Based on record review, interview, and review of the facility policy and procedure, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected one resident (#17) of five residents. The facility census was 45. Findings include: Review of the medical record for Resident #17 revealed an admission date of 04/05/24. Diagnoses included anxiety disorder, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, and schizoaffective disorder. Review of the physician orders for September 2024 for Resident #17 revealed an active order for Olanzapine (antipsychotic) oral tablet 5 milligrams (mg). Give one tablet by mouth at bedtime related to dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with a start date of 04/05/24. Review of the consultant pharmacist medication regimen reviews dated 04/01/24, 05/01/24, 06/01/24, and 08/01/24 revealed a recommendation, noting for the resident is receiving the antipsychotic agent Olanzapine, but lacks an allowable diagnosis to support its use. Please verify why the patient was started on this medication and update their diagnosis list on PCC or consider asking the provider to choose alternate therapy. Interview on 09/05/24 10:09 A.M. with Minimum Data Set (MDS) Nurse #103 stated she talked to the physician and told him that pharmacy recommendations were made but was not sure when that was. MDS Nurse #103 stated he referred to psych to address and when psych saw Resident #17 on 08/05/24, she was diagnosed schizoaffective disorder. MDS Nurse #103 verified the pharmacy recommendations dated 04/01/24, 05/01/24, 06/01/24, and 08/01/24 were all the same recommendation regarding the diagnosis for the use of the Olanzapine. MDS Nurse #103 verified the recommendations were addressed late due to the order being changed on 09/04/24 for the use of the Olanzapine for schizoaffective disorder. Review of the facility policy titled Medication Regimen Reviews, revised May 2019 revealed if the physician does not provide a timely or adequate response or the consultant pharmacist identifies that no action has been taken, he/she contacts the Medical Director or (if the Medical Director is the physician of record) the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor residents using anticoagulant medications. This affected one resident (#27) out of five residents reviewed for medications. The facility census was 45. Findings include: Review of Resident #27's medical record revealed an admission date of 12/07/23 and diagnoses including bipolar disorder, hypertension, vitamin D deficiency, depression, generalized anxiety disorder, mild protein-calorie malnutrition and dementia with other behavior disturbance, schizoaffective disorder-bipolar type. Review of Resident #27's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 had moderate cognitive impairment, was dependent on staff for bathing utilized a wheelchair for mobility and received antipsychotic medications, antidepressant medications and anticoagulants. Review of Resident #27's physician's orders revealed an order dated 04/17/24 for Eliquis (anticoagulant or blood thinning medication) oral tablet five milligrams (mg) with directions to give by mouth twice a day for cardiovascular disease. Continued review revealed the facility had no orders in place to monitor the resident for side effects related to her high-risk medication. Continued review of Resident #27's medical record revealed there was no side-effect monitoring in the Point of Care system. Review of Resident #27's care plan dated 12/18/23 and revised 12/27/23 revealed residents taking medications in high-risk drug classes are at risk of side effects that can adversely affect their health, safety and quality of life. The resident is currently prescribed medications from the following high-risk drug class(es): Anticoagulant, Antidepressant, Antipsychotic, Hypoglycemic. A listed intervention dated 12/18/23 revealed monitor resident for adverse effects of medications. Review of a second care plan dated 12/18/23 revised 12/27/23 revealed Resident #27 was at risk for decreased cardiac output and abnormal lab values related to Cardiac Arrhythmias, Hypertension, Use of anticoagulation medication. A listed intervention dated 12/28/23 revealed monitor for adverse affects of anticoagulant medications: abnormal bleeding, blood in stool, urine, emesis, mucous & gums, c/o abdominal pain, back pain, severe headaches; check skin for bruises, cuts, scratches. Interview on 09/04/24 at 10:41 A.M. with Licensed Practical Nurse (LPN) #116 revealed Resident #27 was on an anticoagulant so they had to monitor her for bleeding but this was not documented anywhere in the medical record. Interview on 09/04/24 at 3:27 P.M. with the Director of Nursing (DON) and MDS/LPN #103 revealed there was not an order in place relative to medication monitoring for Resident #27's anticoagulant and confirmed there was no evidence the facility was monitoring for side effects relative to Resident #27's medication. Follow-up interview on 09/04/24 at 3:37 P.M. with the DON verified the facility did not have an anticoagulation policy to provide for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure influenza and pneumococcal vaccines were adminsitered as required. This finding affected two (Residents #6 and #30) of five residents reviewed for immunizations. Findings include: 1. Review of Resident #6's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified dementia, bipolar disorder and diffuse traumatic brain injury with loss of consciousness of unspecified duration. Review of Resident #6's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #6's Pneumococcal Vaccine Consent form dated 10/25/20 revealed the resident wished to receive the pneumococcal vaccine. Review of Resident #6's Influenza Vaccine Consent form dated 10/25/20 revealed the resident wished to receive the influenza vaccine on an annual basis while he/she was residing in the facility. Review of Resident #6's medical record did not reveal evidence the resident received the influenza vaccine for 2023 or the pneumococcal vaccine during the admission to the facility. Interview on 09/04/24 at 12:57 P.M. with Registered Nurse (RN) Clinical Manager #102 (infection preventionist or IP) confirmed Resident #6's influenza and pneumococcal vaccines were not administered as required. 2. Review of Resident #30's medical record revealed the resident was admitted on [DATE] with diagnoses including diffuse traumatic brain injury with loss of consciousness of unspecified duration, unspecified dementia and late Alzheimer's disease with late onset. Review of Resident #30's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #30's Influenza Vaccine Consent form dated 03/09/20 revealed the resident wished to receive the influenza vaccine on an annual basis while he/she was residing in the facility. Review of Resident #30's medical record revealed the last influenza vaccine was completed on 10/12/22. Interview on 09/04/24 at 12:57 P.M. with RN Clinical Manager #102 confirmed Resident #30's influenza vaccine was not administered for 2023 as required. Review of the undated Prevention and Control of Seasonal Influenza policy indicated antiviral treatment and chemoprophylaxis were adminsitered to residents and staff when appropriate, and in accordance with current Centers for Disease Control (CDC) guidelines. Review of the Clinical Protocol for Pneumonia, Bronchitis and Lower Respiratory Infections policy revised 10/2018 revealed as part of the initial assessment, the physician would help identify residents who have recently had pneumonia or bronchitis and those who were at risk for getting respiratory infections.

