**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, medical record review, review of a police report, review of facility investigation documents, and policy review, the facility failed to ensure a resident's change in condition was reported to the physician in a timely manner. This affected two (#23 and #20) of four residents reviewed for assessments and monitoring. The census was 69. Findings include:1. Record review for Resident #70 revealed an admission date of 02/04/25 and a discharge date of 05/01/25. Diagnoses included bipolar disorder, cocaine use, and alcohol abuse. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 was cognitively intact. Resident #70 had no impairment to the upper or lower extremities, was independent with eating, used a wheelchair for mobility and was independent for wheelchair mobility. Review of a progress note dated 01/30/25 from Resident #70 ' s emergency room physician, prior to admission to the facility, revealed Resident #70 was a [AGE] year-old male with a past medical history of polysubstance use. The note further indicated Resident #70 had been admitted to the same hospital from a substance use treatment setting. Record review of Resident #70 ' s medical record for 04/28/25 through 05/01/25 revealed no documentation of Resident #70 smoking an illegal substance while inside the facility.Review of a handwritten statement signed and dated 04/28/25, untimed, completed by Certified Nurse Aide (CNA) #229 revealed at 11:15 (no A.M. or P.M. documented) the nurse aide went into Resident #70 ' s room because the nurse aide saw him roll his wheelchair into the hallway. When CNA #229 went into his room he told the nurse aide to come into the bathroom. The resident rolled into his bathroom and he told the nurse aide to look as he was unfolding a ball of toilet paper. CNA #229 noticed white chunks inside and asked Resident #229 if it was an illicit drug. Resident #70 told CNA #229 to be quiet and lifted a paper towel and exposed two pipes that were obviously used to smoke the substance in the toilet paper. CNA #229 told Resident #70 he needed to give the nurse aide everything he had but he refused. The resident then asked CNA #229 to party with him. CNA #229 immediately left the room and got Licensed Practical Nurse (LPN) #202, and LPN #358 was also called to assess Resident #70. Review of the handwritten statement signed and dated 04/28/25, untimed, completed by LPN #202 revealed she was notified by her CNA (#229) that Resident #70 was seen in the bathroom smoking an illicit drug. LPN #202 then called LPN #358 to have a witness and both nurses entered Resident #70 ' s room and witnessed Resident #70 smoking in the bathroom. LPN #358 asked Resident #70 for the substance, he refused to let go of it, he asked if he could throw it out himself.Review of the handwritten statement signed and dated 04/28/25, untimed, completed LPN #358 revealed the nurse was called to Resident #70 ' s room at approximately 11:19 P.M. She ran to his room and found Resident #70 smoking from a crack pipe and thick white smoke was coming out. As she approached him, Resident #70 blew a cloud of smoke into her face. She stepped into the bathroom and told Resident #70 he needed to give her the pipe and lighter. She grabbed onto them and he would not let go. After about 15 minutes, he let the nurse have them. The Director of Nursing (DON), police, and the Administrator were notified. The police confiscated the drug items. Review of the police incident report date 04/28/25 at 11:56:38 P.M. revealed nurses observed Resident #70 actively smoking out of a pipe. After talking to the resident, he did not know what it was and indicated he found it outside. Review of the progress note dated 04/29/25 at 2:30 P.M. completed by the Administrator revealed he and the DON presented Resident #70 with a behavior contract and the resident refused to sign it. Resident #70 informed the staff another facility would no longer accept him and the facility reviewed alternative options as his Medicaid authorization ended on 4/30/25. Interview on 09/02/25 at 4:57 P.M. with the Administrator revealed on 04/28/25 Resident #70 was found by a CNA smoking an illicit substance in the bathroom of his room. The CNA tried to confiscate the paraphernalia. Resident #70 blew smoke in the CNA ' s face. The police were called, and the CNA and the nurses went to the hospital to get checked out. The resident did give the paraphernalia to the staff, and it was found to just be residue left over. The police did not want to test the residue and said it was because it was not a chargeable amount. The Administer revealed he and the police went through the resident's room and nothing else was found. The next day, Resident #70 was presented with a contract to remain drug free. Resident #70 refused to sign the contract and discharged himself to the community on 05/01/25. The Administrator confirmed Resident #70 had a roommate at the time the incident occurred and revealed he was unaware of any restrictions or further monitoring/interventions put into place for Resident #70 to prevent further drug use while in the facility. The Administrator reiterated Resident #70 refused to sign the contract. Interview on 09/04/25 at 2:02 P.M. with the DON revealed Resident #70 went on leave of absences (LOAs) before the incident with the drugs on 04/28/25. The DON revealed there were no restrictions or interventions put into place after the incident to monitor Resident #70 from bringing and smoking paraphernalia in the facility potentially affecting other residents. The DON confirmed Resident #23 was Resident #70 ' s roommate including from 04/28/25 through 05/01/25.2. Record review for Resident #23 revealed an admission date of 07/26/14. Diagnoses included chronic obstructive pulmonary disease (COPD) , dementia, Alzheimer ' s disease, schizophrenia, chronic respiratory failure with hypoxia, and emphysema.Review of the quarterly MDS assessment dated [DATE] revealed Resident #23 was moderately cognitively impaired. Resident # 23 received continuous oxygen therapy.Review of Resident #23's physician orders for April 2025 revealed an order for oxygen at two liters per minute via nasal cannula for shortness of breath every shift related to chronic obstructive pulmonary disease and a continuous positive airway pressure device to be worn at bedtime and taken off in the morning.Review of the medical record for Resident #23 revealed there was no assessment complete on 04/28/25 after Resident #23 ' s roommate, Resident #70, was found to be smoking in the bathroom near where Resident #23 resided. Record review revealed an initial assessment dated [DATE] at 4:01 P.M. completed by Assistant Director of Nursing (ADON) LPN #336 included vital signs with a blood pressure result of 86/50 millimeters of mercury (mmhg). Record review revealed the next assessment of vital signs was completed 05/01/25.Observation on 09/02/25 at 4:19 P.M. revealed Resident #23 lying in bed. Resident #23 had his oxygen infusing via nasal cannula. Interview with Resident #23 at that time revealed he did not recall the situation on 04/28/25. Interview on 09/04/25 at 11:37 A.M. with ADON LPN #336 confirmed Resident #23 ' s initial assessment after his roommate, Resident #70, was found to be smoking was not completed until 04/29/25 at 4:01 P.M. Record review of Resident #23 ' s vital sign history with ADON LPN #336 confirmed Resident #23 ' s blood pressure of 86/50 mmhg obtained and documented on 04/29/25 at 4:01 P.M. was the lowest, both systolic and diastolic, he had during the timeframe reviewed between 01/01/25 through 04/28/25. ADON LPN #336 confirmed there was no documentation of the physician or Certified Nurse Practitioner (CNP) being notified of the abnormal vital sign. ADON LPN #336 revealed she did not recall if she notified anyone or not of the abnormal vital sign.Telephone interview on 09/04/25 at 12:55 P.M. with Certified Nurse Practitioner (CNP) #360 confirmed she was Resident #23 ' s CNP and revealed she was made aware Resident #70 was smoking illicit drugs in the bathroom and confirmed it was close proximity to Resident #23. CNP #360 revealed she was told Resident #23 was never exposed. CNP #360 revealed if a resident was exposed, she would have expected an assessment to be done on the resident immediately after the exposure and revealed the assessment should include vital signs, a respiratory assessment , and any change in condition including a mental status change and the staff would need to monitor the resident over the next hours to days depending on the amount of exposure. CNP #360 also revealed she would have expected to be notified of abnormal vital signs and confirmed she had no documentation of the notification and could not confirm if she was or was not notified of Resident #23's abnormal vital signs on 04/29/25. Telephone interview on 09/04/25 at 1:45 P.M. with Physician #361 revealed if a resident was smoking illicit drugs in the same room as another resident, he would expect staff to assess both residents' breathing, vital signs, cough, phlegm, and for a headache. The exposed resident could experience breathing problems and burning of the eyes depending on how much exposure there was. Observation on 09/04/25 at 1:55 P.M. with Maintenance Director #293 measured the distance between Resident #23 ' s bed and the bathroom and revealed the distance was approximately seven feet.Interview on 09/04/25 at 2:02 P.M. with the DON confirmed an assessment was not documented on Resident #23 until 04/29/25 at 4:01 P.M. and revealed she did not have an answer why. The DON revealed she came in the facility that night, she took over for the nurses who went to the hospital to be assessed due to exposure. Neither Resident #70 nor Resident #23 were sent to the hospital. The DON revealed she saw Resident #23 sleeping in bed and had no concerns. The DON revealed she worked the remainder of the night until 6:30 A.M. the following morning as the charge nurse and revealed Resident #23 was not woke up during that time for a physical assessment. Telephone interview on 09/04/25 at 5:13 P.M. with LPN #202 revealed on 04/28/25 she was one of the nurses who witnessed Resident #70 smoking an illegal substance in his bathroom. LPN #202 revealed the roommate (Resident #23) was lying in his bed and revealed Resident #23 was not wearing his CPAP but he had his oxygen on with his nasal cannula. LPN #202 revealed Resident #23 often refused his CPAP and revealed he may have worn it later that night but at that time he did not have it on. LPN #202 revealed Resident #70 was smoking the substance in the bathroom sitting in his wheelchair just inside the doorway of the bathroom, the door was opened, and as soon as she entered the doorway of Resident #70 ' s and Resident #23 ' s room, she could smell the odor of the illegal substance and seen Resident #70 smoking from the pipe.3. Record review for Resident #20 revealed an admission date of 03/07/25. Diagnoses included muscle weakness, peripheral vascular disease, and hereditary and idiopathic neuropathy.Review of the quarterly MDS assessment dated [DATE] for Resident #20 revealed Resident #20 was cognitively intact. Review of the care plan initiated 09/02/25 revealed Resident #20 was on antibiotic therapy related to a toe infection. Interventions included to administer medication as ordered. Any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity /allergic reactions. Staff were to observe and report to the medical doctor (MD) for adverse reaction noted. Review of the physician order dated 09/01/25 for Resident #20 revealed an order for doxycycline hyclate oral tablet (antibiotic)100 milligrams (mg) with instructions to give 100 mg by mouth two times a day for infection of toe for seven days with a start date of 09/01/25 in the morning. Review of the medication administration record for Resident #20 conformed doxycycline hyclate oral tablet 100 mg was initiated 09/01/25 in the morning.Observation and interview on 09/02/25 at 9:38 A.M. revealed Resident #20 was lying in bed. Resident #20 revealed she was not feeling well, she was nauseous and vomited all her breakfast up into a bag she kept by her bed. Resident #20 revealed she had just started a new antibiotic the day before and after receiving the first dose in the morning the day before, she also vomited that one up. Resident #20 revealed she told her CNA (#341) she was not feeling well that morning and she vomited in the bag. CNA #341 removed the bag with the vomit and gave her a clean bag to use if she got sick again. Resident #20 revealed her charge nurse had not been in yet to assess her since she vomited morning of 09/02/25. Resident #20 revealed she did not tell the nurse the day before that she vomited because she felt better after she vomited. Review of the progress note dated 09/02/25 at 9:46 A.M. completed by LPN #222 revealed Resident #20 was alert and oriented to person, place, and time and tolerated by mouth medications and breakfast.Interview on 09/02/25 at 11:51 A.M. with Resident #20 revealed she still felt nauseous. Resident #20 revealed her nurse still had not been in to assess yet.Interview on 09/02/25 at 11:52 A.M. with CNA #341 confirmed Resident #20 vomited that morning in a bag and revealed she threw it away for Resident #20. CNA #341 revealed it was between 8:00 A.M. and 9:00 A.M. CNA #341 stated she had not told the charge nurse about the resident vomiting. Observation revealed CNA #341 then approached LPN #222 and reported Resident #20 vomited that morning. LPN #222 confirmed she was not aware.Review of the facility policy titled, Change in condition or status, dated August 2024, revealed the facility shall promptly notify the resident, his or her physician and representative of changes in the resident ' s medical/mental condition and or status.The deficiency represents an incidental finding discovered during investigation of Complaint Number 2600408, Complaint Number OH00165746 (1393119), and Complaint Number OH00165124 (1393117).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, incident file review, and staff interview, the facility failed to ensure comprehensive resident centered care plans were developed to address resident medical and psychosocial needs. This affected one (#70) of four residents reviewed for care plans. The facility census was 69.Findings include:Review of the medical record revealed Resident #70 was admitted to the facility on [DATE] with diagnoses that included alcohol abuse, cocaine use, type II diabetes, and morbid obesity.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 was cognitively intact and required extensive assistance to complete activities of daily living. Resident #70 discharged to the community on 05/01/25.Review of a progress note dated 01/30/25 from Resident #70's emergency room physician, prior to admission to the facility, revealed Resident #70 was a [AGE] year-old male with a past medical history of polysubstance use. The note further indicated Resident #70 had been admitted to the same hospital from a substance use treatment setting.Review of the incident file for Resident #70 revealed that on 04/28/25, Resident #70 was found smoking an illicit substance in his room at the facility. When confronted, Resident #70 did not deny his drug use.Review of the care plan for Resident #70 revealed no care plans with goals or interventions related to Resident #70's history of or continued drug use.Social Worker #700 verified Resident #70's medical record lacked a care plan with goals and interventions for drug use during an interview conducted on 08/29/25 at 2:11 P.M.This deficiency represents non-compliance investigated under Complaint Number OH00165746 (1393119).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, medical record review, and review of the facility policy, the facility failed to ensure dependent residents received timely care and services from staff to provide activities of daily living (ADLs). This affected one (#38) of three residents reviewed for ADLs care. The facility census was 69.Findings include:Record review for Resident #38 revealed an admission date of 12/09/21. Diagnoses included cerebral infarction due to embolism of the right middle cerebral artery, muscle weakness, congestive heart failure, cardiac pacemaker, contracture of the right and left knee, unspecified moderate dementia with agitation, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was cognitively intact. Resident #38 had impairment on one side of the upper extremity and both sides of the lower extremities. Resident #38 required set up or clean up assist with eating, was dependent for toileting hygiene, personal hygiene, chair/bed to chair transfers, required substantial/maximal assistance for bed mobility, and was independent for wheelchair mobility. Resident #38 was always incontinent of bowel and bladder, and was assessed at risk for pressure ulcers but had no unhealed pressure ulcers or other wounds or skin problems during the assessment look-back period. Review of the care plan dated 07/18/24 revealed Resident #38 required assistance for all ADLs related to weakness, cardiovascular accident with hemiparesis, decreased range of motion (ROM) to the left hand, and bilateral knee contractures. Interventions included set up or clean up assistance for eating, and two staff assistance for toileting tasks, dressing, bathing, and hygiene.Record review of the care plan for Resident #38 dated 12/09/23 revealed Resident #38 experienced bowel and bladder incontinence. Interventions included to check and change Resident #38 every two hours and as needed. Staff were to provide peri-care with incontinent episodes.Observation on 09/03/25 at 8:49 A.M. revealed Resident #38 was sitting in her chair in the dining room. Resident #38 had dried liquid and crumbs on her shirt. Observation on 09/03/25 at 10:55 A.M. revealed Resident #38 was sleeping in her chair in the dining room. Resident #38 had her same clothes on with the dried liquid spilled on her shirt. Observation and interview on 09/03/25 at 1:33 P.M. revealed Resident #38 was sitting in her chair in the dining room. Resident #38's shirt and pants were soiled with dried food and her pants were visibly wet in the peri-area. Resident #38 had the same clothes on from the previous two observations. Resident #38 revealed the staff got her up at 7:00 A.M., placed her in the dining room, and have not checked her for incontinence or changed her all day. Resident #38 revealed she had not been moved from the dining room since staff took her there that morning and Resident #38 confirmed she was wet and stated she would prefer to lay down after breakfast and changed. Observation and interview on 09/03/25 at 1:37 P.M. with Certified Nurse Aide (CNA) #324 confirmed she was Resident #38's primary CNA that day. CNA #324 revealed she got Resident #38 up in her chair around 7:00 A.M. CNA #324 confirmed this would be the first time since 7:00 A.M. Resident #38 would be laid down and checked for incontinence or changed. CNA #324 stated, She (Resident #38) has to be up for breakfast and lunch. It's part of her daily plan so we don't lay her down until after lunch. CNA #324 again confirmed Resident #38 was not checked or changed since 7:00 A.M. and CNA #341 was also present at that time. Observation revealed CNA #324 pushed Resident #38's chair to her room, and both CNA #324 and CNA #341 transferred Resident #38 from her geriatric chair to her bed via mechanical lift. CNA #324 confirmed Resident #38's shirt and pants were soiled with dried food and drink items and confirmed Resident #38's pants were wet inside and out. The brief was heavily saturated with urine and Resident #38 had a foul odor of urine. Resident #38's buttocks had deep creases in her skin from where the brief had wrinkled and created temporary indentations in the skin where the brief was located. Resident #38's buttocks was also red. CNA #324 stated, It's just routine to not change her until after lunch. Interview on 09/03/25 at 2:37 P.M. with the Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) #356 revealed staff should check and change residents every two hours and as needed for incontinence. Review of the facility policy titled, Incontinence care policy, dated December 2023, revealed the policy was to provide individualized incontinence care based on a comprehensive assessment and care plan. Residents will be offered timely assistance, appropriate continence aids, and preventative skin care to promote health, comfort, and dignity. The procedures included to provide timely and respectful assistants for toileting, changing, and hygiene needs. Staff are to change incontinent products promptly when soiled to prevent odor, discomfort, and skin irritation.This deficiency represents non-compliance investigated under Complaint Number 2572439, Complaint Number OH00165746 (1393119), and Complaint Number OH00165124 (1393117).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, review of a police report, and review of facility investigation documents, the facility failed to ensure a resident (#70) was properly monitored for behaviors regarding drug use following know usage in the facility and failed to timely assess a resident (#23) following exposure to illicit substances. This affected two (#23 and #70) of four residents reviewed for assessments and monitoring. The census was 69.Findings include:1. Record review for Resident #70 revealed an admission date of 02/04/25 and a discharge date of 05/01/25. Diagnoses included bipolar disorder, cocaine use, and alcohol abuse. