failed to ensure residents with chronic wounds and those with indwelling medical devices were placed in enhanced barrier precautions (EBP) as required. This affected four residents (#8, #10, #26, and #39) of five residents reviewed for infection control. The facility census was 50. Findings include: On 06/17/24 from 8:50 A.M. to 9:00 A.M., observations during tour of the facility revealed there were no residents in EBP. There were several residents throughout the facility that had indwelling urinary catheters or wounds that were not in EBP as required. 1. A review of records for Resident #8 revealed an admission date of 12/28/22 with diagnoses including obstructive uropathy. The resident had an indwelling urinary catheter. Review of the care plan updated on 05/21/24 revealed Resident #8 was at risk for infection related to the indwelling urinary catheter, and staff was to wear a gown and gloves when providing resident care. On 06/17/24 at 8:55 A.M. an observation of Resident #8 room revealed no EBP were in place. The observation was verified by Wellness Coordinator (WC) #126 at the time of the observation. 2. A review of records for Resident #10 revealed an admission date of 10/03/22 with diagnoses including reflux uropathy. Significant orders included Glucerna 1.5 (nutritional supplement) at 50 milliliters (ml) per hour continuously via a percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted into the abdomen to administer nutrition). The medical records also revealed Resident #10 had a stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) on his coccyx. Review of the care plan updated on 05/21/24 to indicate Resident #10 was at risk for infection related to the PEG tube, and staff were to wear a gown and gloves when providing resident care. On 06/17/24 at 8:55 A.M. an observation of Resident #10 room revealed no EBP were in place. The observation was verified by WC #126 at the time of the observation. 3. A review of records for Resident #39 revealed an admission date of 09/26/23with diagnoses including obstructive uropathy. The resident had a supra-pubic catheter (a tube inserted directly into the bladder through the abdomen for urine drainage). Review of the care plan updated on 05/21/24 revealed Resident #39 is at risk for infection, and staff was to wear gown and gloves with high contact resident care. On 06/17/24 at 8:57 A.M. an observation of Resident #39 room revealed no EBP were in place. The observation was verified by WC #126 at the time of the observation. 4. A review of records for Resident #26 revealed an admission date of 06/10/24 with diagnoses including retention of urine, unspecified. The resident had an indwelling urinary catheter. Review of the care plan revealed no interventions in place for EBP. On 06/17/24 at 9:00 A.M. an observation of Resident #26 room revealed no EBP were in place. The observation was verified by WC #126 at the time of the observation. On 06/17/24 at 10:00 A.M., an interview with the Director of Nursing (DON) revealed they did not have any residents in EBP as she was going to institute the precautions today. Review of CMS's QSO-24-08-NH dated 03/20/24 pertaining to Enhanced Barrier Precautions in Nursing Homes revealed CMS was issuing new guidance for State survey agencies and long-term care facilities on the use of enhanced barrier precautions (EBP) to align with nationally accepted standards. EBP recommendations now included use of EBP's for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multi-drug resistant organism (MRDOs status. The new guidance related to EBP's was being incorporated into F880 Infection Prevention and Control. Guidance under F880 indicated EBP's referred to an infection control intervention designed to reduce transmission of multi-drug resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. EBP's were to be used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. Review of the undated facility policy on Enhanced Barrier Precautions (EBP) that revealed EBP should be in place for residents with indwelling medical devices and wounds. This deficiency represents non-compliance investigated under Complaint Number OH00154138

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility policy review, and review of the Centers for Disease Control (CDC) guidance, the facility failed to maintain proper infection control procedures to prevent the spread of COVID-19 infection. This affected two residents (Resident #14 and #23) but had the potential to affect all 51 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 01/08/21. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed resident had impaired cognition and required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Resident #14 medical record reviewed they were diagnosed with COVID-19 on 04/07/23. Review of physician orders dated 04/07/23 revealed the resident was to be on transmission based precautions (TBP) for ten days duration. Interview on 04/17/23 at 8:39 A.M. with Infection Preventionist (IP) #150 revealed the facility was in a COVID-19 outbreak status. IP #150 reported staff were to wear N95 masks, surgical mask over top of N95 mask, eye protection, gown, and gloves to enter in the COVID-19 rooms. IP #150 reported before exiting the COVID-19 rooms staff were to doff (take off) surgical mask, gown, gloves, and then upon exit disinfect their goggles or face shields and perform hand hygiene. Observation on 04/17/23 at 9:31 A.M. revealed STNA #103 donned (put on) personal protective equipment (PPE) to enter Resident #14's room with her goggles on her head. Resident #14 was observed to be on TBP. STNA #103 exited the room at 9:36 A.M. and her goggles still on her head. STNA #103 preceded to go down the hall. STNA #103 did not disinfect her goggles as required due to COVID-19 outbreak status at the facility. Interview on 04/17/23 at 9:37 A.M. with STNA #103 revealed she forgot to wear the goggles correctly as she entered Resident #14's COVID-19 positive room room to perform personal care and exited the room with the goggles remaining on her head. STNA #103 proceeded to head down the hall without disinfecting her goggles. She reported I just forgot. STNA #103 confirmed she did not wear her goggles correctly and did not clean goggles after exiting the room. Interview on 04/17/23 at 10:08 A.M. with IP #150 confirmed staff were to disinfect goggles or face shields upon exiting room and hand hygiene is to be performed upon exiting resident rooms. Interview on 04/17/23 at 12:15 P.M. with Director of Nursing (DON) regarding observation of STNA #103 revealed staff were to wear a N95 mask, surgical mask over N95 mask, gown, gloves, and eye protection to inter a COVID-19 positive room and upon exit remove the surgical mask gown, and gloves. DON reported upon exit staff are to clean their goggles or face shield and perform hand hygiene. 