Based on interview, record review and review of the facility policy, facility failed to provide spend-down letters for each month residents were approaching or over the resource limit. This affected three residents (#13, #32 and #33) of five residents reviewed for resident funds. The facility census was 45. Findings include: 1. Review of Resident #13's medical record revealed an admission date of 10/28/19 and diagnoses including cerebral infarction, dementia with other behavioral disturbance, adjustment disorder and schizoaffective disorder. Review of Resident #13's quarterly financial report for April 2024 through June 2024 revealed a balance of $4868.52 on 04/01/24, a balance of $3815.35 on 05/01/24 and a balance of $3810.19 on 06/04/24. Review of available spend-down letters for 2024 revealed one letter on 07/17/24. Interview on 09/04/24 at 12:15 P.M. with Business Office Manager (BOM) #105 and Sister Facility Business Office Manager (SFBOM) #106 revealed SFBOM #106 was assisting in training BOM #105 in her role, including with resident funds. BM #105 indicated as of this week she realized spend-down letters were to be sent every month a resident was approaching or over the resource limit and confirmed no there were no spend-down letters for Resident #13 for April, May or June during the interview. 2. Review of Resident #32's medical record revealed an admission date of 01/28/20 and diagnoses including psychotic disorder with delusions, intermittent explosive disorder, unspecified dementia (moderate), morbid obesity, pseudobulbar affect and schizoaffective disorder, bipolar type. Review of Resident #32's quarterly financial report for April 2024 through June 2024 revealed a balance of $8613.47 on 04/03/24, a balance of $9628.15 on 05/03/24 and a balance of $10518.47 on 06/03/24. Review of available spend-down letters for 2024 revealed letters on 01/09/24, 03/11/24 and 07/17/24. Interview on 09/04/24 at 12:15 P.M. with BOM #105 and SFBOM #106 revealed SFBOM #106 was assisting in training BOM #105 in her role, including with resident funds. BOM #105 indicated as of this week she realized spend-down letters were to be sent every month a resident was approaching or over the resource limit and confirmed no there were no spend-down letters for Resident #32 for April, May or June during the interview. 3. Review of Resident #33's medical record revealed an admission date of 08/29/23 and diagnoses including osteoarthritis, iron deficiency anemia, alcoholic myopathy, gout and nicotine dependence. Review of Resident #33's quarterly financial report for April 2024 through June 2024 revealed a balance of $2205.77 on 05/03/24 and a balance of $2883.52 on 06/03/24. Review of available spend-down letters for 2024 revealed one letter on 07/17/24. Interview on 09/04/24 at 12:15 P.M. with BOM #105 and SFBOM #106 revealed SFBOM #106 was assisting in training BOM #105 in her role, including with resident funds. BOM #105 indicated as of this week she realized spend-down letters were to be sent every month a resident was approaching or over the resource limit and confirmed no there were no spend-down letters for Resident #33 for May or June during the interview. Review of the policy, Accounting and Records of Resident Funds, revised April 2018 revealed a representative of the business office will inform the resident if the balance in his/her personal funds account reaches $200 less than the supplemental security income (SSI) resource limit and if the amount in the account reaches the SSI resource limit for one person, the resident may lose eligibility for medicaid or SSI.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure appropriate personal protective equipment (PPE) was maintained while providing care for Resident #41 who was in isolation precautions related to a COVID-19 diagnosis. This finding affected one resident (Resident #41) and had the potential to affect an additional 26 residents who reside on the second floor including Residents #1, #2, #12, #13, #14, #15, #16, #17, #18, #22, #24, #28, #29, #30, #31, #33, #34, #35, #36, #37, #39, #40, #42, #43, #47 and #96. The facility census was 45. Findings include: Review of Resident #41's medical record revealed the resident was admitted on [DATE] with diagnoses including spastic quadriplegic cerebral palsy, COVID-19 and impulse disorder. Review of Resident #41's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #41's progress note dated 08/30/24 at 10:18 A.M. authored by Licensed Practical Nurse (LPN) #113 revealed the resident complained of not feeing well, was sneezing and had congestion. The resident had tested positive for COVID-19. Strict isolation precautions were started. The physician and power-of-attorney (POA) were updated. Review of Resident #41's physician orders revealed an order dated 08/30/24 reveled an order for strict isolation precautions to be maintained and all services to be provided in the room. Discontinue when completed. Review of Resident #41's progress note dated 09/03/24 at 11:48 A.M. authored by LPN #113 revealed the resident remained on strict isolation precautions per the facility protocol due to a positive COVID-19 result. The resident stated she was feeling better and requested to be up in her wheelchair in the room. The COVID-19 test for day five was negative. Observation on 09/04/24 at 8:30 A.M. revealed State Tested Nursing Assistant (STNA) #134 donned (put on) an N95 duck bill type respirator mask and gloves. STNA #134 took the resident's breakfast tray into the resident's room, adjusted the resident's bedside table and took the covers