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 was cognitively intact. Resident #70 had no impairment to the upper or lower extremities, was independent with eating, used a wheelchair for mobility and was independent for wheelchair mobility. Review of a progress note dated 01/30/25 from Resident #70's emergency room physician, prior to admission to the facility, revealed Resident #70 was a [AGE] year-old male with a past medical history of polysubstance use. The note further indicated Resident #70 had been admitted to the same hospital from a substance use treatment setting. Record review of Resident #70's medical record for 04/28/25 through 05/01/25 revealed no documentation of Resident #70 smoking an illegal substance while inside the facility. Review of a handwritten statement signed and dated 04/28/25, untimed, completed by Certified Nurse Aide (CNA) #229 revealed at 11:15 (no A.M. or P.M. documented) the nurse aide went into Resident #70's room because the nurse aide saw him roll his wheelchair into the hallway. When CNA #229 went into his room he told the nurse aide to come into the bathroom. The resident rolled into his bathroom and he told the nurse aide to look as he was unfolding a ball of toilet paper. CNA #229 noticed white chunks inside and asked Resident #229 if it was an illicit drug. Resident #70 told CNA #229 to be quiet and lifted a paper towel and exposed two pipes that were obviously used to smoke the substance in the toilet paper. CNA #229 told Resident #70 he needed to give the nurse aide everything he had but he refused. The resident then asked CNA #229 to party with him. CNA #229 immediately left the room and got Licensed Practical Nurse (LPN) #202, and LPN #358 was also called to assess Resident #70. Review of the handwritten statement signed and dated 04/28/25, untimed, completed by LPN #202 revealed she was notified by her CNA (#229) that Resident #70 was seen in the bathroom smoking an illicit drug. LPN #202 then called LPN #358 to have a witness and both nurses entered Resident #70's room and witnessed Resident #70 smoking in the bathroom. LPN #358 asked Resident #70 for the substance, he refused to let go of it, he asked if he could throw it out himself. Review of the handwritten statement signed and dated 04/28/25, untimed, completed LPN #358 revealed the nurse was called to Resident #70's room at approximately 11:19 P.M. She ran to his room and found Resident #70 smoking from a crack pipe and thick white smoke was coming out. As she approached him, Resident #70 blew a cloud of smoke into her face. She stepped into the bathroom and told Resident #70 he needed to give her the pipe and lighter. She grabbed onto them and he would not let go. After about 15 minutes, he let the nurse have them. The Director of Nursing (DON), police, and the Administrator were notified. The police confiscated the drug items. Review of the police incident report date 04/28/25 at 11:56:38 P.M. revealed nurses observed Resident #70 actively smoking out of a pipe. After talking to the resident, he did not know what it was and indicated he found it outside. Review of the progress note dated 04/29/25 at 2:30 P.M. completed by the Administrator revealed he and the DON presented Resident #70 with a behavior contract and the resident refused to sign it. Resident #70 informed the staff another facility would no longer accept him and the facility reviewed alternative options as his Medicaid authorization ended on 4/30/25. Interview on 09/02/25 at 4:57 P.M. with the Administrator revealed on 04/28/25 Resident #70 was found by a CNA smoking an illicit substance in the bathroom of his room. The CNA tried to confiscate the paraphernalia. Resident #70 blew smoke in the CNA's face. The police were called, and the CNA and the nurses went to the hospital to get checked out. The resident did give the paraphernalia to the staff, and it was found to just be residue left over. The police did not want to test the residue and said it was because it was not a chargeable amount. The Administer revealed he and the police went through the resident's room and nothing else was found. The next day, Resident #70 was presented with a contract to remain drug free. Resident #70 refused to sign the contract and discharged himself to the community on 05/01/25. The Administrator confirmed Resident #70 had a roommate at the time the incident occurred and revealed he was unaware of any restrictions or further monitoring/interventions put into place for Resident #70 to prevent further drug use while in the facility. The Administrator reiterated Resident #70 refused to sign the contract. Interview on 09/04/25 at 2:02 P.M. with the DON revealed Resident #70 went on leave of absences (LOAs) before the incident with the drugs on 04/28/25. The DON revealed there were no restrictions or interventions put into place after the incident to monitor Resident #70 from bringing and smoking paraphernalia in the facility potentially affecting other residents. The DON confirmed Resident #23 was Resident #70's roommate including from 04/28/25 through 05/01/25. 2. Record review for Resident #23 revealed an admission date of 07/26/14. Diagnoses included chronic obstructive pulmonary disease (COPD) , dementia, Alzheimer's disease, schizophrenia, chronic respiratory failure with hypoxia, and emphysema. Review of the quarterly MDS assessment dated [DATE] revealed Resident #23 was moderately cognitively impaired. Resident # 23 received continuous oxygen therapy. Review of Resident #23's physician orders for April 2025 revealed an order for oxygen at two liters per minute via nasal cannula for shortness of breath every shift related to chronic obstructive pulmonary disease and a continuous positive airway pressure device to be worn at bedtime and taken off in the morning. Review of the medical record for Resident #23 revealed there was no assessment complete on 04/28/25 after Resident #23's roommate, Resident #70, was found to be smoking in the bathroom near where Resident #23 resided. Record review revealed an initial assessment dated [DATE] at 4:01 P.M. completed by Assistant Director of Nursing (ADON) LPN #336 included vital signs with a blood pressure result of 86/50 millimeters of mercury (mmhg). Record review revealed the next assessment of vital signs was completed 05/01/25. Observation on 09/02/25 at 4:19 P.M. revealed Resident #23 lying in bed. Resident #23 had his oxygen infusing via nasal cannula. Interview with Resident #23 at that time revealed he did not recall the situation on 04/28/25. Interview on 09/04/25 at 11:37 A.M. with ADON LPN #336 confirmed Resident #23's initial assessment after his roommate, Resident #70, was found to be smoking was not completed until 04/29/25 at 4:01 P.M. Record review of Resident #23's vital sign history with ADON LPN #336 confirmed Resident #23's blood pressure of 86/50 mmhg obtained and documented on 04/29/25 at 4:01 P.M. was the lowest, both systolic and diastolic, he had during the timeframe reviewed between 01/01/25 through 04/28/25. ADON LPN #336 confirmed there was no documentation of the physician or Certified Nurse Practitioner (CNP) being notified of the abnormal vital sign. ADON LPN #336 revealed she did not recall if she notified anyone or not of the abnormal vital sign. Telephone interview on 09/04/25 at 12:55 P.M. with Certified Nurse Practitioner (CNP) #360 confirmed she was Resident #23's CNP and revealed she was made aware Resident #70 was smoking illicit drugs in the bathroom and confirmed it was close proximity to Resident #23. CNP #360 revealed she was told Resident #23 was never exposed. CNP #360 revealed if a resident was exposed, she would have expected an assessment to be done on the resident immediately after the exposure and revealed the assessment should include vital signs, a respiratory assessment , and any change in condition including a mental status change and the staff would need to monitor the resident over the next hours to days depending on the amount of exposure. CNP #360 also revealed she would have expected to be notified of abnormal vital signs and confirmed she had no documentation of the notification and could not confirm if she was or was not notified of Resident #23's abnormal vital signs on 04/29/25. Telephone interview on 09/04/25 at 1:45 P.M. with Physician #361 revealed if a resident was smoking illicit drugs in the same room as another resident, he would expect staff to assess both residents' breathing, vital signs, cough, phlegm, and for a headache. The exposed resident could experience breathing problems and burning of the eyes depending on how much exposure there was. Observation on 09/04/25 at 1:55 P.M. with Maintenance Director #293 measured the distance between Resident #23's bed and the bathroom and revealed the distance was approximately seven feet. Interview on 09/04/25 at 2:02 P.M. with the DON confirmed an assessment was not documented on Resident #23 until 04/29/25 at 4:01 P.M. and revealed she did not have an answer why. The DON revealed she came in the facility that night, she took over for the nurses who went to the hospital to be assessed due to exposure. Neither Resident #70 nor Resident #23 were sent to the hospital. The DON revealed she saw Resident #23 sleeping in bed and had no concerns. The DON revealed she worked the remainder of the night until 6:30 A.M. the following morning as the charge nurse and revealed Resident #23 was not woke up during that time for a physical assessment. Telephone interview on 09/04/25 at 5:13 P.M. with LPN #202 revealed on 04/28/25 she was one of the nurses who witnessed Resident #70 smoking an illegal substance in his bathroom. LPN #202 revealed the roommate (Resident #23) was lying in his bed and revealed Resident #23 was not wearing his CPAP but he had his oxygen on with his nasal cannula. LPN #202 revealed Resident #23 often refused his CPAP and revealed he may have worn it later that night but at that time he did not have it on. LPN #202 revealed Resident #70 was smoking the substance in the bathroom sitting in his wheelchair just inside the doorway of the bathroom, the door was opened, and as soon as she entered the doorway of Resident #70's and Resident #23's room, she could smell the odor of the illegal substance and seen Resident #70 smoking from the pipe. The deficiency represents non-compliance investigated under Complaint Number 2600408, Complaint Number OH00165746 (1393119), and Complaint Number OH00165124 (1393117).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to assure residents received supplemental oxygen per physicians orders. This affected one (#72) of three residents reviewed for oxygen therapy. The facility census was 69.Findings include:Record review for Resident #72 revealed an admission date of 08/30/25. Diagnoses included anoxic brain damage, pneumonia due to methicillin resistant staphylococcus aureus (MRSA), chronic obstructive pulmonary disease (COPD), asthma, emphysema, and acute and chronic respiratory failure. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was rarely or never understood and cognitive skills were severely impaired. Resident #72 was dependent for eating, toileting hygiene, and bed mobility. Resident #72 received oxygen therapy continuous. Review of the care plan for Resident #72 dated 09/01/25 revealed the resident had potential for complications related to diagnoses of COPD, asthma, and emphysema. Interventions included to administer medications, inhalers as ordered, and to give oxygen as ordered. Review of the physician orders for Resident #72 dated 08/30/25 revealed an order for oxygen delivery via nasal cannula with a liter flow of two liters and the duration was continuous every shift for breathing. Observation on 09/03/25 at 9:56 A.M. revealed Resident #72 was lying in bed. Resident #72's eyes were closed. Observation revealed Resident #72's oxygen concentrator was running. The nasal cannula was lying on the floor under the tube feeding pole next to Resident #72's bed. Resident #72 was not receiving oxygen from the concentrator. Observation on 09/03/25 at 9:57 A.M., as surveyor was exiting the room, revealed Licensed Practical Nurse (LPN) #202 was walking towards the surveyor and entered Resident #72's room. LPN #202 confirmed she was Resident #72's primary care nurse that day. LPN #202 walked over to Resident #72's bed, proceeded to shut off the tube feeding, then exited the room without addressing Resident #72 nasal cannula on the floor at the bottom of the tube feeding pole. LPN #202 returned to the medication cart and proceeded to walk up the hall, away from Resident #72's room pushing the cart. The Surveyor immediately approached LPN #202 and requested information about Resident #72's oxygen therapy. LPN #202 revealed she was not sure if Resident #72 was supposed to receive oxygen. LPN #202 opened Resident #72's physician orders on her computer located on the medication cart and revealed Resident #72 had an order to be on oxygen continuously. After requesting LPN #202 to assess Resident #72's oxygen status, LPN #202 returned to Resident #72's room and verified the oxygen tubing was on the floor. LPN #202 then monitored Resident #72's oxygen saturation level (percentage of oxygen in the blood) via a pulse oximeter and confirmed Resident #72's oxygen saturation was between 86 percent (%) and 88%. LPN #202 revealed Resident #72's oxygen saturation level was 95% that morning when she assessed it. LPN #202 obtained new oxygen tubing and connected the tubing to the concentrator then placed the cannula in Resident #72's nostrils. LPN #202 then exited the room. Observation revealed the concentrator was set at 1.5 liters per minute. The surveyor immediately returned to LPN #202 who returned to the medication cart. When asked how many liters per minute of oxygen Resident #72 should be receiving, LPN #202 again stated she was not sure and again pulled the order up on the computer on the medication cart. LPN #202 revealed Resident #72 should be on two liters of oxygen per minute per the physician orders. LPN #202 returned to Resident #72's room and confirmed the oxygen was set at 1.5 liters per minute. Review of the facility policy titled, Oxygen Administration, revised 10/2022, revealed the purpose of the procedure was to provide guidelines for safe oxygen administration. Staff are to verify the physicians order for the procedure and turn the oxygen on as directed by the Medical Practitioner. The deficiency represents an incidental finding discovered during the investigation for Complaint Number OH00165746 (1393119).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure medications were administered per the physicians orders. This affected two (#17 and #30) of 14 residents identified by the facility with orders for insulin injections via insulin pen. The facility census was 69. Findings include:1. Record review for Resident #17 revealed an admission date of 11/06/23. Diagnoses included type two diabetes mellitus with hyperglycemia and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment completed 08/16/25 revealed Resident #17 was cognitively intact. Resident #17 had impairment on one side to the upper extremity, received insulin injections, and had a diagnosis of diabetes mellitus. Review of the care plan for Resident #17 dated 11/07/23 revealed Resident #17 had potential risk for hyper/hypoglycemia due to a diagnosis of diabetes. Interventions included to administer medications as ordered. Review of the physician orders for Resident #17 dated 08/06/24 revealed an order for Novolog flex pen 100 unit/milliliter (ml) solution pen-injector to give 10 units subcutaneously three times daily before meals. Observation on 09/02/25 at 11:47 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #230 administered insulin to Resident #17 via Novolog flex pen and revealed LPN #230 primed the insulin pen prior to placing the needle on the pen. When asked, LPN #230 confirmed she primed the insulin injector pen prior to placing the needle on the pen. LPN #230 then continued (without repriming the pen) her procedure, dialed in 10 units of Novolog insulin and administered the insulin to Resident #17 via injection.2. Record review for Resident #30 revealed an admission date of 07/07/25. Diagnoses included type one diabetes mellitus with other circulatory complications, diabetic polyneuropathy, hyperglycemia, and muscle weakness. Review of the admission MDS assessment dated [DATE] revealed Resident #30 was cognitively intact. Resident #30 had impairment on one side of the lower extremity, had a diagnosis of diabetes mellitus, and received insulin injections. Review of the care plan for Resident #30 dated 07/25/25 revealed Resident #30 had potential risk for hyper/hypoglycemia due to diagnosis of diabetes. Interventions included to administer medications as ordered. Review of the physician orders for Resident #30 revealed an order dated 07/11/25 for Novolog flex pen subcutaneous solution pen-injector 100 units per milliliter with instructions to inject 13 units subcutaneous in the evening for diabetes management. THe medication was scheduled to be given at dinner. Further review revealed an additional order for Resident #30 to receive Novolog insulin before meals, timed at 7:00 A.M., 11:00 A.M., and 4:00 P.M., via sliding scale including for the resident to receive seven units of insulin for blood sugars between 376 milligrams per deciliter (mg/dL) and 399 mg/dL. Observation on 09/02/25 at 4:00 P.M. of medication administration revealed LPN #222 assessed Resident #30's blood sugar for a result of 383 mg/dL. LPN #222 then dialed in 20 units of Novolog insulin via flex pen. LPN #222 did not prime the pen prior to dialing the amount to administer.Interview on 09/02/25 at 4:11 P.M. with LPN #222 confirmed she did not prime Resident #30's Novolog insulin pen prior to administering the insulin via the pen. LPN #222 revealed she forgot to and stated, To prime the insulin pen, take it to zero and push so you don't lose any insulin.Interview on 09/02/25 at 4:37 P.M. with the Director of Nursing (DON) revealed all insulin pens need to be primed with the needle on, and dialing the pen to two units prior to administration.Review of the facility policy titled, Insulin Pen Priming and Administration Policy, dated July 2024, revealed all injections must be administered by licensed nursing staff trained in insulin pen use. Priming is required before each injection to ensure correct dosing. A new sterile needle is required for each use. Preparation and priming included attach a new sterile needle to the insulin pen. Prime the pen, dial two units, hold the pen upright, press injection button until a drop of insulin appears at the tip. Repeat priming if no insulin appears.The deficiency represents non-compliance investigated under Master Complaint 2601734, Complaint Number 2572439, and Complaint Number OH00165746 (1393119).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to maintain infection control practices after providing resident care. This had the potential to affect all 69 residents residing at the facility. The facility census was 69.Findings include:Record review for Resident #38 revealed an admission date of 12/09/21. Diagnoses included muscle weakness, unspecified dementia, and hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was dependent for toileting hygiene and was always incontinent of bowel and bladder. Record review of the care plan for Resident #38 dated 12/09/23 revealed Resident #38 experienced bowel and bladder incontinence. Interventions included to check and change Resident #38 every two hours and as needed. Staff were to provide peri-care with incontinent episodes. Observation on 09/03/25 at 1:37 P.M. with Certified Nurse Aide (CNA) #324 and CNA #341 revealed the staff members transferred Resident #38 to bed using a mechanical lift. Further observation revealed CNA #324 and CNA #341 needed to provide Resident #38 with incontinence care as well as changing the resident's brief, pants, and linen due to the items being saturated with urine. After incontinence care was completed, both CNA #324 and CNA #341 removed their gloves, each grabbed the bags of soiled linen and trash, and both left the room with the soiled items without washing their hands or using hand sanitizer. After disposing of the soiled linen and trash bags, CNA #324 went directly to the clean linen cart and obtained clean sheets, returned to Resident #38's room and placed the linen on the bed, covering Resident #38 up with the linen. CNA #341 returned the mechanical lift to the hall and disposed of the soiled bags, returned to Resident #38's room then used hand sanitizer to clean her hands. CNA #324 then went to the lounge to retrieve Resident #67 who was sitting in her wheelchair and which time CNA #324 was interviewed to review the previous observation of incontinence care. Interview with CNA #324 at approximately 1:45 P.M. confirmed she was preparing to provide care for Resident #67 and confirmed she did not use hand sanitizer or washed her hands after proving incontinence care for Resident #38. CNA #324 confirmed she obtained clean linen from a linen cart used and available for all residents after providing peri-care to Resident #38 without washing her hands or using hand sanitizer. Interview with CNA #341 at this time also confirmed she never washed her hands or used hand sanitizer after providing peri-care for Resident #38 and before exiting the room. Interview on 09/03/25 at 2:37 P.M. with the Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) #356 confirmed staff were expected to wash their hands or use hand sanitizer before going in a resident room, after care, and before leaving the room. Interview on 09/09/25 at 2:48 P.M. with the DON confirmed all nursing staff are able to work or have worked throughout the facility with all residents. Review of the facility policy titled, Hand Hygiene, dated October 2024, revealed the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene included use of an alcohol-based hand rub or soap and water for situations which included before and after direct contact with a resident; after contact with a resident's intact skin; after contact with bodily fluids; after contact with medical equipment; after removing gloves; and after conducting personal hygiene. The policy included the use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.This deficiency represents an incidental finding discovered during investigation for Complaint Number 2572439, Complaint Number OH00165746 (1393119), and Complaint Number OH00165124 (1393117).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and resident and staff interview, the facility failed to ensure residents were treated with dignity and respect. This affected two (Resident #13 and #74) of four residents reviewed for dignity. The facility census was 74. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of [DATE]. Diagnoses included psychosis, depression, anxiety, delusional disorders, altered mental status, heart failure, chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 was cognitively intact. Interview on [DATE] at 1:22 P.M. with Resident #13 stated Licensed Practical Nurse (LPN) #346 was always saying things that were sarcastic and rude. Resident #13 also reported being pretty sure LPN #346 cursed at her on an unknown date. 2. Review of the medical record for Resident #74 revealed an admission date of [DATE]. The resident expired in the facility on [DATE]. Diagnoses included hypertensive heart and chronic kidney disease, heart failure, depression, anxiety, and insomnia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #74 had intact cognition. Interview on [DATE] at 10:45 A.M. with Former Licensed Practical Nurse (LPN) #405 revealed they previously worked as a nurse at the facility. LPN #405 reported observing LPN #346 demanding Resident #74 to open their mouth to take medications, pushing the resident because they had been leaning, and shoving the medications into the resident's mouth. Interview on [DATE] at 4:28 P.M. with the Administrator verified they were unaware of any concerns regarding LPN #346 treating the residents. Interview on [DATE] at 11:06 A.M. with Registered Nurse (RN) #355 stated LPN #346 cursed a lot and would yell at residents. RN #355 reported they heard LPN #346 yelling at an unknown resident stating take your medications mother-explicit. RN #355 verified they did not report the observation of LPN #346 yelling at the resident because everyone knew of how LPN #346 treated residents and the administrative staff did not do anything. Interview on [DATE] at 11:38 A.M. with LPN #315 stated the staff member observed LPN #346 yelling at residents and used to report it. LPN #315 was unable to report any specific resident name and/or date of incidents. This deficiency represents non-compliance investigated under Complaint Number OH00161986 and Complaint Number OH00161487.