2. Review of the medical record for Resident #23 revealed an admission date of 01/20/23. Review of MDS dated [DATE] revealed resident had intact cognition and required extensive assistance for bed mobility, transfers, dressing and was dependent for toileting and bathing. Resident #23's medical record revealed the resident was diagnoses with COVID-19 on 04/10/23. Review of physician orders dated 04/10/23 revealed Resident #23 was to be in TBP for ten days duration. Observation on 04/17/23 at 9:41 A.M. of Housekeeping Supervisor (HKS) #119 revealed she had donned PPE to enter Resident #23 to answer a call light. Resident #23 was observed to be in TBP. Upon exiting the room at 9:44 A.M. after deactivating the call light (HKS) #119 did not disinfect her goggles or perform hand hygiene. Interview on 04/17/23 at 9:45 A.M. with (HKS) #119 revealed she didn't know how to clean her goggles and was going to use the hand sanitizer at the end of the hall. (HKS) #119 was asking this surveyor what she was supposed to do and how to clean the goggles. HKS #110 reported I was going to use the hand sanitizer at the end of the hall. HKS #110 confirmed she did not clean her goggles and did not perform hand hygiene after exiting the room. Interview on 04/17/23 at 10:08 A.M. with IP #150 confirmed staff were to disinfect goggles or face shields upon exiting room and hand hygiene is to be performed upon exiting resident rooms. Interview on 04/17/23 at 12:15 P.M. with DON regarding observation of HKS #119 revealed staff are to wear N95 mask, surgical mask over N95 mask, gown, gloves, and eye protection to inter a COVID-19 positive room and before exit remove the surgical mask gown, and gloves. DON reported upon exit staff are to clean their goggles or face shield and perform hand hygiene. Review of facility policy, Novel Coronavirus Prevention and Response, revised 07/24/22, revealed N95 mask, eye protection, gloves and gown to be worn and hand hygiene performed. Review of the CDC guidance updated 09/27/22 titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic revealed health care personnel who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).

Based on record review, review of the Ohio Administrative Code (OAC) for Prescription Processes, observation of medication administration and interview the facility failed to ensure nurses followed acceptable standards of practice for obtaining medication orders. This affected two (Residents #45 and #151) of five residents reviewed for medication administration. The facility census was 42. Findings include: 1. Record review for Resident #151 revealed an admission date of 02/18/23 and a physician order dated 02/19/23 for vitamin B12 oral tablet 500 micrograms (mcg) give 500 mcg by mouth one time a day. On 03/01/23 at 8:52 A.M., Registered Nurse (RN) #28 was observed administering medication to Resident #151. While preparing Resident #151's medication for administration RN #28 stated he was unable to locate the appropriate dose of guaifenesin (expectorant) or vitamin B12, stating he would have to administer them later. A request was made for RN #28 to notify the surveyor when the medication was located for observation. 2. Record review for Resident #45 revealed and admission date of 01/26/23 and a physician order dated 01/27/23 for Calcium-Magnesium oral tablet 500-250 milligrams (mg) give one tablet by mouth one time a day. On 03/01/23 between 9:22 A.M. and 9:31 A.M., RN #28 was observed administering medication to Resident #45. While preparing Resident #45's medication for administration he stated he was unable to locate the ordered Calcium-Magnesium 500-250 mg to give to Resident #45. A request was made for RN #28 to notify the surveyor when the medication was located for observation. On 03/01/23 at 10:44 A.M., RN #28 approached the surveyor and revealed the following information related to the B12 oral tablet for Resident #151 and the Calcium-Magnesium tablet for Resident #45 RN #28 had been unable to locate and administer to these residents during the medication administration observation: RN #28 explained Resident #151 had orders for vitamin B12 500 mcg but he only had 1000 mcg tablets which were not scored (an indented line in the middle of the tablet so the tablet could be cut in half). Since RN #28 only had vitamin B12 available in 1000 mcg doses, RN #28 had spoken to the Director of Nursing (DON) who told him she (the DON) was told by the physician previously that when giving over the counter medication such as the B12 and Calcium-Magnesium supplement it was okay to re-write the order to reflect what the facility had in stock and without RN #28 getting the order directly from a prescriber. RN #28 indicated he planned to re-write Resident #151's order for vitamin B12 for 1000 mcg every day and re-write Resident #45's order for Calcium-Magnesium for 600-400 mg tablet because that is all he had available to give to Resident #45. When asked if the DON had prescribing authority for RN #28 to accept an order from her he stated she did not, but he trusted her, so he would re-write the orders. After again asking if it was appropriate to change an order based on something told to him by the DON or another nurse who was not a certified nurse practitioner who could act as a prescriber he verified it was not and stated he would check with the physician about the orders. On 03/01/23 at 11:14 A.M., RN #72 verified a nurse should never instruct another nurse to write an order or give a change in medication orders absent the legal authority to prescribe medications. At 12:12 P.M. RN #72 stated although the DON was given an order approving the change to the original orders it was not appropriate for another nurse to write orders he or she had not personally received from the physician. Review of the OAC 4729:5-5 for prescription processes stated a prescription, to be valid, must be issued for a legitimate medical purpose by an individual prescriber acting in the usual course of the prescriber's professional practice.