off of the food. STNA #134 walked back into the hall and asked STNA #149 to help pull the resident up for the breakfast meal. STNA #149 implemented an isolation gown, gloves and N95 duck bill type respirator mask. STNA #134 at that time implemented an isolation gown while leaving her N95 respirator mask and gloves in place and followed STNA #149 into the room to pull Resident #41 up in the bed. Neither staff member were observed with any type of eye protection. Signage on the door indicated for staff to use an N95 respirator mask and gloves as well as to wash/sanitize their hands upon entry and when leaving the resident's room. Interview on 09/04/24 at 11:37 A.M. with STNA #134 confirmed the plastic bin outside of Resident #41's room had PPE including gowns, gloves and eye protection but she did not don the isolation gown when she had first entered Resident #41's room and she did not implement eye protection at any point during the interaction with Resident #41. She confirmed she was educated on the appropriate PPE while caring for residents on COVID-19 precautions and was aware Resident #41 was COVID-19 positive. Interview on 09/04/24 at 1:16 P.M. with STNA #149 with Clinical Manager RN #102 (infection preventionist) in attendance confirmed the STNA did not use appropriate PPE which included eye protection while providing care for Resident #41 who was COVID-19 positive. Interview on 09/04/24 at 1:20 P.M. with Clinical Manager RN #102 confirmed the entrance to Resident #41's room had signage for airborne isolation precautions which stated for staff to use an N95 respirator mask, keep the door closed and wash their hands. The signage did not include staff/visitor instructions to don an isolation gown and eye protection while providing care for Resident #41 as required. Review of the Personal Protective Equipment - Contingency and Crisis Use of N-95 Respirators (COVID-19 Outbreak) policy revised 09/21 revealed the policy was to prevent transmission of infectious agents through the inhalation of airborne particles or droplet nuclei and the equipment and supplies including respirator masks and additional PPE as required (gloves, gown and eyewear). Review of the Centers for Disease Control Infection Control (CDC) Guidance titled COVID-19 dated 06/24/24 revealed healthcare providers (HCP) who enter the room of a resident with suspected or confirmed COVID-19 infection should adhere to standard precautions and use a N95 respirator mask, gown, gloves and eye protection (i.e. goggles or a face shield that covers the front and sides of the face).

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and staff interview, the facility failed to maintain registered nurse (RN) coverage in the facility at least eight consecutive hours a day seven days a week as required. This had the potential to affect all 45 residents who reside in the facility. Findings include: Review of the nursing staff punch detail, nursing staff schedule, and payroll based journal (PBJ) submission for 12/22/23, 12/23/23, and 12/25/24 revealed no registered nurses were present working in the facility. Interview on 09/05/24 at 10:39 A.M. with Human Resources (HR) #105 verified the identified findings. The deficient practice was corrected on 04/01/24 when the facility implemented the following corrective actions: • Beginning 03/01/24 Director of Nursing (DON)/Designee reviewed the current number of RN's employed by the facility and update the roster intermittently. • Beginning 03/01/24 the facility would advertise for RN's on job recruitment sites and review daily. • Beginning 03/01/24 the facility would audit daily scheduling sheets to ensure 8-hour RN covered was provided. • Beginning 03/01/24 the DON would provided the 8 hour coverage in the event there was a call off to ensure the facility met state and federal regulation.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility failed to completely and accurately report staff hours worked in Payroll Based Journal (PBJ). This had the potential to affect all 45 residents residing in the facility. Findings include: Review of facility time punches revealed no Registered Nurse (RN) and no Director of Nursing (DON) punches were recorded on 12/23/23, 12/24/23 and 12/25/23. Review of PBJ data revealed on 12/23/23, eight RN hours and eight DON hours were submitted; on 12/24/23, eight RN hours and eight DON hours were submitted and on 12/25/23, no RN hours or DON hours were submitted. Interview on 09/05/24 at 10:39 A.M. with Business Office Manager (BOM) #105 revealed she was responsible for submitting PBJ data and while it was checked over by the Administrator, she was the only one who input the staffing data for submission. BOM #105 was unaware the PBJ reporting did not reflect the staffing as recorded on 12/23/23 and 12/24/24 as of the time of the interview. The deficient practice was corrected on 03/01/24 when the facility implemented the following corrective actions: • Beginning 03/01/24 Director of Nursing (DON)/Designee reviewed the number of RNs employed and updated the roster intermittently • Beginning 03/01/24 DON advertised for RNs on job recruitment sites and reviewed applicants daily • Beginning 03/01/24 the facility audited daily scheduling sheets to ensure 8-hour consecutive RN coverage was provided, and the DON provided the RN coverage in the event that there was a call off to ensure facility meets state and federal regulations. These action steps have been ongoing to ensure consistent and future compliance. • Review of PBJ data from 04/01/24 through 06/30/24 showed accurate data submission.