Based on medical record review, observation, resident and staff interviews, and policy review, the facility failed to ensure all residents' call lights were within reach. This affected three (Residents #14, #34, and #42) of 74 residents reviewed for call lights within reach. The facility census was 74. Findings include: 1) Review of the medical record for Resident #42 revealed an admission date of 07/28/20. Review of the plan of care dated 04/19/21 revealed Resident #42 was at a potential risk for falls related to dementia, bipolar and decreased safety awareness. Interventions included to ensure call light was within reach. Observation on 01/28/25 at 11:10 A.M. revealed Resident #42's call light laying on floor at the bottom of bed. Resident #42 was unable to reach the call light. Interview on 01/28/25 at 11:15 A.M. with Certified Nursing Assistant (CNA) #334 verified Resident #42's call light was at the bottom of bed and out of reach. CNA #334 stated staff were to ensure call lights were within reach and residents were able to use the call light. 2) Review of the medical record for Resident #14 revealed an admission date of 12/01/22. Review of the plan of care dated 02/06/24 revealed Resident #14 was at potential risk for falls related to dementia, incontinence and safety awareness. Intervention included to ensure call light was within reach. Observation on 01/28/25 at 10:49 A.M. of Resident #14's call light cord laying on the floor by the wall at the bottom of the bed. Resident #14 was unable to reach the call light. Interview on 01/28/25 at 11:11 A.M. with Certified Nursing Assistant (CNA) #334 verified Resident #14's call light was not within reach. CNA #334 stated staff were to ensure call lights were within reach and residents were able to use the call light. 3) Review of the medical record for Resident #34 revealed an admission date 02/02/24. Review of the plan of care dated 02/05/24 revealed Resident #34 was at potential risk for falls related to brain damage and seizures. Intervention included to ensure call light was within reach. Observation on 01/28/25 at 10:47 A.M. of Resident #34's call light not within reach and Resident #34 stated she hurt and would like a pain medication. Interview on 01/28/25 at 11:13 A.M. with Certified Nursing Assistant (CNA) #334 verified Resident #34's call light was on the floor at the bottom of the bed and out of reach. CNA #334 stated staff were to ensure call lights were within reach and residents were able to use the call light. Review of the facility policy titled Call Lights: Accessibility and Timely Response, dated 04/01/22 revealed with each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interview and policy review, the facility failed to ensure a resident's family was notified of a resident's decline in condition. This affected one (#178) of four residents reviewed for change in condition. The facility census was 74. Findings include: Review of the closed medical record for Resident #178 revealed an admission date of [DATE], a readmission date of [DATE] and a discharge date of [DATE]. Diagnoses included pneumonia, hypertension, and acute and chronic respiratory failure with hypoxia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #178 had impaired cognition. Review of a physician order dated [DATE] revealed Resident #178's code status was Do Not Resuscitate Comfort Care (DNRCC). Review of nurse's note dated [DATE] at 11:16 A.M. revealed the nurse went to assess and provide resident medication and resident was noted with respiratory distress. The resident's pulse oximetry level was 80 percent on four liters via trach collar. The resident was suctioned with copious amount of thick clear sputum. Pulse oximetry level increased to 83-84 percent. The resident's inner cannula and tracheostomy care were completed and an as needed aerosol was administered. Pulse oximeter level increased to 85 percent. Resident resting comfortably with eyes closed. The nursing dated dated [DATE] at 1:02 P.M. revealed the resident had an absence of vital signs at 10:55 A.M. There was no documentation the family was notified of Resident #178's change in condition. Interview on [DATE] at 11:47 A.M., Licensed Practical Nurse (LPN) #353 stated Resident #178 had been declining. LPN #353 revealed she went to administer the residents medications around 8:30 A.M. to 8:45 A.M. and noticed the resident was in respiratory distress. LPN #353 stated she increased the resident's oxygen, suctioned the resident, and changed the inner cannula and administered an aerosol treatment. LPN #353 stated the resident had a DNRCC code status. LPN #353 stated she notified the Assistant Director of Nursing (ADON) #392 and the Director of Nursing (DON) who then administered suctioning again and another aerosol treatment. LPN #353 stated the DON and ADON #392 notified her the resident's oxygen level came back up. LPN #353 stated she periodically kept checking the resident while passing medications to other residents. LPN #353 verified she had not called the family to notify them of the decline in the resident's condition. LPN #353 stated she thought ADON #392 was going to notify the family. LPN #353 also verified she had not documented the progress note until after the resident had expired. Interview on [DATE] at 12:02 P.M. with ADON #392 and the DON stated the nurse requested assistance for Resident #178. ADON #392 and the DON stated they suctioned the resident, changed the inner cannula and provided an aerosol treatment and the resident's pulse oximetry increased to 93 percent. The DON stated LPN #353 was notified the resident's oxygen level was back up. The DON stated she then went to a meeting and was notified ten to 20 minutes later the resident had passed away. The DON verified the care she provided to the resident with ADON #392 had not been documented in the medical record. The DON stated, too many hands were in the pot. Interview on [DATE] at 3:31 P.M. stated ADON #392 stated she did not notify the resident's family when Resident #178 had a decline in condition. Interview on [DATE] at 11:35 A.M. with the DON verified there was no documentation Resident #178's family was notified of the decline in condition. Review of the policy titled Notification of Changes, revised [DATE], revealed the facility would notify a resident's family member or legal representative when there was a significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status. This deficiency represents non-compliance investigated under Complaint Number OH00161986.

Based on staff interview, record review, and review of the facility policy, the facility failed to ensure a care plan was completed for Resident #61 to include depression, anxiety, and the use of psychotropic medications. This affected one (Resident #61) of 27 residents reviewed for care plans. The facility census was 74. Findings include: Review of the medical record for Resident #61 revealed an admission date of 11/04/24. Diagnoses included delirium, dementia without behavioral disturbance, psychotic disturbance and mood disturbance, and major depressive disorder. Review of Resident #61's care plan initiated on 11/13/24 revealed the resident's anxiety, depression, behaviors, and use of antipsychotic and psychotropic medications were not addressed in the comprehensive care plan. Review of the physician orders revealed the following psychotropic medications: on 11/04/24, an order for quetiapine 50 milligrams (mg) at bedtime for anxiety. On 11/09/24, an order for Zoloft 25 mg in the morning for dementia and anxiety and Depakote sprinkles 125 mg at bedtime for delirium, dementia and anxiety. On 11/28/24 the order for the quetiapine was updated for the diagnosis of unspecified dementia and anxiety. On 01/22/25, the Zoloft diagnosis was noted as depression. On 01/22/25, the Depakote sprinkles had a diagnosis for behaviors. Interview on 02/04/25 at 9:48 A.M. with Minimum Data Set (MDS) Nurse #354 stated she began working in the facility three weeks ago and did not have a chance to review all the previous care plans. MDS Nurse #354 verified Resident #61 had no care plan in place for depression, anxiety, behaviors, and for the use of antipsychotic and psychotropic medications. Review of the policy titled Comprehensive Care Plans, revised 06/01/24, revealed the comprehensive care plan would include the service to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, record review, and review of the facility policy the facility failed to ensure a resident who required assistance from staff with activities of daily living received the care and services with bathing/showers. This affected one (Resident #182) of three residents reviewed for bathing/showers. The facility census was 74. Findings include: Record review for Resident #182 revealed an admission date of 11/21/24 and a discharge date of 12/30/24. Diagnoses included presence of right artificial hip joint and encounter for orthopedic aftercare. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #182 was cognitively intact. Resident #182 had impairment on one side of the lower extremity. Resident #182 was dependent on staff for showering/bathing. Review of the care plan dated 11/21/24 revealed Resident #182 had no care plan for activities of daily living (ADL). Review of the physician orders for Resident #182 dated 11/24/24 revealed skin checks weekly with showers on Mondays and Thursdays. Review of the shower/bath schedule for Resident #182 revealed Resident #182 was scheduled to receive a shower 11 times on 11/25/24, 11/28/24, 12/02/24, 12/05/24, 12/09/24, 12/12/24, 12/16/24, 12/19/24 12/23/24, 12/26/24 and 12/30/24. Review of the Shower/Tub Bath/Bed Bath Sheets provided by Regional Registered Nurse (RRN) #410 revealed Resident #182 was not offered a shower/bath six times on 11/25/24, 11/28/24, 12/05/24, 12/09/24, 12/12/24, 12/23/24, and 12/30/24. There were no other records indicating the resident was offered a shower or bath on other days of the week. Interview on 02/03/25 at 2:00 P.M. with Resident #182 stated he was admitted to the facility to recuperate from a shattered femur. Resident #182 stated after his admission, three days went by before he was offered a toothbrush and 15 days went by before he was even offered a shower or bath. Interview on 02/06/25 at 11:40 A.M. with RRN #410 stated each resident was scheduled showers/baths weekly. Resident #182 was scheduled two showers/baths a week. When the shower/bath was offered and or completed, the Shower/Tub Bath/Bed Bath Sheet was filled out and signed by the Certified Nursing Assistant (CNA) and the Licensed Nurse, even if the resident refused. RRN #410 confirmed only four Shower/Tub Bath/Bed Bath Sheets were completed for Resident #182 confirming Resident #182 was offered a shower/bath only four of the scheduled 11 to be offered. Interview on 02/06/25 at 12:00 P.M. with CNA #307 confirmed she cared for Resident #182 during his stay at the facility. CNA #307 stated some days there were enough staff to offer showers and other days there were not. CNA #307 stated if there was not enough staff then showers were not done because there was just not enough time to get to them. Review of the facility policy titled Activities of Daily Living, reviewed/revised 01/01/25, revealed care and services will be provided for the following activities of daily living: Bathing, dressing, grooming, and oral care. This deficiency represents non-compliance investigated under Complaint Number OH00161986.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family and staff interview, record review, and review of the facility policy, the facility failed to ensure physician ordered compression socks were implemented for Resident #55 and failed to timely provide care and treatment to treat a resident's excessive sweating causing skin issues. This affected two (Residents #54 and #55) of seven residents reviewed for care and services. The facility census was 74. Findings include: 1. Record review for Resident #55 revealed an admission date of 05/15/23. Diagnoses included Parkinson's disease, dementia, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was severely cognitively impaired. Resident #55 had impairment on both sides of the upper and lower extremities. Resident #55 was dependent on staff for personal hygiene. Review of the care plan for Resident #55 dated 05/15/23 and revised 07/17/24 revealed an intervention was to apply TED (thrombo-embolic deterrent; type of compression stocking that helps prevent blood clots in the legs) hose in the morning and remove them at night. Review of the physician orders for Resident #55 dated 03/27/24 revealed an order to apply TED hose knee high on in the morning and off in the evening for deep vein thrombosis (DVT) prophylactic. Observation on 01/30/25 at 12:55 P.M. revealed Certified Nursing Assistant (CNA) #401 pushed Resident #55's Broda chair from the dining room to the lounge. Resident #55's feet were dangling and Resident #55 did not have TED hose on. Continued observation on 01/30/25 from 1:28 P.M. through 2:23 P.M. revealed Resident #55 stayed in the lounge in the Broda chair in the upright position with his feet dangling. No staff addressed Resident #55 to offer care. Record review on 01/30/25 at 2:17 P.M. of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for 01/30/25 revealed Licensed Practical Nurse (LPN) #353 signed the orders as completed for Resident #55 to apply TED hose knee high on in the morning and off in the evening for DVT prophylactic. Observation on 01/30/25 at 2:24 P.M. revealed CNA #357 and #395 assisted Resident #55 to his room. CNA #357 confirmed she was Resident #55's primary CNA and stated she assisted Resident #55 up out of bed at 6:30 A.M. that day (01/30/25). CNA #357 and #395 stated Resident #55 never wore TED hose, they had both worked with him over the past six months and he never wore TED hose. Interview on 01/30/25 at 2:37 P.M. with Licensed Practical Nurse (LPN) #353 confirmed she was Resident #55's Charge Nurse. LPN #353 verified Resident #55 was supposed to wear TED hose daily but she was not sure if they were on him because she does not look. Observation on 02/04/25 at 4:52 P.M. with Registered Nurse Supervisor (RNS) #308 confirmed Resident #55 did not have his TED hose on. RNS #308 stated she told the CNA earlier in the day to apply the TED hose, the CNA informed her there was none in his room to apply so she told the CNA she would get him some out of stock but she just had not done it yet. Observation with RNS #308 confirmed Resident #55 did not have any TED hose available in his room to be applied. RNS #308 confirmed the TED hose was signed in the medical record as being applied in the A.M. 2. Record review for Resident #54 revealed an admission dated of 05/30/23. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was rarely or never understood. Resident #54 was dependent on staff for activities of daily living (ADLs). Resident #54 had an indwelling catheter and was always incontinent of bowel. Resident #54 had moisture associated skin damage (MASD) and received applications of ointments/medications. Review of the care plan dated 12/18/23 revealed Resident #54 required assistance for activities of daily living. Interventions included to inspect skin condition daily during personal care and report any impaired areas to charge nurse. Resident #54 was totally dependent on staff and does not participate in any aspect of the task including toileting hygiene or personal hygiene. Resident #54 experiences bowel incontinence interventions included to provide incontinence care every two hours and as needed. Resident #54 had potential for alteration in skin integrity: required protective/preventative skin care maintenance related to bowel incontinence, decreased mobility, apply house moisture barrier as ordered, assist with cleansing the peri area and apply the house protective barrier after each episode of incontinence. There was no mention of Resident #54 having an issue with excessive sweating. Record review of the physician orders for Resident #54 revealed venelex external ointment apply to sacrum topically two times a day for prevention dated 11/15/23. Record review of the medical record for Resident #54 revealed no documentation of excoriation to the buttocks or moisture-associated skin damage (MASD). Interview on 01/28/25 at 12:44 P.M. with Resident #54's spouse stated she was concerned about the rash on Resident #54's bottom, she felt Resident #54 was not being changed enough. Interview on 01/30/25 at 12:01 P.M. with CNA #395 stated Resident #54 had an indwelling catheter and only needed changed if he had a bowel movement. Resident #54 had not had a bowel movement so there was no need to change him that day. Observation and interview on 02/05/25 at 11:07 A.M. revealed CNA #357 and #395 were completing a brief change for Resident #54. Resident #54 was wet with sweat on his shirt and in his brief. CNA #357 and #395 stated Resident #54 always sweats and that was why his bottom was wet and very red. Observation revealed Resident #54's bilateral buttocks was deep red/discoloration with open excoriated areas to bilateral buttocks. CNA #357 and #395 stated Resident #54 was unable to move without assistance. Interview on 02/05/25 at 12:58 P.M. with Wound Care Certified Nurse Practitioner (CNP) #611 confirmed she assessed Resident #54 on this day and observed the buttocks was discolored and diagnosed with MASD; MASD was caused by moisture, the moisture could be caused by the sweating, and the area needed to be kept clean and dry. Interview on 02/06/25 at 11:36 A.M. with Regional Registered Nurse (RRN) #410 confirmed there was no documentation of MASD in Resident #54's medical record and stated it looked like it comes and goes because the venelex external ointment, ordered in November 2023 was used for the MASD. RRN #410 stated each time Resident #54 had MASD, the nurses should have measured, monitored, and documented the areas. Interview on 02/06/25 at 11:56 A.M. with Licensed Practical Nurse (LPN) #361 stated Resident #54's excoriation (MASD) comes and goes on Resident #54's buttocks and it has been going on for at least six months. LPN #361 stated it was from his sweat. This deficiency represents non-compliance investigated under Complaint Number OH00161986.