Based on medical record review and interview, the facility failed to ensure appropriate treatments were applied to a pressure ulcer for one resident (Resident #5) of five residents reviewed for pressure ulcers. The facility census was 42. Findings include: Review of Resident #5's medical record revealed diagnoses included left hip fracture, diabetes mellitus, and macular degeneration. An order dated 02/21/23 indicated the wound bed on the coccyx was to be irrigated with normal saline then covered with calcium alginate (a treatment for wounds) and a foam dressing every day and as necessary. A wound consultant note dated 02/27/23 indicated Resident #5 had a stage three pressure ulcer on the coccyx (full thickness tissue loss without bone, tendon or muscle being exposed). Instructions revealed to continue calcium alginate to aid in autolytic debridement of the wound. On 03/02/23 between 11:00 A.M. and 11:20 A.M., Licensed Practical Nurse (LPN) #22 was observed gathering supplies to complete Resident #5's dressing change to the pressure ulcer on her coccyx. LPN #22 gathered normal saline, gauze, a tube of santyl (an ointment used to debride a wound), a cotton applicator, and a foam dressing. When asked if Resident #5 had an order for santyl, LPN #22 stated she would have to check with Registered Nurse (RN) #28 because she was not sure of the order. The orders were not in view and LPN #22 was not heard asking RN #28 for verification of the orders. When the old dressing was removed LPN #22 observed there was a piece of calcium alginate on the wound and she sent RN #28 to obtain calcium alginate from the cart. When placing the new dressing on the pressure ulcer site, LPN #22 placed santyl on a piece of calcium alginate and applied it to the pressure ulcer then covered it with a foam dressing. On 03/02/23 at 1:40 P.M., LPN #22 verified she had applied santyl and calcium alginate to the wound bed. LPN #22 verified she had not reviewed the treatment order before applying the dressing, stating she did it on the fly. LPN #22 stated she figured RN #28 would tell her if the order was incorrect. Review of the facility's Wound and Skin Care policy, revised 06/07/16 revealed treatments would be initiated as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to thoroughly and consistently record bowel movements for assessment of constipation for Resident #9. This affected one (Resident #9) of 12 residents interviewed regarding constipation. The facility census was 42. Findings include: Review of Resident #9's medical record revealed an admission date of 02/03/23 and diagnoses including right hip fracture, traumatic subarachnoid hemorrhage, arthritis, pain in the right leg and neuropathy. An admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #9 was able to make herself understood. Resident #9 was dependent for toilet use. A plan of care initiated 02/15/23 indicated Resident #9 had potential for constipation related to decreased mobility and medications. The stated goal was for Resident #9 to have a bowel movement at least every three days. Interventions included observing for and documenting bowel movements, observing for complaints of abdominal discomfort and abdominal distention, and administering medications as ordered. Resident #9 had an order for psyllium husk powder one unit every day for constipation. Review of bowel movement records revealed no record of a bowel movement from 02/04/23 through 02/11/23. No bowel movement was recorded between 02/16/23 and 02/23/23. Review of the February 2023 Medication Administration Record (MAR) revealed the following orders for treatment of constipation with start dates of 02/03/23: Colace (stool softener) 100 milligrams (mg) every 12 hours as needed, one Dulcolax suppository as needed if no results were achieved within eight hours of administration of Milk of Magnesia (MOM). If there were no results within 15 to 20 minutes of administration of the Dulcolax suppository, it could be repeated; one Fleet enema as needed if no results were achieved from administration of the suppository, and MOM 30 milliliters as needed if there was no bowel movement within six shifts. The February MAR nor the progress notes revealed administration of any of the medications ordered on an as necessary basis for constipation. There was no documentation of Resident #9 being interviewed or assessed related to the extended periods without documentation of a bowel movement. During an interview on 02/27/23 at 10:00 A.M., Resident #9 verified she did have constipation and had not received any medications to promote bowel movements. On 03/03/23 at 1:15 P.M., Registered Nurse (RN) #72 stated the electronic health record provided an alert to the nurse when a resident did not have a bowel movement. If alerted, nurses should check with aides to ensure they had documented bowel movements for each resident and if they had not, the nurse should offer something for constipation in accordance with the orders. On 03/03/23 at 1:45 P.M. RN #72 verified the lack of documentation of bowel movements for Resident #9.