Based on observation, Employee Phone List review and interview, the facility infection preventionist (IP) failed to ensure staff were appropriately fit tested for N95 respirator masks to prevent the potential for cross contamination and spread of infectious diseases in the facility. This finding had the potential to affect all 45 residents residing in the facility. Findings include: Review of the Employee Phone List form dated 09/02/24 revealed 3 Registered Nurses (RNs), 13 Licensed Practical Nurses (LPNs) and 27 State Tested Nursing Assistants (STNAs) were employed in the facility. Observation on 09/04/24 at 8:30 A.M. revealed State Tested Nursing Assistant (STNA) #134 donned an N95 duck bill type respirator mask and gloves. STNA #134 took the resident's breakfast tray into the resident's room, adjusted the resident's bedside table and took the covers off of the food. STNA #134 walked back into the hall and asked STNA #149 to help pull the resident up for the breakfast meal. STNA #149 implemented an isolation gown, gloves and N95 duck bill type respirator mask. STNA #134 at that time implemented an isolation gown while leaving her N95 respirator mask and gloves in place and followed STNA #149 into the room to pull up Resident #41. Neither staff member were observed with any type of eye protection. Signage on the door indicated for staff to use an N95 respirator mask and gloves as well as to wash/sanitize their hands upon entry and when leaving the resident's room. Interview on 09/04/24 at 11:37 A.M. with STNA #134 confirmed she was hired 04/2024 and was not fit tested for an N95 respirator mask since hire and prior to providing care for residents on COVID-19 precautions Interview on 09/04/24 at 1:16 P.M. with STNA #149 with Clinical Manager RN #102 (infection preventionist or IP) in attendance confirmed she was not fit tested for an N95 respirator mask since hire and prior to providing care for residents on COVID-19 precautions. Interview on 09/04/24 at 11:15 A.M. with Clinical Manager RN #102 confirmed the facility did not ensure nursing staff were fit tested annually to ensure each staff member had an approved respirator mask when providing care to COVID-19 positive residents to prevent the spread of infectious diseases throughout the facility. Clinical Manager RN #102 also confirmed she was hired 03/23 as a social service designee (SSD) and took on the role of IP in 01/24 and she was not fit tested for an N95 respirator mask since hire. Review of the Centers for Disease Control Infection Control (CDC) Guidance titled COVID-19 dated 06/24/24 revealed N95 respirators should be used in the context of a comprehensive respiratory protection program, which includes medical evaluations, fit testing and training in accordance with the Occupational Safety and Health Administration's (OSHA) Respiratory Protection Standard.

Based on review of facility staffing schedules and interview, the facility failed to ensure staffing included a Registered Nurse (RN) for at least eight hours a day, seven days a week and a full-time Director of Nursing (DON). This had the potential to affect all the residents in the facility. The facility census was 41 residents. Findings Include: Review of facility staffing schedules and posted staffing information from 03/01/24 through 03/14/24 revealed the facility did not have a full-time DON nor RN coverage eight consecutive hours daily from 03/01/24 to 03/10/24. Interview on 03/24/24 at 4:00 P.M. with the Administrator verified there was no full-time Director of Nursing (DON) from 03/01/24 through 03/10/24 and there was no Register Nurse (RN) scheduled eight consecutive hours a day. This deficiency represents noncompliance identified during the investigation of Complaint Number OH00151741.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation, the facility failed to ensure the resident's bathroom were safe, functional, sanitary, and comfortable environment for residents, staff and the public. This had the potential to affect eight residents (Resident #3, Resident #8, Resident #13, Resident #17, Resident #21, Resident #24, Resident #30, and Resident #34) out of eight residents reviewed. The facility census was 36. Findings include: Walking tour of the facility on 11/09/22 from 11:30 P.M. to 1:00 P.M. with Maintenance Director (MD) #142 and Housekeeping Supervisor #144 revealed the following concerns: 1. The radiator in the bathroom of Resident #24 revealed a sharp metal piece of the radiator cover hanging on the floor creating a potential tripping hazard. The metal bracket was laying on the floor in the entrance to the bathroom. 2. The radiator cover in the bathroom of Resident #13's bathroom revealed a sharp piece of metal sticking out laying on the floor. 3. Resident #17's bathroom had stains of dried stool on the toilet seat, 4. Resident #34's bathroom had dried stool stains on the toilet sit and down the outsides of the toilet. 5. The wall in the hallway across from room [ROOM NUMBER] revealed a radiator unit with no radiator cover. Sharp metal wall brackets were exposed and were close to residents when walking. 6. room [ROOM NUMBER], recently vacated, revealed the bathroom had dark brown stains on the grout in the shower. The tile behind the toilet had brownish black stains and the corner of the bathroom floor had dirt and debris. 7. Resident #21's bathroom had a smell of urine; the floor was sticky, and the bathroom tiles had brownish/black stains. 8. Resident #3's bathroom floor had black stains around the toilet. 9. The SR's bathroom had dark brown stain on the floor next to the baseboard near the left wall. The floor below radiator had brown stains on tile and the grout was a dark gray color. Interview with the MD and the Housekeeping supervisor on 11/09/22 at 1:20 P.M. verified the above findings. Per the MD, he stated they would get right on these rooms and get them cleaned. This deficiency represents non-compliance investigated under complaint OH00137186.