Based on medical record review, observation, and resident and staff interview, the facility failed to ensure a resident received the appropriate treatment and services to maintain/improve mobility according to physician orders. This affected one (Resident #26) of one resident reviewed for range of motion. The facility census was 74. Findings include: Review of the medical record for Resident #26 revealed an admission date 12/09/21. Diagnoses included left hand contracture. Review of the physician orders for February 2025 revealed palm protective splint to left hand on in the PM and off in the AM, activated on 01/20/23. Review of the plan of care revealed Resident #26 required assistance with needed for activities of daily living (ADL) related to decreased range of motion to left hand. Interventions included palm protective splint to left hand on in the PM and off in the AM. Observation and interview on 01/28/25 at 2:51 P.M. revealed Resident #26 was propelling self in her wheelchair down the hall and her left hand was contracted and no splint was on. Interview with Resident #26 stated the staff have not put her splint, on for months. Staff were unable to find her splint, so she has not been able to wear it. Resident #26 stated if staff can find her splint she would like to wear it. Observation and interview on 02/05/25 at 5:40 A.M. revealed Resident #26 was lying in bed and not wearing her left palm splint. The resident stated the certified nursing aide (CNA) did not put her splint on when she went to bed the night before (02/04/25). Interview on 02/05/25 at 5:40 A.M. with Licensed Practical Nurse (LPN) #367 verified Resident #26 was to have a splint or rolled up towel in her left hand at night. LPN #367 verified Resident #26 was not wearing her splint and did not have a rolled-up washcloth in her hand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of the medical record for Resident #173 revealed an admission date 08/09/24 and discharged on 09/17/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left dominant side and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #173 had intact cognition. Review of the fall investigation completed on 08/12/24 revealed Resident #173 was found on the floor in bedroom and stated he was trying to get in his dresser drawer and the drawer was stuck. Resident #173 tried to pull it open and he leaned forward and fell. Review of Registered Nurse (RN) #381 witness statement dated 08/12/24 revealed Resident #173 stated he was attempting to open dresser drawer, it was stuck, and he pulled too hard and he fell on his left shoulder. Review of the fall investigation did not have witness statement from the Certified Nurses Assistant (CNA) that found Resident #173 nor a statement from Resident #173. Interview on 01/30/25 at 11:24 A.M. with Resident #173's wife via telephone stated on 08/12/24, Resident #173 called her and stated he fell out of the Hoyer oft. When the CNA used a Hoyer pad, the one strap was broke and when she lifted him to be put in the wheelchair, the strap completely broke and he fell laying on the wheels of the Hoyer. Interview on 01/30/25 at 11:59 A.M. with Resident #173 via telephone stated he fell out of the Hoyer during a transfer. He stated he was up in the air and he fell when the Hoyer pad strap completely broke and he fell landing on the wheels of the Hoyer. His left shoulder hit the Hoyer wheels and it still hurts. The facility did an X-ray at the facility of his shoulder and it came back negative. Then they came back about a week later and said he had a dislocated shoulder, and someone pulled his arm and put his shoulder back in place. There was just one CNA using the Hoyer when he fell. Interview on 01/30/24 at 4:10 P.M. with the Director of Nursing (DON) verified she did not have a statement from the CNA #381 that was working on 08/12/24 at the time of Resident #173's fall and did not have a statement from Resident #173. The DON verified all staff that were working during the fall should be interviewed regarding the fall incident to ensure a accurate and full investigation was completed. Interview on 01/30/24 at 8:15 A.M. with the Regional Administrator #407, Regional Nurse #408 stated CNA #381 stated she filled out a statement on 08/12/24 for Resident #173's fall. Regional Administrator #407 stated they were unable to find any statement for CNA #381. Interview on 01/30/24 at 10:00 A.M. with CNA #381 stated she was the CNA that found Resident #173 on the floor when he pulled too hard on his drawer and fell out of his wheelchair. CNA #381 stated she wrote a statement on the day of the fall. CNA #381 denied that she was using the Hoyer and the strap on the Hoyer pad breaking. Interview on 02/03/25 at 10:40 A.M. via telephone with Registered Nurse (RN) #380 stated she was the nurse that went in to Resident #173's room after he fell out of his wheelchair. RN #380 stated Resident #173 stated he was trying to open his drawer and fell out of his wheelchair hitting his left shoulder on the ground. RN #380 stated she could not remember anything else if it was not written on the witness statement. Review of the facility policy titled Fall Prevention and Management Policy, dated 01/08/25 revealed that in the event of a fall, the resident will be assessed by a nurse the Physician/Nurse Practitioner and the responsible party will be notified and an intervention aimed to prevent further falls will be implemented. Details of the fall will be gathered and documentation completed as indicated. This deficiency represents non-compliance investigated under Complaint Number OH00161986. Based on observation, staff interview, record review and review of the facility policy, the facility failed to prevent an avoidable fall with minor injury for Resident #54, failed to ensure fall interventions were in place for Resident #54 who was at a fall risk, and did not complete a thorough fall investigation into Resident #173' fall. This affected two (Residents #54 and #173) of three residents reviewed for falls. The facility census was 74. Findings include: 1) Record review for Resident #54 revealed an admission date of 05/30/23. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, aphasia, muscle weakness, tracheostomy, cerebral infarction, and acute respiratory failure. Review of the care plan created 06/05/23 revealed Resident #54 was totally dependent on staff for ADLs and does not participate in any aspect of the task for bed mobility. Interventions included to use two persons assistance for repositioning, hygiene and bathing. The care plan was revised on 12/18/23 revealed Resident #54 had a potential risk for falls. Interventions included bed to be in the lowest position while occupied. Ensure call light within reach at all times. Review of the significant change Minimum Dat Set (MDS) assessment dated [DATE] revealed Resident #54 was unable to complete the cognitive interview. Resident #54 was dependent on staff for all activities of daily living (ADLs), Resident #54 had impairment on one side of the upper and lower extremities, was dependent for bed mobility and personal hygiene. Resident #54 had no falls since admission. Review of the Fall Risk Evaluation dated 12/05/24 at 2:54 P.M. completed by Licensed Practical Nurse (LPN) #613 revealed Resident #54 was a moderate risk for falls. Review of the progress note for Resident #54 dated 12/31/24 at 5:00 A.M. completed by LPN #394 included the certified nursing aide (CNA) called the nurse into the room stating the resident had rolled out of bed while being given a bed bath. This nurse went to assess the resident and witnessed the resident on the left side of the bed on the floor. The resident had a large skin tear on his left forearm. The nurse attempted to clean the area and wrap it up. Review of the Skin Grid Non-Pressure form for Resident #54 dated 12/31/24 at 9:42 A.M. completed by Registered Nurse Supervisor (RNS) #308 revealed the left forearm skin tear, was newly acquired on 12/31/24, measuring 9.7 centimeters (cm) in length by 3.3 cm in width. Moderate amount of drainage, attempted to place skin back in place, open. Observation on 01/30/25 at 11:05 A.M. revealed Resident #54 was lying in a bed, and the bed was positioned in the high position. There were no staff or visitors present in Resident #54's room. Observation on 01/30/25 at 11:07 A.M. with CNA #401 confirmed Resident #54's bed was left in the high position. CNA #401 stated the bed should be in the lowest position. Telephone interview on 01/30/25 at 4:00 P.M. with LPN #394 stated she did remember the incident on 12/31/24 when Resident #54 fell out of bed. LPN #394 stated the CNA was giving Resident #54 a bed bath when Resident #54 rolled out of bed. LPN #394 confirmed the CNA was working with Resident #54 by himself, and no staff were assisting with the care. Interview 02/05/25 at 10:30 A.M. with RNS #308 confirmed the left arm skin tear was obtained from the fall on 12/31/24. Interview with Regional Registered Nurse (RRN) #410 on 02/05/25 at 11:01 A.M. confirmed Resident #54 was to have two staff members to assist with bed mobility and bathing on 12/31/24 when Resident #54 fell out of bed. RRN #410 confirmed there was only one staff member providing the bathing and bed mobility when Resident #54 fell out of bed and stated she believed it was not communicated to the staff that Resident #54 required two-persons assistance with ADL care. Review of the facility policy titled Fall prevention and Management revised 01/08/25 revealed each resident will be assessed for fall risk on admission, quarterly, after any fall and as needed. If risks are identified, preventative measures will be put into place and added to the resident's care plan. Individualized interventions will be implemented based on assessment and risk factors. Interventions will be monitored for effectiveness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Review of the medical record for Resident #5 revealed an admission date of 01/19/23. Diagnoses included dementia, generalized anxiety, and retention of urine. Resident #5 had impaired cognition. Review of the plan of care dated 07/24/24 revealed Resident #5 had the potential for complications related to the use of indwelling catheter. Interventions included to assist with catheter care as needed, follow facility policy for enhanced barrier precautions and observe for signs and symptoms of infections. Review of the physician order dated 09/26/24 revealed staff were to provide catheter care every shift and as needed. Observation and interview on 02/03/25 at 11:45 A.M. revealed Resident #5's tubing was not secured to the resident. Licensed Practical Nurse (LPN) #369 verified the tubing for the catheter was not secured to the resident. LPN #369 stated she would secure the tubing. 4) Review of medical record for Resident #47 revealed an admission date of 01/11/22. Diagnoses included obstructive and reflux uropathy. Resident #47 had intact cognition. Review of the plan of care dated 11/06/24 revealed Resident #47 had the potential for complications related to the use of indwelling catheter. Interventions included to assist with catheter care as needed, follow facility policy for enhanced barrier precautions and observe for signs and symptoms of infections. Review of the physician order dated 10/05/24 revealed staff were to provide catheter care every shift and as needed. Observation on 02/03/25 at 12:01 P.M. revealed Licensed Practical Nurse (LPN) #359 verified Resident #47's tubing for the catheter was not secured to the resident. LPN #369 stated she would secure the tubing. This deficiency represents non-compliance investigated under Complaint Number OH00161986 and OH00161487. Based on record review, observations, resident, family, and staff interview, and policy review, the facility failed to ensure the resident's indwelling catheter tubing was secured to the resident to prevent dislodgement of the urinary catheter. Additionally, the facility failed to ensure residents receive timely incontinence care. This affected two (Resident #5 and #47) of three residents reviewed for indwelling catheters and two (Residents #55 and #181) of three residents reviewed for incontinence care. The facility identified seven residents who have an indwelling catheters. The facility census was 74. Findings include: 1) Record review for Resident #181 revealed an admission date of 01/15/25. Diagnoses included atrial fibrillation, atherosclerotic heart disease of native coronary artery, and chronic kidney disease. Review of the care plan dated 01/16/25 revealed Resident #181 experienced bowel and/or bladder incontinence. Interventions included to provide incontinence care every two hours and as needed. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #181 was cognitively intact. Resident #181 required partial/moderate assistance with toileting hygiene, personal hygiene, and transfers. Resident #181 was occasionally incontinent of urine and frequently incontinent of bowel. Interview on 01/29/25 at 3:25 P.M. with Certified Nursing Assistant (CNA) #309 stated at times the facility did not have enough staff to complete resident's care timely including incontinence care and not being assisted to bed timely. CNA #309 stated yesterday (01/28/25), while she went to the dining room to assist with meals, that only left one CNA on the floor to assist the residents. Last Thursday (01/23/25), the assigned CNA #399 refused to change Resident #181 during dinner service. Starting at 4:00 P.M., CNA #309 was assigned to the dining room. LPN #364 went into Resident #181's room and turned her call light off twice. Resident #181 had diarrhea and needed changed. LPN #364 did not assist the resident and no one told her Resident #181 needed changed. At 5:20 P.M., Resident #181 was passed a meal tray by CNA #399. CNA #399 told her she could not change her while dinner was being passed. Resident #181 tried to refuse her dinner tray hoping she would then be able to be changed. CNA #399 said no she had to pass trays. CNA #309 was in the dining room, and Resident #181's husband came and got her (CNA #309) around 6:15 P.M. and CNA #309 changed her. Resident #181 had stool everywhere. Interview on 01/29/25 at 3:40 P.M. with Resident #181 stated she was sitting up in her chair in her room. Resident #181 stated she had diarrhea really bad last Thursday (01/23/25) and after she put her call light on, an unidentified CNA came into her room, turned her call light off and said she was giving a shower. Resident #181 stated she waited about a half hour sitting in diarrhea and then the CNA came back in and said she had to wait until after dinner to avoid cross contamination. Resident #181 said it took a few hours for her to receive incontinence care. Resident #181 stated it was very upsetting and embarrassing when she had to sit in diarrhea and no one would help her. Interview on 01/29/25 at 4:03 P.M. with Licensed Practical Nurse (LPN) #364 confirmed she worked the previous Thursday (01/23/25) at dinner time when Resident #181 had diarrhea and needed changed. LPN #364 stated she never shut the call light off. LPN #364 stated Resident #181 said she needed changed, CNA #399 went in there, and told Resident #181 it was dinner. LPN #364 explained during dinner, generally they do not change residents, and the residents need to wait until after the meal. Interview on 02/06/25 at 11:10 A.M. with Regional Nurse (RN) #410 stated if a resident was incontinent and staff were passing trays, she would expect the staff member to get assistance so the resident could be changed at the time the resident was incontinent. The resident should not have to wait until after meal service to receive incontinence care. 2) Record review for Resident #55 revealed an admission date of 05/15/23. Diagnoses included Parkinson's disease, dementia and muscle weakness. Review of the care plan for Resident #55 dated 05/15/23 and revised 07/17/24 revealed Resident #55 was totally dependent on staff for activities of daily living and does not participate in locomotion in wheelchair, provide incontinence care with routine rounds and as needed. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was severely cognitively impaired. Resident #55 had impairment on both sides of the upper and lower extremities. Resident #55 was dependent for toileting hygiene, personal hygiene, and transfers. Resident #55 required substantial/maximal assistants for bed mobility and was frequently incontinent of urine and always incontinent of bowel. Review of the physician orders for Resident #55 dated 01/14/25 revealed to check and change Resident #55 every two hours to offload coccyx - peri area. Resident #55 was to be up in the Broda chair (a chair that provides comfort, support, and mobility) for a maximum of four hours a day. An order dated 07/10/24 revealed to encourage Resident #55 to let staff put him back to bed after lunch. Interview and observation on 01/30/25 at 11:14 A.M. with Resident #55's wife revealed she visited Resident #55 frequently. Resident #55 was supposed to be changed every two hours, the staff get him up at 5:00 A.M. every morning and he would sit in the chair all day without being laid down or changed. Observation with Resident #55's wife revealed Resident #55 was sitting in the Broda chair in an upright position sleeping in the dining room. Observations revealed on 01/30/25 at 11:56 A.M., Resident #55 was still sitting in the Broda chair in an upright position sleeping in the dining room. The meal was not served. On 01/30/25 at 12:54 P.M., Resident #55 was still sitting in the Broda chair in an upright position sleeping in the dining room. The meal was completed and the tray was removed. On 01/30/25 at 12:55 P.M., Certified Nursing Assistant (CNA) #401 pushed Resident #55's Broda chair from the dining room to the lounge. CNA #401 did not offer Resident #55 to lay down after lunch, after taking him in the lounge. CNA #401 left Resident #55 in the Broda in the upright position in the lounge. Continuous observations on 01/30/25 from 1:28 P.M. through 2:23 P.M. revealed Resident #55 stayed in the lounge in the Broda chair in the upright position with his feet dangling. No staff addressed Resident #55 to offer care. Record review on 01/30/25 at 2:17 P.M. of Resident #55's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for 01/30/25 revealed Licensed Practical Nurse (LPN) #353 signed the orders as completed for Resident #55 to check and change Resident #55 every two hours to offload coccyx - peri area, to be up in the Broda chair for a maximum of four hours a day, and to encourage Resident #55 to let staff put him back to bed after lunch. Observation and interview on 01/30/25 at 2:24 P.M. revealed CNA #357 and #395 assisted Resident #55 to his room. CNA #357 confirmed she was Resident #55's primary CNA and stated she assisted Resident #55 up out of bed at 6:30 A.M. that day (01/30/25) CNA #357 confirmed this was the first time today she laid Resident #55 down and confirmed she did not check or change him either until now. CNA #357 stated she thought hospice was in earlier and changed him. CNA #357 stated she was busy and did not have time. Observation of incontinence care provided by CNA #357 and #395 revealed Resident #55's brief was saturated with urine. Resident #55's pants were also wet and CNA #395 confirmed the seat cushion in the Broda chair was also wet with urine. Resident #55's scrotum and peri area were red. CNA #357 stated Resident #55 gets up again before dinner and will stay up until laid down by the next shift. Interview on 01/30/25 at 2:37 P.M. with Licensed Practical Nurse (LPN) #353 confirmed she was Resident #55's Charge Nurse. LPN #353 stated the hospice aid was in today and provided care for Resident #55 then left between 7:00 A.M. and 7:30 A.M. LPN #353 stated she was not sure how long Resident #55 was to be up in the chair, maybe two or three hours. LPN #353 confirmed she signed all orders on MAR and TAR as completed for 01/30/25. Observation on 02/04/25 at 4:52 P.M. with Registered Nurse (RN) Supervisor #308 confirmed Resident #55 was sitting up in his chair. Review of the facility policy titled Incontinence reviewed 07/01/24 revealed based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure residents on psychotropic medications were monitored for adverse consequences and behaviors were routinely monitored. This affected three (Residents #13, #42, and #61) of five residents reviewed for unnecessary medications. The facility identified 48 residents receiving psychotropic medications. The facility census was 74. Findings include: 1. Review of the medical record for Resident #61 revealed an admission date of 11/04/24. Diagnoses included delirium, hypertension, unspecified dementia without behavioral disturbance, psychotic disturbance and mood disturbance, urinary tract infection, pneumonia, and major depressive disorder. Review of the care plan initiated 11/13/24 revealed no plan of care was in place for anxiety, depression, behaviors, use of antipsychotic and psychotropic medications. Review of the physician orders revealed the following psychotropic medications for Resident #61: on 11/04/24, an orders for quetiapine 50 milligrams (mg) at bedtime for anxiety. On 11/09/24, an order for Zoloft 25 mg in the morning for dementia and anxiety and Depakote sprinkles 125 mg at bedtime for delirium, dementia and anxiety. Review of the Medication Administration Records (MARs) and the nursing progress notes from 11/04/24 through 02/04/25 revealed no documentation Resident #61 was monitored for potential adverse effects for the antipsychotic medication quetiapine and psychoactive medication Zoloft. Interview on 02/05/25 at 11:01 A.M. with Regional Nurse (RN) #410 verified there was no documentation the facility had been monitoring Resident #61 for adverse effects of antipsychotic and psychotropic medications. RN #410 stated the nursing staff should have documented the monitoring on the medication administration record or the treatment administration record. 3. Review of the medical record for Resident #42 revealed an admission date 07/28/20. Diagnoses included dementia with agitation, bipolar, depression and anxiety. Review of the physician orders for February 2025 revealed Resident #42 had the following psychotropic medications: Olanzapine (antipsychotic) and Mirtazapine (antidepressant). Reviews of Resident #42's medical record revealed there was no documentation of side effects or behaviors for the antipsychotic and antidepressant medications. Interview on 02/05/25 at 8:40 A.M with Registered Nurse (RN) #410 verified there was no documentation of side effects or behaviors for Resident #42. RN #410 stated it should be in the orders and documented daily. Review of the facility policy titled Psychotropic Medication, dated 01/01/25 revealed the response to the medications, including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. 2. Review of the medical record for Resident #13 revealed an admission date of 12/05/21. Diagnoses included psychosis, depression, anxiety, delusional disorders, and altered mental status. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/04/24, revealed Resident #13 was cognitively intact. Review of the active physician orders for January 2025 revealed the following psychotropic medications: on 09/13/24 for Duloxetine (antidepressant medication) 30 milligrams (mg) give three capsules by mouth one time per day for antidepressant, and an order dated for 09/23/24 for Quetiapine Fumarate (antipsychotic medication) 50 mg give one tablet by mouth two times per day for behaviors related to major depressive disorder, recurrent severe with psychotic symptoms. Review of Resident #13's medical record revealed no evidence of behavior monitoring or the monitoring of medications for efficacy and adverse consequences. Interview on 02/05/25 at 11:01 A.M. with Regional Nurse (RN) #410 verified behavior monitoring should be documented within the administration record and verified behavior monitoring was not completed for Resident #13.

Based on record review, observation, staff interview, review of Medscape guidance, and policy review, the facility failed to prime an insulin pen per manufacturer instructions prior to administration, resulting in a significant medication error. This affected one (Resident #30) of five residents reviewed for medication administration. The facility identified 14 residents who receive insulin via a pen-injector. The facility census was 74. Findings include: Review of the medical record for Resident #30 revealed an admission date of 11/06/23. Diagnosis included type two diabetes mellitus with hyperglycemia. Review of the plan of care dated 11/07/23 revealed Resident #30 was at risk for hyper/hypoglycemia related to diabetes mellitus. Intervention included to administer medications as ordered. Review of the physician orders revealed Resident #30 was ordered Lantus Solostar 50 units subcutaneously via a pen-injector, two times a day and Novolog 10 units via a pen-injector before meals. Observation on 01/29/25 at 6:46 A.M. revealed Licensed Practical Nurse (LPN) #353 administered 20 medications including insulin to Resident #30. LPN #353 grabbed two pen-injectors, dialed up 10 units of Novolog and 50 units of Lantus. LPN #353 failed to prime the pen-injectors removing any air before administering insulin to Resident #30. Interview on 01/29/25 at 7:05 A.M., LPN #353 verified she did not prime the Novolog and Lantus pens as she should have. Review of the facility policy titled Medication Administration, dated 2017 noted insulin pens require priming or an air-shot, prior to administration. Review of Medscape guidance titled Intermittent Insulin Injections Insulin Overview dated 11/05/20 and located at https://emedicine.medscape.com/article/2049311-overview#a1 revealed to avoid air and to ensure proper dose, you will need to prime the syringe each time; to do this, dial two units; hold the pen with the needle pointing up and tap the cartridge gently a few times to get rid of any air bubble; press the push button all the way in until the dose selector returns to zero; a drop of insulin must appear at the needle tip; if not, change the needle and repeat the procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, and record review, the facility failed to ensure all medications were stored appropriately and residents were watched when taking medications. This affected two of sevens (Resident #24 and #181) for medication storage. The facility census was 74. Findings include: 1. Review of the medical record for Resident #181 revealed an admission date 02/01/25. Diagnosis included pain management. Review of the physician orders for February 2025 revealed an order for Tylenol 325 milligrams (mg) give 650 mg by mouth every four hours as needed for pain. Observation and interview on 02/03/25 at 4:35 P.M. of Resident #181 revealed there was a pill cup sitting on the bedside table with two round tablets in it. Resident #181 stated she did not know what was in the pill cup, the nurse just set them down and left the room. There were no staff in the room or insight of Resident #181. Interview on 02/03/25 at 4:40 P.M. with Registered Nurse (RN) #358 stated she though Resident #181 took them, they were Tylenol 325 milligrams (mg). RN #358 verified the medication in the medication cup was Tylenol 325 mg, two tablets and verified she should have observed Resident #181 consume the medication prior to leaving the resident unattended. 2. Review of Resident #24's medical record revealed an admission date of 11/20/24. Diagnoses included hallucinations and altered mental status. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of the self-administration assessment dated [DATE] revealed all areas were marked as not applicable, and Resident #24 was not marked as being able to self-administer any medications. Observation on 02/04/25 8:18 A.M. revealed Resident #24 called out and stated they had been given medications but needed apple juice to take them. The resident was sitting up on the side of their bed. Resident #24 was holding a small, clear-plastic cup containing a mixture of approximately eight medication capsules/tablets. There were no staff members in or near Resident #24's room. Interview on 02/04/25 at 8:20 A.M. with Registered Nurse (RN) #380 verified the staff member gave Resident #24 their medications and did not observe the resident consuming them. RN #380 stated Resident #24 did not say they needed apple juice and RN #380 thought the resident was taking the medications as they left the resident's room. Observation on 02/04/25 at 8:22 A.M. revealed RN #380 entered the room of Resident #24 and stated you are supposed to take your medications in front of me. RN #380 then verified Resident #24 was given eight different medications, documented the medications as administered, and did not observe the resident taking the medications as they should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, record review, and review of the facility policy, the facility failed to have routine/scheduled care plan meetings for the residents and/or resident representative in 2024. This affected one (Resident #51) of one resident reviewed for care plan meetings. The facility identified all residents residing at the facility with the exception of 18 residents admitted after November 2024 (Residents #17, #18, #23, #24, #29, #34, #45, #51, #53, #59, #61, #66, #65, #135, #179, #181, #182, and #183) did not have care conferences in 2024. The facility census was 74. Findings include: Record review for Resident #51 revealed an admission date of 12/13/22. Diagnoses included displaced midcervical fracture of the left femur, atrial fibrillation, and hemiplegia and hemiparesis following cerebral infarction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was moderately cognitively impaired. Resident #51 had impairment on both sides of the lower extremities. Interview on 01/28/25 at 2:08 P.M. with Resident #51 stated he was not invited to a care plan meeting that he could recall. Record review for Resident #51 revealed the last care plan meeting was documented 08/18/23 at 8:03 A.M. Interview on 02/03/25 at 12:47 P.M. with Licensed Social Worker (LSW) #330 confirmed Resident #51 or his responsible party did not have a care plan meeting at all in 2024. LSW #330 stated several other residents also did not have a care plan meeting or did not have quarterly care plan meetings in 2024 prior to November 2024. LSW #330 provided a list which included residents who did not have all quarterly care plan meetings in 2024 and new admission residents. LSW #330 identified all residents, with the exception of new admissions (Resident #17, #18, #23, #24, #29, #34, #45, #51, #53, #59, #61, #66, #65, #135, #179, #181, #182, and #183) did not have the annual and quarterly care plan meetings. Interview on 02/03/25 at 1:10 P.M. with Regional Director of Clinical Services (RDCS) #615 confirmed care plan meetings were not consistently completed for residents residing in the facility in 2024. RDCS #615 revealed the meetings should have been completed at the minimum quarterly for each resident. Review of the facility policy titled titled Care Planning-Resident Participation dated 06/01/24 revealed the facility will discuss the plan of care with the resident and or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. This deficiency represents non-compliance investigated under Complaint Number OH00161487 and Complaint Number OH00161986.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5) Review of the medical record for Resident #57 revealed an admission date of 01/11/24. Diagnoses included anoxic brain damage, and sudden cardiac arrest. Review of the annual Minimum Data Set (MDS) assessment revealed SR #57 had impaired cognition. Review of census rosters dated 01/02/25, 01/07/25, 01/10/25, 01/14/25, and 01/17/25 revealed all the residents had a plus or minus by their name indicating if the resident had tested positive or negative for COVID-19 that day. Review of the nurse progress notes dated 01/02/25 and 01/17/24 revealed no documentation Resident #57 had been tested for COVID-19. Interview on 02/06/25 beginning at 11:00 A.M. with Regional Nurse (RN) #410 verified there was no documentation in the medical record of COVID-19 testing on 01/02/25 and 01/17/25 for Resident #57. 6) Review of the medical record for Resident #35 revealed an admission date of 11/26/18. Diagnoses included heart failure, hypertension, atrial fibrillation, chronic kidney disease, and type two diabetes mellitus. Review of census rosters dated 01/02/25, 01/07/25, 01/10/25, 01/14/25, and 01/17/25 revealed all the residents had a plus or minus by their name indicating if the resident had tested positive or negative for COVID-19 that day. Resident #35 was listed with minuses on all five testing dates. Review of the nurse progress notes dated 01/02/25 through 01/18/25 revealed there was no documentation Resident #35 had been tested for COVID-19 on 01/02/25. Interview on 02/06/25 beginning at 11:00 A.M. with Regional Nurse (RN) #410 verified there was no documentation in the medical record of COVID-19 testing on 01/02/25 for Resident #35. 7) Review of the medical record for Resident #38 revealed an admission date of 01/28/24. Diagnoses included chronic obstructive pulmonary disease and chronic pain syndrome. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of census rosters dated 01/02/25, 01/07/25, 01/10/25, 01/14/25, and 01/17/25 revealed all the residents had a plus or minus by their name indicating if the resident had tested positive or negative for COVID-19 that day. Resident #38 was listed with minuses on all five testing dates. Review of the nurse progress notes dated 01/02/25 through 01/18/25 revealed no documentation Resident #38 had been tested for COVID-19 on 01/17/25. Interview on 02/06/25 beginning at 11:00 A.M. with Regional Nurse (RN) #410 verified there was no documentation in the medical record of COVID-19 testing on 01/17/25 for Resident #38. 8) Review of the medical record for Resident #53 revealed an admission date of 08/05/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertension, and post-traumatic stress disorder. Review of a significant change assessment dated [DATE] revealed the resident had intact cognition. Review of census rosters dated 01/02/25, 01/07/25, 01/10/25, 01/14/25, and 01/17/25 revealed all the residents had a plus or minus by their name indicating if the resident had tested positive or negative for COVID-19 that day. Resident #53 was listed with minuses on all five testing dates. Review of the nurse progress notes dated 01/02/25 through 01/18/25 revealed no documentation Resident #53 had been tested for COVID-19 on 01/10/25 and 01/17/25. Interview on 02/06/25 beginning at 11:00 A.M. with Regional Nurse (RN) #410 verified there was no documentation in the medical record of COVID-19 testing on 01/10/25 and 01/17/25 for Resident #53. Review of the facility policy titled Documentation in Medical Record, revised 11/12/24, revealed the medical record would contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members would document all assessments, observations, and services provided in the resident's medical record in accordance with state law. Documentation would be completed at the time of service, but no later than 24/48 hours in which the assessment, observation, or care service occurred. Based on observations, resident, family, and staff interviews, and record review, the facility failed to ensure medical records were accurate and factual. This affected eight (Residents #26, #35, #38, #53, #53, #55, #57, and #177) of 27 residents medical records reviewed during the annual survey. The facility census was 74. Findings include: 1 Review of the medical record for Resident #26 revealed an admission date 12/09/21. Diagnoses included left hand contracture. Review of the physician orders for February 2025 revealed palm protective splint to left hand on in the PM and off in the AM, activated 01/20/23. Review of the plan of care revealed assistance needed for activities of daily living (ADL) related to decreased range of motion to left hand. Interventions included palm protective splint to left hand on in the PM and off in the AM. Review of the Treatment Administration Record (TAR) for February 2025 revealed treatment for palm protector splint to left hand was marked that it was put on 02/04/25 and signed off that the splint was in place and taken off. Observation and interview on 02/04/25 at 2:51 P.M. with Resident #26 stated she was to have a palm protector on her left hand at night and the staff have not been putting the splint on for months. Observation and interview on 02/05/25 at 5:40 A.M. revealed Resident #26 was still in bed, not wearing her left palm splint. The resident stated the certified nursing aide did not put her splint on when she went to bed. An interview on 02/05/25 at 5:40 A.M. with Licensed Practical Nurse (LPN) #367 stated Resident #26 was to have a splint or rolled up towel in her left hand at night. LPN #367 verified Resident #26 was not wearing her splint and did not have a rolled-up washcloth in her hand. LPN #673 stated she did not look to see if the splint was on and just signed off the order on the TAR. 2) Record review for Resident #55 revealed an admission date of 05/15/23. Diagnoses included Parkinson's disease, dementia, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #55 was severely cognitively impaired. Resident #55 had impairment on both sides of the upper and lower extremities. Resident #55 was dependent on staff for toileting hygiene, personal hygiene, and transfers. Resident #55 required substantial/maximal assistance for bed mobility and was frequently incontinent of urine and always incontinent of bowel. Resident #55 used a wheelchair with assistants for mobility. Review of the care plan for Resident #55 dated 05/15/23 and revised 07/17/24 revealed Resident #55 was totally dependent and does not participate in locomotion in wheelchair, provide incontinence care with routine rounds and as needed. Apply ted hose in the morning and remove them at night. Review of the physician orders for Resident #55 dated 01/14/25 revealed to check and change Resident #55 every two hours to offload coccyx - peri area. Resident #55 to be up in the Broda chair for a maximum of four hours a day dated 01/14/25. The physician orders also included to encourage Resident #55 to let staff put him back to bed after lunch dated 07/10/24 and to apply ted hose knee high on in the morning and off in the evening for (deep vein thrombosis) DVT prophylactic dated 03/27/24. Interview on 01/30/25 at 11:14 A.M. with Resident #55's wife revealed she visited Resident #55 frequently. Resident #55 was supposed to be changed every two hours, the staff get him up at 5:00 A.M. every morning and he would sit in the chair all day without being layed down or changed. Observation with Resident #55's wife revealed Resident #55 was sitting in the Broda chair in an upright position sleeping in the dining room. Observations on 01/30/25 revealed at 11:56 A.M., Resident #55 was still sitting in the Broda chair in an upright position sleeping in the dining room. The meal was not served. At 12:54 P.M., Resident #55 was still sitting in the Broda chair in an upright position sleeping in the dining room. The meal was completed and the tray was removed. At 12:55 P.M., Certified Nursing Assistant (CNA) #401 pushed Resident #55's Broda chair from the dining room to the lounge. CNA #401 did not offer Resident #55 to lay down after lunch, after taking him in the lounge, she left leaving Resident #55 in the Broda in the upright position. Resident #55's feet were dangling, observation revealed Resident #55 did not have ted hose on. From 1:28 P.M. through 2:23 P.M., continuous observations revealed Resident #55 stayed in the lounge in the Broda chair in the upright position with his feet dangling. No staff addressed Resident #55 to offer care. Record review on 01/30/25 at 2:17 P.M. of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) for 01/30/25 revealed Licensed Practical Nurse (LPN) #353 signed the orders as completed for Resident #55 to check and change Resident #55 every two hours to offload coccyx - peri area, to be up in the Broda chair for a maximum of four hours a day, to encourage Resident #55 to let staff put him back to bed after lunch, and to apply ted hose knee high on in the morning and off in the evening for DVT prophylactic. Further review of the MAR/TAR for the entire month of January 2025 revealed all orders for the month were signed as completed. Observation and interview on 01/30/25 at 2:24 P.M. revealed CNA #357 and #395 assisted Resident #55 to his room. CNA #357 confirmed she was Resident #55's primary CNA and stated she assisted Resident #55 up out of bed at 6:30 this A.M. Both CNA #357 and #395 stated Resident #55 never wore ted hose, they had both worked with him over the past six months and he never wore ted hose. CNA #357 confirmed this was the first time today she laid Resident #55 down and confirmed she did not check or change him either until now. CNA #357 stated she thought hospice was in earlier and changed him. CNA #357 stated she was busy and did not have time. Observation of incontinence care provided by CNA #357 and #395 revealed Resident #55's brief was saturated with urine. Resident #55's pants were also wet and CNA #395 confirmed the seat cushion in the Broda chair was also wet with urine. Resident #55's scrotum and peri area were red. CNA #357 stated Resident #55 gets up again before dinner and will stay up until laid down by the next shift. Interview on 01/30/25 at 2:37 P.M. with LPN #353 confirmed she was Resident #55's Charge Nurse. LPN #353 stated the hospice aide was in today and provided care for Resident #55 then left between 7:00 A.M. and 7:30 A.M. LPN #353 confirmed Resident #55 was supposed to wear ted hose daily but she was not sure if they were on him because she does not look. LPN #353 stated she was not sure how long Resident #55 was to be up in the chair, maybe two or three hours. Observation on 02/04/25 at 4:52 P.M. with Registered Nurse (RN) Supervisor #308 confirmed Resident #55 was sitting up in his chair. Resident #55 did not have his ted hose on. RN Supervisor #308 stated she told the CNA earlier in the day to apply the ted hose, the CNA informed her there was none in his room to apply so she told the CNA she would get him some out of stock but she just had not done it yet. Observation with RN Supervisor #308 revealed Resident #55 did not have any ted hose available in his room to be applied. RN Supervisor #308 confirmed the ted hose was signed in the medical record as being applied in the A.M. and this was inaccurate. Record review of the TAR revealed the orders to apply the ted hose in the A.M. was signed for Resident #55 as completed. 3) Record review for Resident #177 revealed an admission date of 08/23/14 and a discharge date of 01/14/25. Resident #177 had a hospital stay from 01/05/25 through 01/11/25. Diagnoses included diastolic congestive heart failure (CHF), hypertensive heart and chronic kidney disease with heart failure, Parkinsonism, emphysema, vascular dementia, bradycardia, muscle weakness, atrial fibrillation, and chronic obstructive pulmonary disease (COPD). Review of the quarterly MDS assessment dared 11/11/24 revealed Resident #177 was cognitively intact. Resident #177 had no chronic condition, or chronic disease that may result in a life expectancy of less than six months. Review of the physician orders for Resident #177 revealed orders dated 01/11/25 for enteral feed order every shift osmolite 1.5 at 60 cubic centimeters per hour continuous. Review of the progress note for Resident #177 dated 01/14/25 at 1:00 P.M. completed by RN #345 revealed family member at bedside. Made this nurse aware Resident #177 began to spit up TF. Resident was suctioned and repositioned. Hospice nurse entered room at this time and stated to hold TF at this time, working on admission. Review of the medical record including the census for Resident #177 revealed no documentation of a physician order for Hospice Services, no documentation of any discussion by the facility of family regarding initiation of hospice services and no documentation of Hospice services initiated. The record review also revealed no documentation of the physician being notified on 01/14/25 at 1:00 P.M. when Resident #177 began to spit up TF. Interview on 02/03/25 at 9:32 A.M. with Business Office Manager (BOM) #610 revealed Hospice came in on 01/14/24 to assess Resident #177, the family was going to sign the paperwork, but they did not because Resident #177 passed and hospice never picked her up. Interview on 02/03/25 at 9:41 A.M. with Registered Nurse (RN) Supervisor #308 and Regional RN #410 revealed the physician should have been notified on 01/14/25 at 1:00 P.M. when Resident #177 was spitting up TF. Regional RN #410 confirmed there was no further documentation of hospice services in the medical records. Interview on 02/04/25 at 10:30 A.M. with RN #345 stated Resident #177 declined very quickly after returning from the hospital that was why hospice was called to assess the resident. Interview on 02/04/25 with Regional RN #410 revealed the facility spoke with Hospice Services and they picked Resident #177 up for about an hour before passing. Regional RN #410 confirmed they were unaware Hospice picked her up until they called Hospice services themselves. 4) Record review for Resident #54 revealed an admission dated of 05/30/23. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side and muscle weakness. Review of the quarterly MDS assessment dated [DATE] revealed Resident #54 was rarely or never understood. Resident #54 was dependent on staff for activities of daily living (ADL's). Resident #54 had an indwelling catheter and was always incontinent of bowel. Resident #54 had moisture associated skin damage (MASD) and received applications of ointments/medications. Interview on 01/28/25 at 12:44 P.M. with Resident #54's spouse revealed she was concerned about the rash on Resident #54's bottom, she felt Resident #54 was not being changed enough. Interview on 01/30/25 at 12:01 P.M. with CNA #395 revealed Resident #54 had an indwelling catheter and only needed changed if he had a bowel movement. Resident #54 had not had a bowel movement so there was no need to change him today. Observation and interview on 02/05/25 at 11:07 A.M. revealed Resident #54's brief was changed by CNA #357 and #395. Resident #54 was wet with sweat on his shirt and in his brief. CNA #357 and #395 stated Resident #54 always sweats and that was why his bottom was wet and very red. Resident #54's bilateral buttocks was deep red/discoloration with open excoriated areas to bilateral buttocks. CNA #357 and #395 stated Resident #54 was unable to move without assistance. Interview on 02/05/25 at 12:58 P.M. with Wound Care Certified Nurse Practitioner (CNP) #611 confirmed she assessed Resident #54 on this day and observed the buttocks was discolored and diagnosed with moisture associated skin damage (MASD); MASD was caused by moisture, the moisture could be caused by the sweating, and the area needed to be kept clean and dry. Record review of the medical record for Resident #54 revealed no documentation of excoriation to the buttocks or MASD. Interview on 02/06/25 at 11:36 A.M. with Regional RN #410 confirmed there was no documentation of MASD in Resident #54's medical record describing the wound and measurements including when it healed and when it returned and revealed it looked like it comes and goes because the venelex external ointment, ordered in November 2023 was used for the MASD. Regional RN #410 stated each time Resident #54 had MASD, the nurses should have measured, monitored, and documented the areas. Interview on 02/06/25 at 11:56 A.M. with LPN #361 revealed the excoriation (MASD) comes and goes on Resident #54's buttocks for at least six months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident, family, and staff interview, record review, and review of the facility assessment, the facility failed to provide sufficient staffing to consistently meet the resident's needs. This affected three (Residents #55, #181, and #182) and had the potential to affect all 74 residents residing at the facility. Findings include: 1) There was inadequate staff to complete timely incontinence care and bathing/showering for the residents. 