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the facility failed to implement their abuse policy to report and thoroughly investigate allegations of abuse involving Resident #1, #16, and #35. This affected three of four residents reviewed for abuse. Facility census was 40. Findings include: 1. Review of the medical record reveal Resident #16 was admitted on [DATE] with diagnoses of unspecified dementia without behavioral disturbance, dementia, and Alzheimer's disease. Review of Resident #16's admission record revealed the diagnosis of other sexual disorders was added on 08/30/21. Review of the plan of care last revised on 02/17/22 revealed Resident #16 was intrusive and wandered into other resident rooms, had a history of inappropriately touching female peers, and was not being easily redirectable. The diagnosis of unspecified dementia with behavioral disturbance was added for Resident #16 on 03/01/22. Review of a nursing progress note dated 04/22/22 at 12:30 P.M. revealed Resident #16 grabbed a female resident's breasts while in the dining room. This resident was later identified as Resident #1. Review of the medical record for Resident #1 revealed she was admitted on [DATE] with diagnosis of Parkinson's disease, dementia without behavioral disturbance, hypertensive heart disease, functional quadriplegia, and major depressive disorder. Review of nursing progress notes and assessment for Resident #1 revealed no information regarding any alleged abuse on 04/22/22. Interview on 04/27/22 at 2:30 P.M. with the Administrator revealed she was unaware of any allegation of abuse involving Resident #16's towards Resident #1. The Administrator verified their abuse policy directed all staff to report all allegations of abuse immediately for investigation. Interview on 04/27/22 at 4:42 P.M. with Licensed Practical Nurse (LPN) #512 revealed she was at nurses' station when State Tested Nursing Assistant (STNA) #546 told her she needed to chart in the medical record that Resident #16 grabbed Resident #1's breast. LPN #512 stated she assessed Resident #1 and charted in Resident #16's chart about the behavior. LPN #512 verified she did not report this allegation of abuse to any management staff. Interview on 04/28/22 at 2:26 P.M. with Resident #1 revealed she felt safe in the facility. Interview on 04/28/22 at 2:29 PM with STNA #546 indicated on 04/22/22 when she returned from lunch, she was told by Activities Aid #574 that Resident # 16 was trying to grab Resident #1. STNA #546 said she reported the incident to LPN #512 per the facility's abuse policy. Interview on 04/28/22 at 2:37 P.M. with Activity Aide #574 revealed she and Resident #1 were at table for an activity when Resident #16 reached down inside Resident #1's shirt. Activity Aid #574 told Resident #16, No, we do not do that, and he moved his hand away. Activity Aide #574 stated Resident #1 also told Resident #16 to stop. Review of the facility Abuse Investigation and Reporting Policy, last revised 12/2017, revealed all alleged violations of abuse would be reported immediately, but no later than two hours of the alleged abuse, and thoroughly investigated. 2. Review of medical record for Resident #35 revealed she was admitted on [DATE] with diagnoses including cerebral palsy and anxiety disorder. Review of progress notes dated 04/14/22 through 04/16/22 revealed no entries for any alleged abuse. Interview with Resident #35 on 04/25/22 at 9:36 A.M. revealed she was afraid of Resident #16 because he had touched her before. Review of the facility investigation dated 04/14/22 at 1:30 P.M. revealed Resident #16 was observed in the dining room by an STNA, rubbing Resident #35's thigh area on top of the blanket on her lap. Resident #35 was smiling and talking. The STNA intervened and removed Resident #16. Resident #35 verified Resident #35 had touched her leg, denied feeling unsafe and said that it didn't mean anything. Review of the medical record reveal Resident #16 was admitted on [DATE] with diagnoses of unspecified dementia without behavioral disturbance, dementia, and Alzheimer's disease. Review of Resident #16's admission record revealed the diagnosis of other sexual disorders was added on 08/30/21. Review of the plan of care last revised on 02/17/22 revealed Resident #16 was intrusive and wandered into other resident rooms, had a history of inappropriately touching female peers, and was not being easily redirectable. The diagnosis of unspecified dementia with behavioral disturbance was added for Resident #16 on 03/01/22. Observation on 04/28/22 at 2:22 P.M. revealed Resident #35 wheeling herself around unit interacting with staff and other residents without any signs of distress. Interview on 04/27/22 at 2:30 P.M. with the Administrator verified she was unaware of this alleged allegation of abuse and verified she did not complete this investigation. The investigation was completed by the director of nursing according to the signature. Their investigation only included an interview of Resident #35, Resident #16 and the STNA who observed the interaction. The Administrator verified they did not follow their abuse policy and procedure to complete a thorough investigation to include interviews with other residents, other staff working at the time of the incident and with resident physicians. The facility Abuse Investigation and Reporting Policy of Abuse, last revised 12/2017, directed them to complete a thorough investigation which included interviews with any witnesses, family, visitors, the attending physician, staff on all shifts who had contact with residents at the time of the alleged incident, and other residents who may have been affected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to promptly report allegations of abuse involving Resident #1 and Resident #16 to the administrator and State Agency as required. This affected two of four residents reviewed for abuse. The facility census was 40. Findings include: Review of the medical record reveal Resident #16 was admitted on [DATE] with diagnoses of unspecified dementia without behavioral disturbance, dementia, and Alzheimer's disease. Review of Resident #16's admission record revealed the diagnosis of other sexual disorders was added on 08/30/21. Review of the plan of care last revised on 02/17/22 revealed Resident #16 was intrusive and wandered into other resident rooms, had a history of inappropriately touching female peers, and was not being easily redirectable. The diagnosis of unspecified dementia with behavioral disturbance was added on 03/01/22. Review of a nursing progress note dated 04/22/22 at 12:30 P.M. revealed Resident #16 grabbed a female resident's breasts while in the dining room. This resident was later identified as Resident #1. Review of the medical record for Resident #1 revealed she was admitted on [DATE] with diagnosis of Parkinson's disease, dementia without behavioral disturbance, hypertensive heart disease, functional quadriplegia, and major depressive disorder. Review of nursing progress notes and assessment for Resident #1 revealed no information regarding any alleged abuse on 04/22/22. Interview on 04/27/22 at 2:30 P.M. with the Administrator revealed she was unaware of any allegation of abuse involving Resident #16's towards Resident #1. The Administrator verified their abuse policy directed all staff to report all allegations of abuse immediately. Interview on 04/27/22 at 4:42 P.M. with Licensed Practical Nurse (LPN) #512 revealed she was at nurses' station when State Tested Nursing Assistant (STNA) #546 told her she needed to chart in the medical record that Resident #16 grabbed Resident #1's breast. LPN #512 stated she assessed Resident #1 and charted in Resident #16's chart about the behavior. LPN #512 verified she did not report this allegation of abuse to any management staff. Interview on 04/28/22 at 2:26 P.M. with Resident #1 revealed she felt safe in the facility. Interview on 04/28/22 at 2:29 PM with STNA #546 indicated