1a. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #181 was cognitively intact. Resident #181 required partial/moderate assistance with toileting hygiene. Resident #181 was occasionally incontinent of urine and frequently incontinent of bowel. Interview on 01/29/25 at 3:25 P.M. with Certified Nursing Assistant (CNA) #309 stated at times the facility did not have enough staff to complete resident's care timely including incontinence care and not being assisted to bed timely. CNA #309 stated yesterday (01/28/25), while she went to the dining room to assist with meals, that only left one CNA on the floor to assist the residents. Last Thursday (01/23/25), the assigned CNA #399 refused to change Resident #181 during dinner service. Resident #181 had diarrhea and needed changed. At 5:20 P.M., Resident #181 passed a meal tray by CNA #399. CNA #399 told her she could not change her while dinner was being passed. Resident #181 tried to refuse her dinner tray hoping she would then be able to be changed. CNA #399 said no she had to pass trays. CNA #309 was in the dining room, and Resident #181's husband came and got her (CNA #309) around 6:15 P.M. and CNA #309 changed her. Resident #181 had stool everywhere. Interview on 01/29/25 at 3:40 P.M. with Resident #181 stated she had diarrhea really bad last Thursday (01/23/25) and after she put her call light on, an unidentified CNA came into her room, turned her call light off and said she was giving a shower. Resident #181 said it took a few hours for her to receive incontinence care. Resident #181 stated it was very upsetting and embarrassing when she had to sit in diarrhea, and no one would help her. Resident #181 stated there were times staff did not assist timely when she requested care. Interview on 01/29/25 at 4:03 P.M. with Licensed Practical Nurse (LPN) #364 confirmed she worked the previous Thursday (01/23/25) at dinner time when Resident #181 had diarrhea and needed changed. LPN #364 stated Resident #181 said she needed changed, CNA #399 went in there, and told Resident #181 it was dinner. LPN #364 explained during dinner, generally they do not change residents, and the residents need to wait until after the meal. Interview on 02/06/25 at 11:10 A.M. with Regional Nurse (RN) #410 stated if a resident was incontinent and staff were passing trays, she would expect the staff member to get assistance so the resident could be changed at the time the resident was incontinent. The resident should not have to wait until after meal service to receive incontinence care. 1b. Review of the quarterly MDS assessment dated [DATE] revealed Resident #55 was severely cognitively impaired. Resident #55 had impairment on both sides of the upper and lower extremities. Resident #55 was dependent on staff for toileting hygiene and was frequently incontinent of urine and always incontinent of bowel. Review of the physician orders for Resident #55 dated 01/14/25 revealed to check and change Resident #55 every two hours to offload coccyx - peri area. Resident #55 was to be up in the Broda chair (a chair that provides comfort, support, and mobility) for a maximum of four hours a day. An order dated 07/10/24 revealed to encourage Resident #55 to let staff put him back to bed after lunch. Interview and observation on 01/30/25 at 11:14 A.M. with Resident #55's wife revealed she visited Resident #55 frequently. Resident #55 was supposed to be changed every two hours, the staff get him up at 5:00 A.M. every morning and he would sit in the chair all day without being laid down or changed. Observation with Resident #55's wife revealed Resident #55 was sitting in the Broda chair in an upright position sleeping in the dining room. Observations revealed on 01/30/25 at 11:56 A.M., Resident #55 was still sitting in the Broda chair in an upright position sleeping in the dining room. On 01/30/25 at 12:55 P.M., Certified Nursing Assistant (CNA) #401 pushed Resident #55's Broda chair from the dining room to the lounge. Continuous observations on 01/30/25 from 1:28 P.M. through 2:23 P.M. revealed Resident #55 stayed in the lounge in the Broda chair in the upright position with his feet dangling. No staff addressed Resident #55 to offer care. Observation and interview on 01/30/25 at 2:24 P.M. revealed CNA #357 and #395 assisted Resident #55 to his room. CNA #357 confirmed she was Resident #55's primary CNA and stated she assisted Resident #55 up out of bed at 6:30 A.M. that day (01/30/25) CNA #357 confirmed this was the first time today she laid Resident #55 down and confirmed she did not check or change him until now. CNA #357 stated she was busy and did not have time. 1c. Review of the physician orders for Resident #182 dated 11/24/24 revealed skin checks weekly with showers on Mondays and Thursdays. Review of the shower/bath schedule for Resident #182 revealed Resident #182 was scheduled to receive a shower 11 times on 11/25/24, 11/28/24, 12/02/24, 12/05/24, 12/09/24, 12/12/24, 12/16/24, 12/19/24 12/23/24, 12/26/24 and 12/30/24. Review of the Shower/Tub Bath/Bed Bath Sheets provided by Regional Registered Nurse (RRN) #410 revealed Resident #182 was not offered a shower/bath six times on 11/25/24, 11/28/24, 12/05/24, 12/09/24, 12/12/24, 12/23/24, and 12/30/24. There were no other records indicating the resident was offered a shower or bath on other days of the week. Interview on 02/03/25 at 2:00 P.M. with Resident #182 stated he was admitted to the facility to recuperate from a shattered femur. Resident #182 stated 15 days went by before he was even offered a shower or bath. Interview on 02/06/25 at 11:40 A.M. with RRN #410 stated each resident was scheduled showers/baths weekly. Resident #182 was scheduled two showers/baths a week. RRN #410 confirmed only four Shower/Tub Bath/Bed Bath Sheets were completed for Resident #182 confirming Resident #182 was offered a shower/bath only four of the scheduled 11 to be offered. Interview on 02/06/25 at 12:00 P.M. with CNA #307 confirmed she cared for Resident #182 during his stay at the facility. CNA #307 stated some days there were enough staff to offer showers and other days there were not. CNA #307 stated if there was not enough staff then showers were not done because there was just not enough time to get to them. 2) Review of the Payroll Based Journal (PBJ) Staffing Data Report for the fourth quarter for 2024 revealed excessively low weekend staffing was triggered (Submitted Weekend Staffing data was excessively low). Review of the Facility Assessment (FA) dated 11/22/24 approved by Administrator and Medical Director #614 and reviewed by Quality Assurance and Assessment (QAA) Committee dated 11/26/24 revealed the purpose of the assessment is to determine what resources are necessary to care for our residents competently both day to day operations (including nights and weekends) and emergencies. The assessment addressed the following elements: The facility's resident population, including but not limited to the number of residents and the facility's resident capacity. The care required by the resident population using evidence-based data, data driven methods that consider the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts that are present within the population, consistent with and informed by individual resident assessments. The FA included staffing needs as per shift using the ratio of staff to residents: Night shift: registered nurse (RN) 1:40, LPN 1:40, and CNA 1:14 Day shift: RN 1:22, LPN 1:22, and CNA 1:8 Evening shift: RN 1:22, LPN 1:22, and CNA 1:8 Review of the staffing time sheets with Human Resource Director #325 for 01/03/25 through 01/09/25 which included department heads who picked up to work on the floor revealed the facility did not meet their staffing needs according to the FA on the following days and shifts: • On 01/03/25, the RN ratio for night shift was 1:78 (FA was 1:40); CNA ratio on evening shift was 1:11 (FA was 1:8), CNA ratio for night shift was 1:15 (FA was 1:14). • On 01/04/25, CNA ratio on day shift was 1:16 (FA was 1:8) and CNA ratio for evening shift was 1:16 ( FA was 1:8). • On 01/05/25, RN ratio on evening shift was 1:79 (FA was 1:22), CNA ratio on day shift was 1:13 (FA was 1:8) , on CNA ratio on evening shift was 1:15 (FA was 1:8). • On 01/06/25, the RN ratio night shift was 1:81 (FA was 1:40) and CNA ratio on night shift was 1:20 (FA was 1:14) • On 01/07/25, the RN ratio on night shift was 1:80 (FA was 1:40), CNA ratio on day shift was 1:11 (FA was 1:8), and CNA ratio on evening shift was 1:13 (FA was 1:8). • On 01/08/25, the RN ratio on night shift was 1:78 (FA was 1:40), CNA ratio on day shift was 1:14 (FA was 1:8), and CNA ratio on evening shift was 1:16 (FA was 1:8). • On 01/09/25, the RN ratio on night shift was 1:72 (FA was 1:40), CNA ratio on day shift was 1:10 (FA was 1:8) and CNA ratio on evening shift was 1:12 (FA was 1:8). Interview with the Regional Licensed Nursing Home Administrator (LNHA) on 02/05/25 at 3:30 P.M. confirmed the FA required staffing ratios for the care of residents residing at the facility was not met for each shift on any of the days reviewed 01/03/25 through 01/09/25. Regional LNHA verified the facility had low weekend staffing for the fourth quarter of 2024. This deficiency represents non-compliance investigated under Complaint Numbers OH00161986 and OH00161487.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of personnel job descriptions, review of personnel files, review of the facility's infection control program, resident, staff, and family interview, and interview with the local health department (LHD), the administration team lacked involvement to ensure staff and resident reports of staff mistreatment were not dismissed before investigating the allegations, did not identify an issue with the resident's medical records being accurate and factual, and did not ensure adequate staffing was maintained to meet the needs of their residents and according the facility's assessment. Administration did not ensure routine care conferences were being held routinely with the residents and resident representatives and did not ensure routine written notices of transfer and bed hold notices were completed upon the resident's transfer to the hospital. Additionally, the administration team demonstrated inaction and failed to perform their job responsibilities to ensure infection control policies and guidelines were implemented to ensure contact tracing was completed to identify close contacts of residents positive for COVID-19, failed to ensure COVID-19 testing was completed for residents and staff identified as close contacts, and furthermore failed to implement broad based testing of staff during a COVID-19 outbreak within the facility. This affected 49 residents (#2, #4, #7, #9, #11, #13, #17, #20, #21, #23, #24, #26, #27, #29, #32, #34, #35, #37, #42, #44, #45, #46, #50, #51, #52, #53, #54. #55, #57, #59, #61, #65, #66, #67, #68, #74, #76, #78, #79, #80, #81, #82, #135, #173, #177, #179, #181, #182, and #183) reviewed during the annual survey and had the potential to affect all 74 residents residing in the facility. Findings include: 1) The facility did not implement effective and recommended infection control practices beginning on [DATE] when two residents (#78 and #32) tested positive for COVID-19. The facility did not complete timely contact tracing to identify close contacts of COVID-19 positive residents and staff, timely reporting of a COVID-19 outbreak to the local health department (LHD), and a system to ensure all staff and residents were tested for COVID-19 per Centers for Disease Control and Prevention (CDC) guidelines and facility policy to prevent the potential spread of COVID-19 to vulnerable residents within the facility. This affected 26 residents who resided throughout the facility (#2, #4, #7, #9, #11, #20, #21, #26, #27, #32, #34, #37, #42, #45, #50, #52, #55, #57, #59, #67, #68, #79, #80, #81, #82, and #177) and three staff (Certified Nursing Assistant (CNA) #357, CNA #366, Licensed Practical Nurse (LPN) #369) who tested positive for COVID-19 and had the potential to affect all residents. In addition, the facility did not ensure the residents and staff were educated on the risks, benefits, and side effects of the COVID-19 vaccine. This affected five (#14, #42, #53, #57, and #64) of five residents reviewed for immunization and seven of seven employees reviewed for immunization and had the potential to affect all residents. Interview on [DATE] at 12:05 P.M. with Assistant Director of Nursing (ADON) #392 stated the staff were offered the COVID-19 vaccine at an all-staff meeting. ADON #392 stated she just offered the staff the vaccine and had not provided any education to the staff about the risks and benefits of the vaccine. ADON #392 verified only one staff member had requested the vaccine. ADON #392 also verified Residents #57, #14, #64, #53, and #42 were offered the COVID-19 vaccine but they were not provided information on the benefits, risks, and side effects. ADON #392 verified there was no separate consent form for the COVID-19 vaccine and she documented refusals on either their influenza or pneumococcal consent forms. Interview on [DATE] at 11:30 A.M. with Regional Nurse (RN) #410 verified no contact tracing or testing of staff caring for residents who had tested positive had been completed. RN #410 verified the facility policy indicated the facility would follow CDC guidelines to test close contacts. RN #410 verified the facility had not completed contact tracing for staff to identify close contacts and had not completed testing of staff. Subsequent interview on [DATE] at 7:35 A.M. with RN #410 stated the facility had not maintained assignment sheets to track staff assignments and was looking into why the building was not completing staff assignment sheets which would assist with contact tracing. Also, some staff could not be determined to have been close contacts as they may not have documented care. Further interview on [DATE] at 8:32 A.M., RN #410 stated the facility should have completed contact tracing and COVID-19 testing on days one, three, and five for the staff and residents identified as close contacts of the COVID-19 positive residents. RN #410 stated as the outbreak expanded throughout all four halls, the facility should have conducted broad-based testing every three to seven days until there were no new positive for two weeks. RN #410 verified the facility stopped testing residents on [DATE] and should have continued testing for one additional week. Interview on [DATE] at 1:46 P.M. with Local Health Department (LHD) Staff #500 revealed all nursing homes were sent an email on [DATE] with directions on reporting and managing a COVID-19 outbreak with a line listing to record positive cases for submission to the LHD. LHD Staff #500 stated COVID-19 was a Class B reportable infectious disease, and the facility was legally required to report COVID-19 cases by the end of the following business day. LHD #500 stated the facility had not reported a COVID-19 outbreak until [DATE]. LHD #500 stated she had reviewed her emails and the facility never submitted a line listing of positive COVID-19 cases. 2) Administration did not identify an issue with the resident's medical records being accurate and factual. 2a. Resident #177's medical record did not have documentation of a physician order for Hospice Services, no documentation of any discussion by the facility of family regarding initiation of hospice services and no documentation of Hospice services initiated. The record review also revealed no documentation of the physician being notified on [DATE] at 1:00 P.M. when Resident #177 began to have a change in condition. Resident #177 expired in the facility on [DATE]. 2b. Resident #54 had ongoing issues for approximately six months with moisture-associated skin damage (MASD) and there was no documentation in the medical records of this MASD. 2c. Resident #57 had been tested for COVID-19 during a COVID-19 outbreak at the facility on [DATE] and [DATE] and there was no documentation in Resident #57's medical record this was completed. Regional Nurse (RN) #410 verified there was no documentation in the medical record of COVID-19 testing on [DATE] and [DATE] for Resident #57. 2d. Resident #35 had been tested for COVID-19 at the facility on [DATE] and there was no documentation in the resident's medical this was completed. RN #410 verified there was no documentation in the medical record of COVID-19 testing on [DATE] for Resident #38. 2e. Resident #53 had been tested for COVID-19 at the facility on [DATE] and [DATE] and there was no documentation in the medical record this was completed. RN #410 verified there was no documentation in the medical record of COVID-19 testing on [DATE] and [DATE] for Resident #53. 3) Administration did not ensure adequate staffing was maintained to meet the needs of their residents and according the facility's assessment. The Payroll Based Journal (PBJ) Staffing Data Report for the fourth quarter for 2024 revealed excessively low weekend staffing was triggered (Submitted Weekend Staffing data was excessively low). Review of the Facility Assessment (FA) dated [DATE] revealed the FA included staffing needs as per shift using the ratio of staff to residents. The staffing time sheets were reviewed with Human Resource Director #325 for [DATE] through [DATE] which included department heads who picked up to work on the floor revealed the facility did not meet their staffing needs according to the FA 19 times for RN and CNA coverage over the shifts. Interview with the Regional Licensed Nursing Home Administrator (LNHA) on [DATE] at 3:30 P.M. confirmed the FA required staffing ratios for the care of residents residing at the facility was not met for each shift on any of the days reviewed [DATE] through [DATE]. Regional LNHA verified the facility had low weekend staffing for the fourth quarter of 2024. 4) Resident #51 did not have a care conference since [DATE]. Licensed Social Worker (LSW) #330 confirmed Resident #51 or his responsible party did not have a care plan meeting at all in 2024. LSW #330 stated several other residents also did not have a care plan meeting or did not have quarterly care plan meetings in 2024 prior to [DATE]. LSW #330 provided a list which included residents who did not have all quarterly care plan meetings in 2024 and new admission residents. LSW #330 identified all residents, with the exception of new admissions (Resident #17, #18, #23, #24, #29, #34, #45, #51, #53, #59, #61, #66, #65, #135, #179, #181, #182, and #183) did not have the annual and quarterly care plan meetings. 5) Residents #44, #46, #76, and #78 were not provided written notice of transfer/discharge and a bed hold notice when sent to the hospital. Interview on [DATE] at 11:08 A.M. with Regional Administrator (RA) #408 verified the facility had not provided a written notice of transfer/discharge or bed hold notices to Residents #44, #46. #76, and #78 and/or resident representative when the residents went to the hospital. RA #408 stated the facility identified the issue on the first day of the annual survey on [DATE] and stated the residents who went to the hospital since 05/2024 were not provided written notice of transfer/discharge when sent to the hospital. Refer to F-623 and F-625 for full details. 6) Residents #13 and #74 were not treated with respect and dignity. Resident #13 stated Licensed Practical Nurse (LPN) #346 was always saying things that were sarcastic and rude. Resident #13 also reported being pretty sure LPN #346 cursed at her on an unknown date. Interview on [DATE] at 10:45 A.M. with Former Licensed Practical Nurse (LPN) #405 revealed they previously worked as a nurse at the facility. LPN #405 reported observing LPN #346 demanding Resident #74 to open their mouth to take medications, pushing the resident because they had been leaning, and shoving the medications into the resident's mouth. Interview on [DATE] at 4:28 P.M. with the Administrator stated they were unaware of any concerns regarding LPN #346 treating the residents. Interview on [DATE] at 11:06 A.M. with Registered Nurse (RN) #355 stated LPN #346 cursed a lot and would yell at residents. RN #355 reported they heard LPN #346 yelling at an unknown resident stating take your medications mother-explicit. RN #355 verified they did not report the observation of LPN #346 yelling at the resident because everyone knew of how LPN #346 treated residents and the administrative staff did not do anything. Interview on [DATE] at 11:38 A.M. with LPN #315 stated the staff member observed LPN #346 yelling at residents and used to report it. LPN #315 was unable to report any specific resident name and/or date of incidents. Interview on [DATE] at 8:00 A.M. with Regional Administrator #407 and Regional RN #408 stated the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) #392, and LPN #346 were suspended related to multiple allegations of dignity issues and not following policies and procedures for following up on concerns related to residents and families. The Regional staff stated Administration members were suspended in order to complete a thorough investigation without interference. Review of the Administrator's job description signed by the Administrator on [DATE] revealed the primary purpose of the job position was to direct the day-to-day function of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to ensure the highest degree of quality care was provided to the residents. Ensure all employees follow established policies and procedures which included infection control. Review and check competence of work force and make necessary adjustments/corrections as required or that may become necessary. Review of the DON's job description signed [DATE] revealed the primary purpose of the position was to plan, organize, develop, control and direct the overall operation of the nursing department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure the highest level of quality care was maintained at all times. The DON would be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines pertaining to long-term care. Review of ADON #392's job description signed [DATE] revealed the primary purpose of the position was to assist the DON in planning, organizing, developing, and directing the day-to-day functions of the nursing department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the DON, Administrator and the Medical Director, to ensure the highest level of quality care was maintained at all times. Also to participate in the development, implementation, and maintenance of the infection control program for monitoring communicable and/or infectious diseases among the residents and personnel. This deficiency represents non-compliance investigated under Complaint Number OH00161487 and Complaint Number OH00161986.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, review of a COVID-19 outbreak log, review of staffing schedules, review of staff timecards, review of the staff call-off log, staff and resident interview, observation, interview with the Local Health Department (LHD), review of the Centers for Disease Control and Prevention (CDC) infection control guidance, and policy review, the facility failed to implement an effective and recommended infection control practices, including timely contact tracing to identify close contacts of COVID-19 positive residents and staff, timely reporting of a COVID-19 outbreak to the LHD, and a system to ensure all staff and residents were tested for COVID-19 per CDC guidelines and facility policy to prevent the potential spread of COVID-19 to vulnerable residents within the facility. This affected 26 residents who resided throughout the facility (#2, #4, #7, #9, #11, #20, #21, #26, #27, #32, #34, #37, #42, #45, #50, #52, #55, #57, #59, #67, #68, #79, #80, #81, #82, and #177) and three staff (Certified Nursing Assistant (CNA) #357, CNA #366, Licensed Practical Nurse (LPN) #369) who tested positive for COVID-19 and had the potential to affect all residents. Additionally, the facility failed to ensure infection control procedures were followed during tracheostomy care. This affected one (#54) of three residents reviewed for respiratory care. The facility identified three residents with a tracheostomy. The facility census was 74. Findings include: 1) Review of the medical record for Resident #79 revealed an admission date of 09/30/24 and a discharge date of 12/31/24. Review of a nurse's note dated 12/31/24 at 9:20 A.M. revealed the resident was discharged to another facility. The other facility notified the facility the resident tested positive for COVID-19 upon arrival. Review of census documentation revealed Resident #79 had a roommate (#134) who was admitted to the hospital on [DATE]. Review of the medical record for Resident #32 revealed an admission date of 06/07/23. Review of a nurses progress note dated 12/31/24 at 10:02 P.M., revealed the hospital notified the facility the resident was positive for COVID-19 and a urinary tract infection. The resident was being sent back to the facility. Resident #32's roommate (#51) was tested and was negative. Review of the medical record for Resident #51 revealed an admission date of 12/13/22. Review of the nurse's note dated 12/31/24 and 01/01/25 revealed no documentation the resident was tested for COVID-19 after his roommate (#32) tested positive for COVID-19 on 12/31/24. Review of a COVID-19 outbreak log revealed two residents (#79, #32) residing on the 300-hall tested positive for COVID-19 on 12/31/24. Review of the staffing schedules and employee timecards revealed 11 staff (Licensed Practical Nurse (LPN) #405, LPN #303, LPN #420, LPN #369, LPN #361, Certified Nurse Assistant (CNA) #305, CNA #324, CNA #397) had provided care for Resident #79 and Resident #32 on 12/30/24 and 12/31/24. Further review of the outbreak documentation revealed no staff contact tracing or testing for COVID-19 was completed for staff identified as close contacts of the two residents. Review of the COVID-19 outbreak log revealed an additional three residents (#177, #80, #68) residing on the 100, 300, and 400 halls had tested positive for COVID-19 on 01/02/25. No contact tracing or staff testing was completed. Review of the COVID-19 outbreak log revealed an additional 21 residents (#57, #7, #81, #9, #50, #11, #26, #2, #67, #21, #27, #59, #52, #82, #37, #20, #4, #45, #55, #34, #42) residing on the 100, 200, 300, and 400 halls tested positive for COVID-19 from 01/03/25 through 01/14/25. There was no documentation staff were tested. CNA #357 and CNA #366 tested positive on 01/02/25. LPN #369 tested positive on 01/05/25. Review of the employee call-off log revealed on 12/30/24 and 12/31/24 one staff member had called off from work, on 01/01/25 five staff had called off, and on 01/02/25 four staff had called off. On 01/03/25 nine staff had called off and five staff called off on 01/04/25. Two staff called off on 01/05/25 and five staff called off on 01/06/25. On 01/07/25 eight staff called off and on 01/08/25 four staff had called off. On 01/09/25 three staff had called off and five staff called off on 01/10/25. On 01/11/25 two staff had called off and on 01/12/25 there were six staff who called off. There was one staff call off on 01/13/25. The type of call offs from 12/30/24 through 01/13/25 were listed as sick or other with two listed as no call no show. Review of census rosters dated 01/02/25, 01/07/25, 01/10/25, 01/14/25, and 01/17/25 revealed all the residents had a plus or minus by their name indicating if the resident had tested positive or negative for COVID-19 that day. Resident #2 was listed on 01/02/25 with a minus. Resident #35, Resident #38, and Resident #53 were listed with minuses on all five testing dates. Review of the medical records revealed there was no documentation Resident #57 was tested on [DATE]. Resident #57 was positive for COVID-19 on 01/03/25 after family requested testing due to respiratory symptoms. The medical record for Resident #35 revealed there was no documentation the resident was tested for COVID-19 on 01/02/25 and 01/17/25. The medical record for Resident #38 revealed there was no documentation the resident was tested for COVID-19 on 01/07/25. The medical record for Resident #53 revealed there was no documentation the resident was tested for COVID-19 on 01/10/25 and 01/17/25. Interviews with staff revealed the following: on 02/03/25 at 2:06 P.M. with CNA #357 stated she tested herself at home and was positive for COVID-19 on 01/02/25. On 02/04/25 at 1:51 P.M., CNA #340 stated she had not been tested during the COVID-19 outbreak. CNA #340 further revealed facility management had poor communication with staff. CNA #340 stated management were directing staff not to tell anyone if they tested positive for COVID-19 as they would not have enough staff. CNA #340 could not pinpoint which management staff as it worked its way down and made it to all the aides. On 02/04/25 at 3:41 P.M., CNA #362 stated the facility had not tested her for COVID-19 during the COVID-19 outbreak. On 02/04/25 at 3:46 P.M., CNA #368 stated the facility had not tested her for COVID-19 during the COVID-19 outbreak. On 02/05/25 at 7:51 A.M., LPN #318 stated the facility had not tested her for COVID-19 during the outbreak. Interview on 02/03/25 beginning at 2:20 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #392 stated staff were tested on [DATE] but there was no documentation of the testing. The DON stated staff would only need tested if they were symptomatic per the facility policy. The DON and ADON #392 revealed the last day residents were tested was on 01/17/25. Interview on 02/04/25 at 11:30 A.M. with Regional Nurse (RN) #410 verified no contact tracing or testing of staff caring for residents who had tested positive had been completed. RN #410 verified the facility policy indicated the facility would follow CDC guidelines to test close contacts. RN #410 verified the facility had not completed contact tracing for staff to identify close contacts and had not completed testing of staff. Interviews with the residents revealed the following: on 02/04/25 at 1:47 P.M., Resident #38 stated he had only been tested twice during the COVID-19 outbreak, once when it first started and then once a couple days later. On 02/04/25 at 12:56 P.M., Resident #35 stated testing for COVID-19 was completed maybe twice during the COVID-19 outbreak. On 02/04/25 at 2:13 P.M., Resident #53 stated only being tested two or three times during the COVID-19 outbreak. Interview on 02/05/25 at 7:35 A.M. with RN #410 stated the facility had not maintained assignment sheets to track staff assignments and was looking into why the building was not completing staff assignment sheets which would assist with contact tracing. Also some staff could not be determined to have been close contacts as they may not have documented care. Further interview on 02/05/25 at 8:32 A.M., RN #410 stated the facility should have completed contact tracing and COVID-19 testing on days one, three, and five for the staff and residents identified as close contacts of the COVID-19 positive residents. RN #410 stated as the outbreak expanded throughout all four halls, the facility should have conducted broad-based testing every three to seven days until there were no new positive for two weeks. RN #410 verified the facility stopped testing residents on 01/17/24 and should have continued testing for one additional week. Interview on 02/05/25 at 7:58 A.M. with LPN #369 stated she was assigned to work on all the halls in the facility. LPN #369 stated she tested positive at home on [DATE] then went to the facility the same day and tested positive again. Interview on 02/05/25 at 9:11 A.M. with ADON #392 stated she thought she had notified the local health department (LHD) of the COVID-19 outbreak on 01/02/25. ADON #392 stated the LHD had not asked for a line listing of COVID-19 positive residents. ADON #392 stated she thought the LHD indicated to conduct contact tracing. ADON #392 verified staff were not tested on [DATE]. ADON #392 stated she left out COVID-19 tests and encouraged the staff to test themselves. ADON #392 stated staff were not checked if they had tested as we could not force anyone to test themselves. Interview on 02/05/25 at 1:46 P.M. with Local Health Department (LHD) Staff #500 revealed all nursing homes were sent an email on 04/01/24 with directions on reporting and managing a COVID-19 outbreak with a line listing to record positive cases for submission to the LHD. LHD Staff #500 stated COVID-19 was a Class B reportable infectious disease and the facility was legally required to report COVID-19 cases by the end of the following business day. LHD #500 stated the facility had not reported a COVID-19 outbreak until 01/08/25. LHD #500 stated she had reviewed her emails and the facility never submitted a line listing of positive COVID-19 cases. Interview on 02/06/25 beginning at 11:00 A.M., RN #410 verified there was no documentation in the medical record of COVID-19 testing on 01/02/25 for Resident #57 and Resident #35, on 01/10/25 for Resident #53, and on 01/17/25 for Resident #38 and Resident #57. Review of the facility policy titled Infection Prevention and Control Program, revised 08/01/23, revealed the facility would implement a system of surveillance for prevention, identification, reporting, investigating, and controlling infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services according to accepted national standards. Residents with close contact with someone with SARS-CoV-2 (COVID-19) infection should have a series of three viral tests for SARS-CoV-2 infection. Testing recommended immediately (but not earlier than 24 hours after exposure) and if negative, again 48 hours after first negative test and if negative, again 48 hours after the second negative test. Typically, on day one, day three, and day five. If healthcare-associated transmission is suspected or identified, the facility may consider expanded testing of health care personnel (HCP) and resident as determined by the distribution and number of cases throughout the facility and ability to identify close contacts. If expanded testing approach is taken and testing identified additional infections, testing should be expanded more broadly. If possible, testing should be repeated every three to seven days until no new cases were identified for at least 14 days. Review of the facility policy COVID-19 Prevention, Response and Reporting, revised 06/01/24, revealed a close contact was being within six feet for a cumulative total of 15 minutes or more over a 24-hour period with someone with SARS-CoV-2 infection. If a COVID-19 threat was detected, the facility would respond promptly and implement emergency and/or outbreak procedures. The facility would perform viral testing for SARS-CoV-2 as per national standards such as CDC recommendations. Review of the CDC Infection Control Guidance: SARS-CoV-2 dated 06/04/24, revealed the approach to an outbreak investigation involves either contact tracing or a broad-based approach. A broad-based approach was preferred if all potential contacts could not be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close-contacts or on the affected units if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day one, day three and day five. 2) Record review for Resident #54 revealed an admission dated of 05/30/23. Diagnoses included tracheostomy, cerebral infarction, and acute respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was rarely or never understood. Resident #54 was dependent on staff for activities of daily living (ADLs). Resident #54 received oxygen, had a tracheostomy and required suctioning. Review of the care plan dated 12/18/23 revealed Resident #54 had a tracheostomy. Resident #54 was at risk for complications including respiratory distress, increased secretions, and infection. Interventions included to follow facility protocol for enhanced barrier precautions and suction as necessary. Review of the physician orders for Resident #54 revealed a number six shiley uncuffed trach and trach care every shift and as needed initiated 05/18/24. Additional orders included tracheostomy suction as needed for excessive secretions initiated 05/30/23. Observation and interview on 02/04/25 at 3:50 P.M. of trach suctioning for Resident #54 with Licensed Practical Nurse (LPN) #361 revealed on the entrance door for Resident #54's room was a sign which revealed Resident #54 was on Enhanced Barrier Precautions (EBP). The information on the sign included providers must clean their hands, including before entering and leaving the room, providers and staff must also wear gloves and a gown for the following high contact resident care activities which included tracheostomy care. Observation revealed LPN #361 did not wash her hands prior to entering Resident #54's room. LPN #361 also did not don a gown or mask. LPN #361 walked over to Resident #54's bed, opened up sterile gloves (did not wash her hands prior to opening or putting on the gloves) then completed trach suctioning for Resident #54. After completing this task, LPN #361 removed her gloves then exited the room (did not wash her hands) then walked back towards the nursing station. LPN #361 confirmed she did not wash her hands prior to or after going in Resident #54's room. LPN #361 also confirmed she did not wash her hands before or after trach care for Resident #54. LPN #361 confirmed Resident #54 was on EBP and confirmed she did not wear a gown or mask while providing trach (respiratory) care for Resident #54. Review of the facility's undated policy titled Suctioning Tracheostomy revealed tracheostomy suctioning removes thick mucous and secretions from the traches and lower airway that the resident is not able to clear by coughing. To reduce the possibility of contamination, a sterile technique is essential. The procedure included to wash hands and tell the resident what you are doing, assemble the equipment, position the resident and wash hands thoroughly. Open the suction kit, it is very important to keep everything as clean as possible to prevent infection. After suction has been completed, wash hands. This deficiency represents non-compliance investigated under Complaint Number OH00161986 and Complaint Number OH00161487.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident immunizations, review of personnel records, staff interview, and policy review, the facility failed to ensure residents and staff were educated on the risks, benefits, and side effects of the COVID-19 vaccine. This affected five (#14, #42, #53, #57, and #64) of five residents reviewed for immunization and seven of seven employees reviewed for immunization and had the potential to affect all residents. The facility census was 74. Findings include 1) Review of the medical record for Resident #57 revealed an admission date of 01/11/24. Diagnoses included anoxic brain injury, and sudden cardiac arrest. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment Review of Resident #57's undated consent form for the pneumococcal vaccine revealed a hand written note stating the resident would like the COVID-19 vaccine. There was no information sheet for the COVID-19 vaccine and no documentation the resident/representative had been provided education on the COVID-19 vaccine. 2) Review of the medical record for Resident #14 revealed an admission date of 12/01/22. Diagnoses included chronic kidney disease, diabetes insipidus, and peripheral vascular disease. Review of the annual MDS assessment dated [DATE] revealed the resident had impaired cognition. Review of the influenza vaccine consent form dated 10/02/24 revealed a handwritten note per the power of attorney, no COVID-19 vaccine at this time. There was no information sheet for the COVID-19 vaccine and no documentation the resident/representative had been provided education on the COVID-19 vaccine. 3) Review of the medical record for Resident #64 revealed an admission date of 09/06/24. Diagnoses included acute respiratory failure, anoxic brain damage, chronic lymphocytic leukemia of B-Cell type, and tracheostomy status. Review of the quarterly MDS assessment dated [DATE] revealed the resident had impaired cognition. Review of Resident #64's influenza form dated 10/01/24 revealed a handwritten note dated 08/15/24 stating no COVID-19 vaccine wanted per the power of attorney. There was no information sheet for the COVID-19 vaccine and no documentation the resident/representative had been provided education on the COVID-19 vaccine. 4) Review of the medical record for Resident #53 revealed an admission date of 08/05/24. Diagnoses included chronic obstructive pulmonary disease, hypertensive heart disease, and chronic pain syndrome. Review of the significant change MDS assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #53's pneumococcal vaccine form dated 10/01/24 revealed a handwritten note stated the resident refused the COVID-19 vaccination. There was no information sheet for the COVID-19 vaccine and no documentation the resident/representative had been provided education on the COVID-19 vaccine. 5) Review of the medical record for Resident #42 revealed an admission date of 07/28/20. Diagnoses included dementia, bipolar disorder and hypothyroidism. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Review of Resident #42's pneumococcal vaccine consent form dated 10/04/24 revealed a handwritten note stating the resident had declined the COVID-19 vaccine at this time. 6) Review of personnel files for seven staff (Certified Nursing Assistant (CNA) #331, CNA #357, Maintenance Director #400, CNA #342, CNA #341, Registered Nurse (RN) #355, Dietary Aide #344) revealed no documentation the staff had been educated regarding the COVID-19 vaccine. There was no documentation the staff had been offered or had refused the COVID-19 vaccine. Interview on 01/29/25 at 12:05 P.M. with Assistant Director of Nursing (ADON) #392 stated the staff were offered the COVID-19 vaccine at an all-staff meeting. ADON #392 stated she just offered the staff the vaccine and had not provided any education to the staff about the risks and benefits of the vaccine. ADON #392 verified only one staff member had requested the vaccine. ADON #392 also verified Residents #57, #14, #64, #53, and #42 were offered the COVID-19 vaccine but they were not provided information on the benefits, risks, and side effects. ADON #392 verified there was no separate consent form for the COVID-19 vaccine and she documented refusals on either their influenza or pneumococcal consent forms. Review of the policy titled Infection Prevention and Control Program, revised 08/01/23 revealed residents and staff would be offered the COVID-19 vaccine when vaccine supplies were available. Education about the vaccine, risks, benefits, and potential side effects would be given to residents and staff prior to offering the vaccine.

Based on record review and staff and resident interviews the facility failed to ensure narcotic pain medication was available for administration. This affected one (#32) of the three residents reviewed for receiving narcotic pain relief. The facility identified 28 residents receiving narcotic pain medications. The facility census was 80. Finding Include: Review of the medical record for Resident #27 revealed an admission date of 08/09/22. Diagnoses included acute kidney failure, lymphedema, obesity, cerebral infarction, obstructive sleep apnea, chronic ulcer of the left lower leg, chronic pain, and cellulitis. Review of the physician order dated 04/15/24 for Resident #27 revealed an order to administer oxycodone five milligram (mg) every four hours as needed (PRN) and an order to administer cyclobenzaprine 10 mg PRN for spasms. Review of Resident #27's Controlled Drug Record/Disposition Form, dated 05/13/24 for oxycodone five mg, revealed the last pill was administered on 06/14/24 at 7:00 A.M. The record revealed the resident was taking the medication consistently in the evenings. Review of the Care Plan dated 05/16/24 revealed the Resident had the potential for alteration in comfort. Intervention included requesting pain medication before pain becomes severe. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/29/24, revealed the resident had intact cognition and required substantial assistance for transfers, bed mobility and was dependent on staff for toileting and showering. Review of the June 2024 Medication Administration Record (MAR) for Resident #27 revealed oxycodone was administered on 06/14/24 at 7:06 A.M. and the next administration was on 06/20/24 at 1:20 P.M. Cyclobenzaprine 10 mg was administered was administered on 06/15/24 at 10:10 P.M. and on 06/20/24 at 1:19 P.M. Review of Resident #27's progress note dated 06/19/24 at 8:46 P.M. written by Licensed Practical Nurse (LPN) #117, revealed the resident was complaining of pain and her narcotic script was not in for days. The pharmacy was called and stated the pain medication needed a new script. The on-call physician stated she would not call in the script because it should have been done during office hours. A progress note dated 06/19/24 at 9:20 P.M. stated the physician called back and said to have the pharmacy call her for a new prescription. Review of the Medication Delivery Receipt, dated 06/20/24 at 7:58 A.M., revealed 14 oxycodone five mg were delivered for Resident #27. Review of the Resident #27's Controlled Drug Record/Disposition Form, dated 06/20/24 for oxycodone five mg, revealed the first pill was administered on 06/20/24 at 1:21 P.M. There were no pills administered from 06/14/24 through 06/20/24. The record revealed the resident was taking the medication consistently in the evenings. Interview on 06/25/24 at 11:30 A.M. with Resident #27 revealed she went without her pain medication for five days and just took her cyclobenzaprine. On 06/14/24, 06/15/24 and 06/16/24 she reminded three nurses the script needed to be called in. Interview on 06/27/24 at 9:27 A.M. with the Assistant Director of Nursing (ADON) stated the nurse should have notified the pharmacy to refill Resident #27's oxycodone on 06/11/24 when there were five pills left. Interview on 06/27/24 at 10:19 A.M. with LPN #117 revealed the resident was complaining of pain and not having her medication. The pharmacy told her a new script was needed to send out the oxycodone. Review of a 08/22/22 facility policy titled Medication Administration revealed medications would be administered as ordered by the physician and in accordance with professional standards. This deficiency represents non-compliance investigated under Complaint Number OH00154355.