on 04/22/22 when she returned from lunch, she was told by Activities Aid #574 that Resident # 16 was trying to grab Resident #1. STNA #546 said she reported the incident to LPN #512 per the facility's abuse policy. Interview on 04/28/22 at 2:37 P.M. with Activity Aide #574 revealed she and Resident #1 were at table for an activity when Resident #16 reached down inside Resident #1's shirt. Activity Aid #574 told Resident #16, No, we do not do that, and he moved his hand away. Activity Aide #574 stated Resident #1 also told Resident #16 to stop. Review of the facility Abuse Investigation and Reporting Policy, last revised 12/2017, revealed all alleged violations of abuse would be reported immediately, but no later than two hours of the alleged abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of facility policy, the facility failed to thoroughly investigate an allegation of abuse involving Resident #16 and #35. This affected two out of four residents reviewed for abuse. Facility census was 40. Findings include: Review of medical record for Resident #35 revealed she was admitted on [DATE] with diagnosis of cerebral palsy, and anxiety disorder. Interview on 04/26/22 with Resident #35 at 9:36 A.M. revealed she was afraid of Resident #16. Resident #35 said Resident #16 had touched her but never hurt her and she did not want to be touched. She said staff redirect him to his room. Review of the medical record reveal Resident #16 was admitted on [DATE] with diagnoses of unspecified dementia without behavioral disturbance, dementia, and Alzheimer's disease. Review of Resident #16's admission record revealed the diagnosis of other sexual disorders was added on 08/30/21. Review of the plan of care plan last revised 02/17/22 revealed Resident #16 had an increase in advances towards women, was intrusive and wandered into other resident rooms, had a history of inappropriately touching female peers, and was not being easily redirectable. He would attempt to kiss, hold hands or put his hands on female peers legs while in the dining room. The diagnosis of unspecified dementia with behavioral disturbance was added on 03/01/22. Review of the facility investigation dated 04/14/22 at 1:30 P.M. revealed Resident #16 was observed touching Resident #35 on her thigh on top of the blanket on her lap. There was documentation of one interview with the state tested nursing assistant and Resident #35. No other staff or residents were listed as interviewed regarding this abuse allegation and it was not thoroughly investigated. Interview with the Administrator on 04/26/22 at 2:30 P.M. revealed a thorough investigation was not included in the file presented to the surveyor. The Administrator stated she normally completes/investigates allegations of abuse but she did not complete this investigation. The Administrator verified there was no evidence the resident's physician was interviewed, no interviews with staff from all shifts who had contact with resident during period of alleged allegation, any other potential witnesses/visitors and other residents to see if any other residents had experience similar incidents. Review of the facility policy, Abuse Investigating and Reporting, last revised 12/2017 revealed each allegation of abuse would be thoroughly investigated and would include interviews with involved parties, the physician of the residents, all staff on all shifts with contact with the resident during the time period of the allegation, all witnesses, resident roommates, family and visitors and other residents who may also be affected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to properly transcribe and obtain physician orders for necessary care/treatment for collection of a stool sample for Resident #8 and for a skin tear for Resident #33. This affected two out of 16 resident records reviewed for care and treatment. Facility census was 40. Findings include: 1. Review of medical record revealed Resident #8 was admitted on [DATE] with diagnoses which included chronic obstructive pulmonary (lung) disease with hypoxia (low oxygen levels), gastroparesis, diarrhea, and irritable bowel syndrome. Review of a nursing progess note dated 04/04/22 at 6:10 P.M. revealed a physician order was received for Resident #8 to have a stool sample collected and checked for clostridioides difficile (bacterium that causes severe diarrhea and inflammation of the colon). Review of the physician handwritten order dated 04/04/22 revealed Resident #8 was to be checked for clostridioides difficile due to having loose stools. Review of the medical record revealed there was no evidence a stool sample was collected for Resident #8. The nursing progress notes from 04/05/22 to 04/22/22 revealed Resident #8 had loose stools daily. Interview on 04/28/22 at 2:56 P.M. with Licensed Practical Nurse (LPN) #512 verified Resident #8 had loose stools daily and the physician ordered stool sample had not been collected. Interview on 04/28/22 at 4:33 P.M. with the Director of Nursing verified there was no evidence a stool sample had been collected and there were no laboratory results for a stool sample for Resident #8. 2. Review of medical record revealed Resident #33 was admitted on [DATE] with diagnoses which included fracture of left pubis, Alzheimer's disease, dementia, and acute kidney failure. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #33 was cognitively impaired and required extensive staff assistance with one staff for bed mobility, transfers, and toilet use. Review of the nursing progress note dated 04/13/22 at 2:56 P.M. revealed Resident #33 reported she had fallen while trying to use the bathroom. The nurse had been in the resident's room two minutes prior and the resident was sitting in her wheelchair. The nurse examined Resident #33 and found a skin tear to her right wrist which measured 1.125 centimeters (cm) long and 0.75 cm wide. A dry sterile dressing was applied. The note indicated that due to Resident #33's mental status and functional ability, it was likely Resident #33 attempted to use the bathroom unassisted and fell back into the chair which caused the skin tear. Review of the facility's non-pressure related skin issues log dated 04/13/22 revealed Resident #33 had a skin tear to her right wrist. Review of the weekly non-pressure wound tracking dated 04/20/22 revealed Resident #33 had a skin tear to her right wrist which measured two cm long and 0.2 cm wide. Observations on 04/25/22 at 8:40 P.M. and 04/26/22 at 9:33 A.M. revealed Resident #33 had a dressing to her right wrist dated 04/20/22. Interview on 04/26/22 at 9:47 A.M. with LPN #519 verified Resident #33 had a dressing to her right wrist dated 04/20/22. Dark drainage could be seen coming through the dressing. LPN #519 verified she did not see a physician order for the dressing to be changed but would change the dressing at that time. Interview on 04/27/22 at 2:59 P.M. with the Director of Nursing verified there were no physician orders or treatments in place since the day Resident #33 obtained the skin tear on 04/13/22 to aid in healing and for nursing staff to routinely monitor the skin condition until healed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was changed weekly for Resident #8 and #26. This affected two (Residents #8 and #26) out of nine residents sampled with oxygen. The facility census was 40. Findings include: 1. Review of the medical record revealed Resident #8 was admitted on [DATE] with diagnoses which included chronic obstructive pulmonary (lung) disease, chronic respiratory failure with hypoxia (low oxygen levels), and anxiety. Review of the plan of care dated 12/03/20 revealed Resident #8 was at risk for ineffective airway clearance and breathing patterns. Interventions included provision of oxygen via nasal cannula two-to-five liters as needed for shortness of breath or comfort. Observation on 04/26/22 at 11:19 A.M. and 04/27/22 at 9:43 A.M. revealed Resident #8 had a nasal cannula in place and was using oxygen. There was no date noted on the oxygen tubing to indicate how long this nasal cannula/oxygen tubing had been un use. Interview on 04/27/22 at 9:43 A.M. with Registered Nurse (RN) #504 verified there was not a date on Resident #8's oxygen tubing. RN #504 could not verify when the oxygen tubing had last been changed. Review of the Departmental (Respiratory Therapy)-Prevention of Infection policy, revised December 2017, revealed oxygen cannula and tubing was to be changed every seven days or as needed. 2. Review of medical record revealed Resident #26 was admitted on [DATE] with diagnoses which included rheumatoid arthritis and Felty's Syndrome (a rare disorder associated with rheumatoid arthritis resulting in an enlarged spleen and a very low white blood cell count which increases their susceptibility to infections). Review of the medical record revealed Resident #26 received hospice services and no order was found for the use of oxygen. Observation on 04/26/22 at 9:39 A.M. and 04/27/22 at 9:43 A.M. revealed Resident #26 had a nasal cannula in place and was using oxygen. There was no date noted on the oxygen tubing to indicate how long this nasal cannula/oxygen tubing had been in use. Interview on 04/27/22 at 9:43 A.M. with RN #504 verified there was not a date on Resident #26's oxygen tubing. RN #504 could not verify when the oxygen tubing had last been changed. Review of the Departmental (Respiratory Therapy)-Prevention of Infection policy, revised December 2017, revealed oxygen cannula and tubing was to be changed every seven days or as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #33 and #37 had appropriate diagnoses for the use of antipsychotic medication. This affected two (Resident #33 and #37) out of five residents reviewed for unnecessary medications. The facility census was 40. Findings include: 1. Review of the medical record revealed Resident #33 was admitted on [DATE] with diagnoses which included fracture of left pubis, Alzheimer's disease, dementia, and brief psychotic disorder. Review of the plan of care dated 02/16/22 revealed Resident #33 exhibited behavioral symptoms of inappropriate behaviors, hallucinations, delusions, and was wandering/exit seeking. Interventions included for staff to medicate per physician orders and to monitor mood/behavior/affect with all hands-on care/interactions. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 had cognitive impairment. Review of the March 2022 pharmacy recommendation revealed Resident #33 received Seroquel (an antipsychotic medication) for psychosis, however psychosis was not listed as a diagnosis. Review of Resident #33's physician orders and medication administration records (MARs) revealed dementia was the diagnosis given for the use of Seroquel. A handwritten note authored by the certified nurse practitioner (no date) directed the staff at the facility to add a diagnosis of brief psychotic disorder, but it was unclear when this note was written. Interview on 04/28/22 at 3:23 P.M. with the Director of Nursing (DON) verified dementia was not an appropriate diagnosis for the use of the antipsychotic medication Seroquel. 2. Review of medical record for Resident #37 revealed an admission date of 10/22/21 with diagnoses which included dementia and major depressive disorder. Review of the plan of care revised on 03/29/22 revealed Resident #37 demonstrated signs and symptoms consistent with depression such as being withdrawn and reluctant to participate in therapy and activities. Interventions included for staff to administer medications as ordered and monitor mood, affect and behaviors with all hands-on care and contacts. Review of the pharmacy recommendation dated March 2022 revealed the diagnosis for behaviors needed to be verified for Resident #37's use of Zyprexa (an antipsychotic medication). Review of Resident #37's March 2022 MAR revealed the diagnosis given for the use of the Zyprexa was dementia with behavioral disturbances. A handwritten note by the certified nurse practitioner (no date) revealed the diagnosis for the use of the Zyprexa was dementia with behavioral disturbances, but it was unclear when this note was written. Interview on 04/28/22 at 3:24 P.M. with the DON verified dementia was not an appropriate diagnoses for the use of the antipsychotic medication Zyprexa. The DON also verified there was no documentation of Resident #37 having behaviors that would require the use of antipsychotic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, Resident Assessment Instrument (RAI) manual review, form review, and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessments for five residents (Residents #5, #11, #14, #15, and #24) out of 13 residents reviewed for assessments. Findings include: 1. Resident #5 was initially admitted to the facility on [DATE] with diagnoses including bipolar disorder, major depressive disorder, dementia with behavioral disturbance, and epilepsy. Review of Resident #5's May 2019 physician orders included an order for padded half side rails secondary to a history of seizures. Review of Resident #5's admission MDS assessment, with an Assessment Reference Date (ARD) of 01/02/19, revealed Resident #5 utilized side rails as a physical restraint daily. Review of Resident #5's quarterly MDS assessment, with an ARD of 02/18/19, revealed Resident #5 had intact cognition and required staff supervision with bed mobility. The 02/18/19 quarterly MDS also indicated Resident #5 utilized side rails as a physical restraint daily. Resident #5's medical record revealed two restraint assessments, dated 01/04/19 and 02/19/19. Both assessments stated Resident #5 used half side rails for turning, positioning, and bed mobility. The side rails were padded for seizure precautions and Resident #5 was able to make his needs known. The assessments concluded the side rails were not considered a restraint for Resident #5 and indicated no restraints were in place. Review of the RAI manual defined a physical restraint as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Interview with Licensed Practical Nurse (LPN) #500 on 05/16/19 at 9:01 A.M. verified the RAI definition of a physical restraint and verified the side rails used for Resident #5 were for positioning and were not a restraint. LPN #500 stated they were trained to mark all side rails as physical restraints. 