Based on record review, staff interview and review of facility policy, the facility failed to ensure a narcotic pain medication was accurately documented in the resident's Medication Administration Record (MAR). This affected one (#27) of three residents reviewed for pain medications. The facility census was 80. Finding Include: Review of the medical record for Resident #27 revealed an admission date of 08/09/22. Diagnoses included acute kidney failure, lymphedema, obesity, cerebral infarction, obstructive sleep apnea, chronic ulcer of the left lower leg, chronic pain, and cellulitis. Review of the physician order dated 04/15/24 for Resident #27 revealed an order to administer oxycodone 5 milligram (mg) every four hours as needed (PRN). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/29/24, revealed the resident had intact cognition and required substantial assistance for transfers, bed mobility and was dependent on staff for toileting and showering. Review of Resident #27's Controlled Drug Record/Disposition Form, dated 5/13/24 revealed the resident's oxycodone five mg was signed out for administration on 5/21/24 at 8:00 P.M., 05/22/24 at 8:00 P.M., 05/23/24 at 8:00 P.M., 05/25/24 at 9:00 P.M., 05/26/24 at 8:30 P.M., 05/28/24 at 9:00 P.M., 05/29/24 at 9:00 P.M., 05/30/24 unable to read time, and 05/31/24 unable to read time. Review of Resident #27's Care Plan dated 05/16/24 revealed the Resident had the potential for alteration in comfort. Intervention included requesting pain medication before pain becomes severe. Review of the May 2024 MAR for Resident #27 revealed there was no documentation for oxycodone five mg being administered on 5/21/24 at 8:00 P.M., 05/22/24 at 8:00 P.M., 05/23/24 at 8:00 P.M., 05/25/24 at 9:00 P.M., 05/26/24 at 8:30 P.M., 05/28/24 at 9:00 P.M., 05/29/24 at 9:00 P.M., 05/30/24 and unknown time, and 05/31/24 at an unknown time. Review of June 2024 MAR for Resident #27 revealed there was no documentation for oxycodone being administered on 06/20/24 at unknown time, 06/21/24 at 9:00 P.M., 06/22/24 9:30 P.M., and 06/23/24 at 8:00 P.M. Review of Resident #27's Controlled Drug Record/Disposition Form, dated 06/20/24, for oxycodone five mg was signed out on 06/20/24 unable to read time, 06/21/24 at 9:00 P.M., 06/22/24 9:30 P.M., 06/23/24 at 8:00 P.M., and on 06/23/24 at 8:00 P.M. Interview on 06/27/25 at 9:27 A.M. with the Assistant Director of Nursing (ADON) verified the findings and stated the narcotic medications were to be documented on the Controlled Drug Record/Disposition Form and in the resident's MAR. Review of a 08/22/22 facility policy titled Medication Administration revealed medications were signed on the MAR after administered. If a medication is a controlled substance, the medication is signed off in the narcotic book. This deficiency represents non-compliance investigated under Complaint Number OH00154355.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and review of facility policy, the facility failed to ensure resident call lights were in reach of residents. This affected two (#32 and #69) of the three residents reviewed for call lights. The facility census was 80. Finding Include: 1)Review of the medical record for Resident #32 revealed an admission date of 01/18/24. Diagnoses included acute respiratory failure, paraplegia, traumatic brain injury (TBI), epilepsy, and type II diabetes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/25/24, revealed Resident #32 had intact cognition and was dependent on staff for bed mobility, transfers and hygiene. Review of Resident #32's Care Plan dated 05/09/24 revealed the resident required assistance for activities of daily living (ADLs) related to immobility. Intervention included to keep the call light in reach. 2)Review of the medical record for Resident #69 revealed an admission date of 08/09/22. Diagnoses included hemiplegia, cerebral infarction, respiratory failure, seizures, anxiety, depression and bipolar. Review of the quarterly MDS assessment dated [DATE], revealed Resident #69 had intact cognition and impairment to one side. The resident required set up with eating and needed substantial assistance for transfers and bed mobility. The resident was dependent on toileting and shower. Review of Resident #69's Care Plan dated 05/16/24 revealed the resident has a self-care deficit related to cognitive impairment and confusion. Interventions included encouraging the resident to participate while performing ADLs and to monitor and report a decline to the physician. Observation of Resident #69 on 06/25/24 at 11:49 A.M. revealed the resident was lying in bed and his call light was lying under the foot of his bed. The roommate, Resident #32, was lying in his bed resting and his call light was wrapped around the grab bar and out of his reach. Resident #32 asked the surveyor to locate his call light. Interview at this time with Resident #69 stated he did not have a call light for a week. Resident #32 stated he used his call light and does not mind using his call light for Resident #69. Interview on 06/25/24 at 12:06 A.M. with State Tested Nursing Assistant (STNA) #172 verified Resident #32 and Resident #67's call lights were not in reach. STNA #172 stated Resident #32 and Resident #67 were not on her assignment. Interview on 06/25/24 at 12:10 P.M. with STNA #128 stated Resident #32 and Resident #67 were on her assignment and Resident #67 utilized his call light earlier that morning. STNA #128 stated Resident #32's call light probably fell to ground during the wound treatment earlier in the morning and Resident #67 may have knocked his call light out of reach. Review of the 04/01/22 facility policy titled, Call lights: Accessibility and Timely Response, revealed with each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of the resident and secured, as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview and review of policy the facility failed to ensure residents were invited to participate in care conference meetings regarding their care. This affected two of two residents (#20, #56) reviewed for care planning. The facility census was 87. Findings include 1. Review of the medical record revealed Resident #20 had an admission date of 12/05/21. Diagnoses included depressive disorder, delusional disorder, anxiety disorder, type two diabetes mellitus, hypertension, chronic obstructive pulmonary disease and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the resident's Care Conference Summary dated 09/22/23 revealed the resident's last care plan meeting was held on this date. There were no care conference meeting notes since 09/22/23. Interview on 02/26/24 at 8:52 A.M., Resident #20 would like a care plan meeting and had not been invited to one recently. Interview on 02/27/24 at 11:14 A.M. with Social Service Designee (SSD) #126 verified the resident had no care conference meetings since 09/22/23. SSD #126 revealed the resident should have had a care conference meeting in December of 2023. SSD #126 verified she was behind on conducting resident care conferences. 2. Review of the medical record revealed Resident #56 had an admission date of 04/30/22 and a readmission date of 04/30/22. Diagnoses included schizoaffective disorder bipolar type, type two diabetes mellitus, hypertension, major depressive disorder, and hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of an Interdisciplinary Care Plan Conference Summary dated 04/07/22 revealed the resident's last documented care plan meeting was held on 04/07/22. Interview on 02/26/24 at 9:42 A.M., Resident #56 stated she had not been invited to participate in a care conference and would like to attend those meetings about her care. Interview on 02/27/24 at 11:14 A.M., SSD #126 revealed there was no documentation of the resident having a care planning meeting in the past year. SSD #126 verified she was behind on care plan conference meetings. Interview on 02/27/24 at 1:00 P.M., the Administrator revealed SSD #126 was new to the position and was not correctly documenting care plan conferences. Review of the undated facility policy Care Planning -- Resident Participation, revealed the facility would discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility would make an effort to schedule the conference at the best time of day for the resident/resident's representative. The facility would obtain a signature from the resident and/or resident representative after discussion or viewing the care plan. If participation of the resident and/or resident representative was determined not practicable for the development of the resident's care plan, an explanation would be documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interviews, the facility failed to ensure skin assessments were completed accurately and the facility failed to follow physician orders for oxygen administration. This affected one of one resident (#45) reviewed for skin assessments and oxygen administration. The facility census was 87. Findings Include: 1. Review of Resident #45 medical records identified Resident #45 was admitted into the facility on [DATE] with diagnoses of unspecified dementia, psychotic disturbance, mood disturbance, anxiety, chronic respiratory failure with hypoxia ,legal blindness, and personal history of traumatic brain injury. Review of the most recent annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 was severely cognitively impaired and required substantial to maximal assistance from staff to aide in completing his activities of daily living. A. Review of Resident #45 current physician orders identified skin checks were to be completed weekly during showers. Review of Resident #45's shower sheets/ skin assessments dated 02/25/24, 02/22/24, 02/18/24, 02/15/24, 02/08/24, 02/04/24, 02/01/24, 01/28/24, 01/23/24, 01/12/24, 01/09/24 for review. Review of Resident #45's shower sheets /skin assessments revealed inaccurate documentation related to the condition of Resident #45's skin. Further review of Resident #45's shower sheets/ skin assessments revealed shower/ skin assessments stating Resident #45's skin was intact and without any rashes, bruising, or redness. Review of facility's Skin Policy (revised on 11/2018) revealed number one on the policy stated skin will be observed upon admission and routinely throughout the residents stay. Number seven on the policy stated to notify Wound Nurse, MD/NP, RD, and Resident Representative upon observation of new skin area. Observation on 02/26/24 at 10:58 A.M. revealed Resident #45's left arm and left hand had multiple purplish discolorations. Interview on 02/26/24 at 10:58 A.M. with Resident #45 revealed he was unable to recall how these purplish discolorations on his hand and arm occurred. Interview on 02/27/24 at 11:47 A.M. with Licensed Practical Nurse (LPN)#161 revealed she was not sure why Resident #45 had black and blue discolorations on his arm. Interview on 02/27/24 at 11:53 A.M. with Assistant Director of Nursing (ADON)#199 revealed she was not aware of anything on Resident #45's arm. Interview on 02/27/24 at 1:33 P.M. with ADON #199 confirmed that after looking at Resident #45's shower sheets/ skin assessments, Resident #45's skin assessments were documented inaccurately. B. Record review of Resident #45's Medication Administration Record (MAR) revealed that Resident #45 had Oxygen orders dated 01/10/24 for 2 Liters O2 via nasal cannula continuously every shift and monitor SpO2 (oxygen saturation). Review of an undated Oxygen Administration Policy revealed: Oxygen is administered under orders of a Physician, except in the case of an emergency. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as but not limited to the type of oxygen delivery system. When to administer such as continuous or intermittent and /or when to discontinue. Equipment settings for the prescribed flow rates. Observation on 02/26/24 at 10:53 A.M. revealed Resident #45 lying in bed with oxygen being administered at 4 liters per nasal cannula. Interview on 02/26/24 at 2:24 P.M. with Licensed Practical Nurse (LPN) #186 verified Resident #45's oxygen was currently set at 4 liters. After LPN #186 looked at Resident #45 MAR, LPN #186 confirmed Resident #45 was receiving the incorrect amount of oxygen per the physician orders.

Based on observation, medical record review and staff interview, the facility failed to administer tube feeding formula according to directions for use. This affected one of two residents (#78) reviewed for enteral tube feedings. The facility census was 87. Findings include: Review of the medical record for Resident #78 revealed an admission date of 05/30/23. Diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, history of pneumonitis due to inhalation of food and vomit, dysphagia, aphasia, tracheotomy, chronic obstructive pulmonary disease, stage three chronic kidney disease, and neuromuscular dysfunction of bladder. Review of 1/18/24 significant change Minimum Data Set (MDS) 3.0 for Resident #78 revealed a Brief Interview of Mental Status (BIMS) score of 03 which indicated the resident had severely impaired cognition. Review of activities of daily living (ADLs) revealed Resident #78 was dependent for all ADLs, was noted to have a history of pocketing food, coughing with meals, used oxygen, and was receiving hospice services. Review of physician orders dated 01/05/24 for Resident #78 revealed an order for enteral feeding of Isosource 1.5 calorie running at 55 cubic centimeters (cc) per hour with 40 cc per hour flush continuously. Observation on 02/26/24 at 10:04 A.M. revealed Resident #78's enteral feeding bag and water flush bag running through an automatic tube feeding pump, were dated 02/22/24 and timed at 7:04 A.M. Interview at the time of the observation with Licensed Practical Nurse (LPN) #153 confirmed the date on the enteral feeding and flush bag was 2/22/24 timed at 7:04 A.M. LPN #153 stated when she was in checking on Resident #78 earlier in the morning, she saw the tube feeding running but did not check the date. LPN #153 confirmed it was ordered to be changed on the night shift and should have been changed to a new bag. Review of the manufacturer's product label for a 1500 milliliter (mL) bag of Nestle Isosource 1.5 enteral tube feeding revealed under the directions for use: use for a maximum of 48 hours after connection when proper technique is followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interviews, the facility failed to ensure a resident's medications were kept secured against unauthorized access. This affected one of one resident (#50) reviewed for medication administration. The facility census was 87. Findings Include: Record review revealed Resident #50 was admitted into the facility on [DATE] with diagnoses of arteriosclerotic heart disease, heart failure, benign prostatic hyperpiesia with lower urinary tract symptoms, muscle weakness, difficulty in walking. Review of the most recent annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 was cognitively intact and required moderate assistance from staff to aide in completing his activities of daily living. Review of the Medication Administration Policy (dated 08/22/22) stated under number 15: observe resident consumption of medication. Observation on 02/26/24 at 11:05 A.M. revealed a small plastic medication cup containing six (6) pills sitting on Resident #50's bedside table. Resident #50 was not in his room at this time, but was observed using his manual wheelchair to enter his room while this observation was made. Resident #50 revealed the nurses will sometimes leave his pills on his bedside table for him to take. Observation on 02/26/24 at 11:13 A.M. revealed an aide walked into Resident #50's room. The nurse was requested by the surveyor. Interview on 02/26/24 at 11:16 A.M. with Licensed Practical Nurse (LPN)#186 verified after she came into Resident #50's room, that six (6) pills were sitting inside the medication cup on Resident #50's bedside table.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure peripherally inserted central catheter (PICC) line needleless connectors and PICC line dressings were changed weekly and as needed. This affected three (#90, #91, and #92) of three residents reviewed for PICC lines. The facility census was 80. Findings include: 1. Medical record review revealed Resident #90 had an admission date of 11/15/22 and a discharge date of 12/08/22. Diagnoses included osteomyelitis right tibia and fibula, methicillin resistant staphylococcus aureus infection, respiratory failure with hypoxia, type two diabetes mellitus, depression, hypothyroidism, and a nondisplaced tri-malleolar fracture of left lower leg, and subsequent encounter for closed fracture with routine healing. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #90 had intact cognition and received intravenous (IV) therapy. Review of the physician orders dated 11/16/22 revealed an order to change Resident #90's PICC line dressing every week. There were no orders to change the PICC line needleless connectors. Review of the treatment administration record (TAR) dated 11/16/22 through 12/08/22 revealed Resident #90's PICC line dressing change was completed weekly; however, there was no documentation the needleless connectors were changed. Interview on 05/17/23 at 10:12 A.M., with the Director of Nursing (DON) stated the needleless connectors would be changed weekly when the PICC line dressing was changed, and verified there were no orders to change the needleless connectors. The DON stated the facility never had separate orders for changing the needleless connectors. 2. Medical record review for Resident #91 revealed an admission date of 03/13/23 and a discharge date of 04/04/23. Diagnoses included pressure ulcer of the sacral region stage four, chronic osteomyelitis with draining sinus, vascular dementia, pressure ulcer of the right heel, pressure ulcer of the left heel, peripheral vascular disease, and chronic obstructive pulmonary disease. Review of the admission MDS assessment revealed Resident #91 had intact cognition. Review of the medical record revealed Resident #91 had a PICC line for IV therapy and the resident was received IV therapy. Review of Resident #91's physician orders revealed there were no orders to change the PICC line dressing or change the needleless connectors weekly and as needed. Review of Resident #91's TAR revealed no documentation the PICC line dressing and needleless connectors were changed weekly and as needed. Interview on 05/17/23 at 4:55 P.M., with the DON verified there was no documentation the PICC line dressing and needleless connectors were changed weekly and as needed for Resident #91. 3. Medical record review for Resident #92 revealed an admission date 03/12/23 and a discharge date of 04/07/23. Diagnoses included type two diabetes mellitus, cellulitis of left lower limb, peripheral vascular disease, heart failure, and methicillin susceptible staphylococcus aureus infection. Review of the admission MDS assessment dated [DATE] revealed Resident #92 had intact cognition, and the resident received IV therapy. Review of Resident #92's medical record revealed the resident had a PICC line for IV therapy. Review of Resident #92's physician orders revealed there were no orders to change the PICC line dressing or change the needleless connectors weekly and as needed. Review of Resident #92's TAR revealed no documentation the PICC line dressing and needleless connectors were changed weekly and as needed. Interview on 05/17/23 at 4:55 P.M., with the DON verified there was no documentation the PICC line dressing and needleless connectors were changed weekly and as needed for Resident #92. Review of the facility policy titled, Catheter Insertion and Care, dated 01/01/21, revealed needleless connectors and extension sets would be changed at specific intervals, or when needed to prevention infections associate with contaminated IV therapy equipment. Review of the policy's appendices revealed the dressing should be changed every five to seven days and as needed. Further review of the policy revealed documentation in the medical record should include the date, time and procedure performed. This deficiency represents non-compliance investigated under Complaint Number OH00142025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical records review, facility policy review and staff interview, revealed the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was current and up to date. This affected two (#28 and #54) of two residents reviewed for PASARR. The facility census was 75. Findings include: 1. Review of medical record for Resident #28 revealed an admission date of 01/29/21. Diagnoses included paranoid schizophrenia, insomnia, major depressive disorder, schizoaffective disorder, generalized anxiety disorder, and schizophrenia unspecified. Review of Resident #28's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #28 was cognitively intact. Resident #28 was independent with bed mobility, transfers, eating and toileting. She required extensive assistance with one person assist with dressing, supervision with set up assistance for personal hygiene and was total dependent for bating. Review of the PASARR dated 01/29/21 revealed a check mark denoted the resident had a serious mental disorder of schizophrenia and delusional disorder. Review of monthly physician orders dated July 2021 revealed the resident had been diagnosed with insomnia, major depressive disorder, and generalized anxiety disorder on 03/02/21. 2. Review of medical record for Resident #54 revealed an admission date of 06/24/19. Diagnoses included unspecified dementia with behavioral disturbances, dementia in other diseases classified with behavioral disturbances, unspecified mental disorder due to known physiological condition, delusional disorder, hallucinations, altered mental status, major depressive disorder, and Parkinson's disease. Review of Resident #54's quarterly MDS assessment dated [DATE] revealed Resident #54 was cognitively impaired. Resident #54 required extensive assistance with two-person assist with bed mobility, dressing, toileting, and personal hygiene. She was total dependent with one person assist with transfers, eating and bathing. Review of the PASARR dated 06/23/19 revealed a check mark denoted the resident had a diagnosis of dementia. Review of the physician orders for 07/2021 revealed the resident had been diagnosed with delusional disorder and hallucinations on 07/24/19. Interview on 07/21/21 at 11:00 A.M., with the Administrator in Training verified Resident #28 and Resident #54 did not have an updated PASARR to reflect the new diagnoses. Review of the undated facility policy titled Embassy Healthcare revealed any resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional resident review. Examples include a resident whose condition or treatment was or will be significantly different than described in the residents most recent PASARR Level II evaluation and determination, Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability or a relation condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record, staff and resident interviews and review of facility policy revealed the facility failed to provide showers per resident preferences. This affected two (#53 of #67) three of residents reviewed for Activities of Daily Living. The facility census was 75. Findings included: 1. Review of the medical record for Resident #53 revealed an admission date of 09/25/15 and re-admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting unspecified side, localization-related symptomatic epilepsy and epileptic syndrome with simple partial seizures, major depressive disorder, insomnia, and unspecified sequelae of unspecified cerebrovascular disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/10/21, revealed Resident #53 had intact cognition. The resident required limited assistance with one person for bed mobility, transfers, and personal hygiene. He required extensive assistance with one person for dressing, toileting, and bathing. Review of the shower sheets revealed Resident #53 received showers on 05/14/21, 05/21/21, 06/04/21, 06/13/21, 06/28/21, 07/02/21, 07/11/21, and 07/16/21. Review of the State Tested Nursing Assistant (STNA) Point of Care (POC) dated 06/22/21 through 07/20/21 revealed Resident #53 received showers on 06/22/21, 06/25/21, 06/26/21, 06/28/21, 07/03/21, and 07/16/21. Interview and observation on 07/19/21 at 10:16 A.M. with Resident #53 revealed he prefers to have his showers twice a week on Mondays and Fridays in the evenings. He was not getting his showers twice a week, and some weeks he was not getting a shower at all. He was sitting in his motorized wheelchair. He was clean and no pervasive odors noted. 2. Review of the medical record for Resident #67 revealed an admission date of 05/01/15 and re-admitted on [DATE]. Diagnoses included chronic pain, low back pain, chronic obstructive pulmonary disease, major depressive disorder, opioid dependence, malignant neoplasm of left and right bronchus or lung, unspecified abdominal pain, heart disease, pain, anxiety disorder, peripheral vascular disease, unspecified dementia without behavioral disturbances, and diabetes mellitus type two. Review of the Medicare five-day Minimum Data Set (MDS) assessment, dated 07/04/21, revealed Resident #67 had intact cognition. The resident required total assistance with bathing and was independent with all other activities of daily living. Review of the shower sheets for Resident #67 revealed he received shower on 07/16/21. He refused showers/bed baths on 05/06/21, 05/13/21, 05/19/21, 06/16/21, 06/25/21, and 06/30/21. Review of the STNA POC documentation revealed Resident #67 received showers on 07/03/21, 07/05/21, 07/06/21, 07/09/21, 07/10/21, 07/11/21, 07/12/21, 07/16/21, 07/20/21. Interview on 07/21/21 at 10:15 A.M., with Resident #67 revealed he prefers showers once a week on Wednesday nights, and prefers with one specific aide. Interview on 07/21/21 at 9:30 A.M., with the Director of Nursing (DON) revealed Resident #67 refuses consistently. He prefers one specific staff member to provide him showers. She verified based on shower sheets the resident had refused showers on 05/06/21, 05/13/21, 05/19/21, 06/16/21, 06/25/21, 06/30/21, 07/07/21 and 07/16/21 and had received only one shower on 07/16/21. Interview on 07/21/21 at 10:25 A.M., with Licensed Practical Nurse (LPN) #500 revealed each unit had a shower book at the nurse's station. When a resident was admitted they place their shower day and time in the book. If residents request showers in between their shower days, they will accommodate. All documentation was completed on the POC from the STNA's and shower sheets the nurses sign off on. Interview on 07/21/21 at 10:45 A.M., with STNA #300 revealed all showers were documented in the POC, even if they were refused. Residents who receive showers on second shift don't receive their showers due to staffing issues. She knows on the days she works the residents receive their showers. She was informed by management if only two STNA's were working then showers didn't have to be completed. Review of facility policy titled Bathing, revealed baths/showers may be given at any time the resident chooses. They may be done in the morning, before bed, or any other time of the resident's preference. A shower may only be necessary two to three times per week of the resident chooses this. A bed bath should be given on days a resident does not get a shower per their preference. Documentation of care given in the STNA POC or nursing notes. Document refusals, re-attempts, and discussions about why refusing and options offered. Complete shower sheets for scheduled and or as needed showers given or refused, skin checks on scheduled shower days whether shower was given. This deficiency substantiates the allegation in Complaint Number OH00123870.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interview and review of the facility policy, the facility failed to ensure an anchoring device for the Foley catheter was implemented to prevent accidental pain or injury from excessive tension and/or removal of a Foley catheter. This affected one (#41) of one resident reviewed for catheter care. The facility identified 11 residents with catheters. The facility census was 75. Findings Include: Review of Resident #41's medical record revealed the resident was admitted on [DATE]. Diagnoses included cerebral infarction, acute respiratory failure with hypoxia, tracheostomy, hypertension, and urinary retention. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed extensive assist of two person for bed mobility and has an indwelling Foley catheter. Review of the most recent plan of care revealed a potential for complications related to the use of a Foley catheter and assist with Foley catheter care as needed. Observation on 07/21/21 at 8:52 A.M., of catheter care for Resident #41 with Registered Nurse (RN) #106, revealed the procedure was observed with no infection control issues. However, there was no anchoring device utilized to secure the Foley catheter in place. Interview on 07/21/21 at 9:32 A.M. with RN #106, verified Resident #41 did not have an anchoring device to keep the Foley securely attached to the leg. In addition, RN #106 reported the anchoring device should have been applied and was missed when the catheter was changed. Interview on 07/21/21 at 10:14 A.M. with RN #161, revealed residents with Foley catheters were to have an anchoring device applied for safety. Review of the facility policy titled, Use and Care of Urinary Catheter Guidelines, dated 04/2016, revealed care of the urinary catheter and drainage, the catheter should have an anchor device in place to reduce the potential for injury from the tubing being pulled.