2. Resident #15 was initially admitted to the facility on [DATE] with diagnoses including major depressive disorder, psychosis, chronic viral hepatitis c, and cerebral infarction (stroke). Review of Resident #15's May 2019 physician orders included an order for half side rails on both sides of the bed for bed mobility. Review of the MDS assessments dated 04/25/18, 07/24/18, 10/19/18, 01/16/19, 02/13/19, and 04/04/19 revealed Resident #15 utilized side rails as a physical restraint daily. The MDS assessment from 04/04/19 revealed Resident #15 had intact cognition and required extensive assist of one person with bed mobility. Resident #15's medical record revealed five restraint assessments since the last annual survey, dated 04/27/18, 07/27/18, 10/26/18, 01/17/19, 02/15/19 and 04/05/19. All five assessments stated Resident #15 used half side rails for bed mobility. Resident #15 was able to make his needs known and the assessments concluded the side rails were not considered a restraint for Resident #15 and no restraints were in place. Review of the RAI manual defined a physical restraint as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Staff interview with LPN #500 on 05/16/19 at 9:01 A.M. verified the RAI definition of a physical restraint and verified the side rails used for Resident #15 were for positioning. LPN #500 stated they were trained that all side rails had to be marked as physical restraints. 3. Record review revealed Resident #11 was admitted to the facility 07/10/06 with diagnoses including cerebral infarct (stroke), hemiplegia (paralysis on one side of the body), abnormality of gait and mobility, chronic heart failure, depression and anxiety disorder. Review of a physician order dated 04/09/19 revealed Resident #11 was to have one half side rail for safety to both sides of the bed to enable bed mobility. Review of the facility Restraint Assessments dated 02/15/19, 03/29/19 and 04/08/19 revealed the resident used half side rails for bed mobility which did not limit her movement and were not considered a restraint. Review of the MDS assessment dated [DATE] revealed the facility coded Resident #11 as having a restraint in use, which was the daily use of side rails. Observations conducted on 05/13/19 10:40 A.M. revealed Resident #11 up in her room and she was self propelling about the room in her wheelchair. The half side rails were in the down position on her bed. Interview with Resident #11 at the time of the observation revealed staff raise the side rails when she is in bed to help her move and turn. Resident #11 stated she could move freely with the rails raised. During an interview on 05/16/19 at 9:01 A.M. with LPN #500, she stated she was trained to code all side rails on the MDS as restraints. LPN #500 confirmed Resident #11 had side rails used for bed mobility and verified they did not restrict her movement and were not restraints. LPN #500 confirmed the 03/27/19 MDS assessment was inaccurate related to restraints for Resident #11. 4. Record review revealed Resident #14 was admitted to the facility 01/14/13 with diagnoses that included epilepsy, chronic heart failure, dementia without behaviors, delusional disorder, muscle wasting and atrophy. The record indicated Resident #14 received hospice services as of 03/26/19. Review of a physician order dated 01/21/19 revealed half side rails for safety were ordered to both sides of the bed to enable bed mobility. This order was updated 04/12/19 for these side rails to be padded for safety for seizure precautions. Review of a significant change MDS assessment dated [DATE] revealed Resident #14 was dependent on staff for bed mobility and revealed the resident side rails on the bed daily and were a restraint. Review of the Restraint Assessments dated 02/14/19 and 04/05/19 revealed the resident had half side rails for bed mobility, turning, and positioning and were not a restraint. During an interview on 05/16/19 at 9:01 A.M., LPN #500 the nurse stated she was trained that all side rails should be coded on the MDS as restraints. LPN #500 confirmed Resident #14 had side rails for bed mobility which did not restrict the resident's movements and were not restraints. LPN #500 confirmed the 04/01/19 MDS assessment was inaccurate related to restraints for Resident #14. 5. Resident #24 was admitted to the facility 12/20/18 with diagnoses that included dementia with behavioral disturbance, schizoaffective disorder, Alzheimer's disease, congestive heart failure, major depressive disorder, restlessness and agitation. Review of the MDS assessment dated [DATE] revealed the resident side rails daily and were listed as a restraint. There was a physician's order dated 03/30/19 for half side rails for bed mobility. Review of Restraint Assessments dated 01/21/19 and 04/19/19 revealed Resident #24 used half side rails for bed mobility, turning, and repositioning, and he was able to make his needs known. These assessments indicated the side rails were not a restraint. Observation on 05/14/19 at 10:54 A.M. revealed Resident #24 walked across the room from the bathroom and used the half side rail for support as he seated himself on the side of the bed. On 05/16/19 at 9:01 A.M., LPN #500 indicated she was trained that all side rails should be coded on the MDS as restraints. LPN #500 confirmed Resident #24 had side rails for bed mobility that did not restrict the resident's movements and were not restraints. LPN #500 confirmed the 04/18/19 MDS assessment was inaccurate related to restraints for Resident #24.

Based on record review and interview the facility failed to ensure a registered nurse was scheduled at least eight consecutive hours every day as required. This had the potential to affect all 32 residents residing in the facility. Findings include: Review of the posted staffing hours for May 2019 revealed the facility had a registered nurse (RN) in the building for five hours on 05/05/19 and for four hours on 05/11/19 and 05/12/19. During an interview with the Administrator on 05/15/19 at 8:20 A.M., the staffing hours for 2019 were reviewed. The Administrator verified they were aware of the requirement for an RN to be working in the facility each day for at least eight consecutive hours. The Administrator said they had an open RN position and were working to hire new RN staff. The Administrator said the director of nursing was working part of each weekend in addition to weekdays to provide an RN in the building each day. The Administrator confirmed the facility had been unable to provide an RN for eight consecutive hours on 05/05/19, 05/11/19 and 05/12/19 as required.