**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure blood glucose testing (BGT) was completed per the physician's order. This finding affected one (Resident #150) of three residents reviewed for BGT. The facility census was 140. Findings include: Review of Resident #150's medical record revealed the resident was admitted on [DATE] with diagnoses including encephalopathy, type two diabetes, and dementia. Resident #150 was discharged on 03/27/25. Review of Resident #150's physician orders revealed an order dated 03/11/25 (discontinued 03/22/25) for a general diet, soft and bite sized texture, thin liquid consistency; and an order dated 03/23/25 for a consistent carbohydrate diet, regular texture, thin liquid consistency (CCD). Review of Resident #150's physician orders revealed an order dated 03/11/25 (discontinued 03/15/25) for sliding scale insulin coverage. The order listed Humalog (fast acting insulin) and provided the following additional parameters: if the blood sugar was zero to 180 inject no insulin; 181 to 200 inject two units; 201 to 250 inject four units; 251 to 300 inject six units; 301 to 350 inject eight units; 351 to 400 inject 10 units; and call provider above 400 before meals and at bedtime. Review of Resident #150's progress note dated 03/14/25 at 12:36 P.M. revealed the power-of-attorney (POA) contacted the facility with concerns/requests. The POA was concerned that staff were waking the resident up during the night for care and medications. The resident requested medication administration times be changed to during the day while the resident was awake. The Nurse Practitioner (NP) was updated and agreeable with the time change. The POA also requested the resident should not be woken up for check and changes during the night as well as not be woken up for breakfast. Per the POA, the family was always in the building around breakfast time and would help the resident with meals if needed. The POA requested for the door to the room to be shut half way due to the light in the hallway. Review of Resident #150's physician orders revealed an order dated 03/15/25 (discontinued 03/21/25) for sliding scale insulin coverage. The order listed Humalog and provided the following additional parameters per sliding scale: if the blood sugar was zero to 180 inject no insulin; 181 to 200 inject two units; 201 to 250 inject four units; 251 to 300 inject six units; 301 to 350 inject eight units, 351 to 400 inject ten units and call provider if above 400 before meals and at bedtime. Review of Resident #150's Medication Administration Record (MAR) for March 2025 revealed the resident's blood sugar level was obtained on 03/17/25 at 9:06 A.M. with a result of 177. The Documentation Survey Report form revealed on 03/17/25 at 8:00 A.M. the resident consumed 75% to 100% of the breakfast meal. The BGT was obtained after the breakfast meal was completed. Review of Resident #150's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #150's physician orders revealed an order dated 03/21/25 (discontinued 03/25/25) for sliding scale insulin coverage. The order listed Humalog and provided the following additional parameters per sliding scale: zero to 180 no insulin; 181 to 200 inject two units; 201 to 250 inject four units; 251 to 300 inject six units; 301 to 350 inject eight units; 351 to 400 inject 10 units; and above four units call the provider two times a day before meals for morning and evening meals. Review of Resident #150's MAR for March 2025 revealed the blood sugar was completed on 03/21/25 at 10:10 A.M. with a result of 174. The Documentation Survey Report form dated 03/21/25 at 9:04 A.M. revealed the resident consumed 75% to 100% of the breakfast meal. The BGT was obtained after the breakfast meal was completed. Telephone interview on 07/02/25 at 1:53 P.M. with Licensed Practical Nurse (LPN) #828 confirmed the staff placed Resident #150's tray on her overbed table for the breakfast meal but did not wake the resident up. LPN #828 revealed she probably completed the BGT after the breakfast meal on 03/21/25 because the resident either woke up early or the resident's family woke up the resident and the resident started eating the breakfast meal and the staff did not realize it. LPN #828 confirmed she completed the BGT as soon as she realized the resident was eating the breakfast meal. Interview on 07/02/25 at 1:58 P.M. with the Director of Nursing (DON) confirmed staff completed Resident #150's BGTs on 03/17/25 and 03/21/25 after the breakfast meals were completed. Review of the Medication Administration policy dated 06/01/23 revealed medications were administered only by licensed nursing, medical, pharmacy or other personnel authored by state laws and regulations to administer medications. Medications were administered in accordance with written orders of the prescriber. This deficiency represents non-compliance investigated under Complaint Number OH00164078.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a complete and accurate medical record for Resident #9. This affected one of twenty six sampled residents for medical record accuracy. Findings Include: Resident #9 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, heart failure and Parkinson's disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 was severely cognitive impaired and required hands on assistance of one staff person for completing activities of daily living such as toileting, transfers and bed mobility. The assessment further noted that Resident #9 required supervision for eating activities. Review of the most recent dietary notes dated 12/04/24 and 11/22/24 revealed concerns related to accuracy of weights related to a hospitalization and concerns related to variations of weights due to diuretic medications (medications that increase urination and can cause significant unintended weight loss quickly). No other dietary notations, assessments or other items were noted in Resident #9's medical for record for November and December 2024. Review of the census records for November 2024 and December 2024 revealed Resident #9 remained in the facility and was not sent to a hospital or any other acute care facility for any length of time. Interview with Dietary Technician (DT) #803 on 12/12/24 at 11:00 A.M. revealed (upon inquiry by the surveyor) DT #803 realized he had mixed up residents and had documented wrong resident's nutritional record into the medical of Resident #9. DT #803 was unsure what resident he documented the wrong information from.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure food was served and stored in a clean and sanitary manner. This had the potential to affect all 142 residents in the facility that consumed food from the kitchen. Findings Include: Observation of the kitchen area with Assistant Dietary Manager (ADM) #522 on 12/09/24 between 8:45 A.M. and 9:15 A.M. revealed the following that was observed and verified the time of discovery: 1. In the dry storage area an open packed of white rice with no date, an open bag of dinner rolls with no date, an open box of stuffing with no date, two containers of granulated sugar that were open with no date, an open box of bread crumbs with no date, and an open box of yellow cake with no date. 2. In the walk-in refrigerator two bags of open salad mix that were not sealed, an open package of pepperoni with no date, an open package of cheddar cheese with no date, an open package of tater tots with no date, and an open package of catfish with no date. 3. The fryer was noted to be extremely dirty with brown oil indicating the oil had gone bad and was not suitable for cooking food. ADM # 522 was stated I wouldn't eat out of that. Review of the undated dietary close down checklist posted on the dietary information board revealed before kitchen staff end their shift they are to ensure All items labeled & Dated-any items not labeled with date or name is to be discarded. Review of the undated procedure for dating food items posted on the outside of the [NAME] refrigerator and freezer All Opened Items Need To Be Put Into A Clear Bag Tied Off Or Container With A Lid. Placed A Label On Each Item Write The Items Name, Date It Was Opened and Expiration Date. This Must Be Followed For All Items.

Based on observations, interview, review of facility menu and review of staff training, the facility failed to follow menus in regard to portion sizes and recipes in regard to food preparation. This affected 29 (#78, #80, #81, #82, #83, #86, #87, #88, #89, #91, #93, #96, #100, #101, #103, #104 #107, #108, #112, #113, #114, #115, #116, #118, #122, #123, #124, #125, and Resident #126) of 49 residents residing on the east wing of the third floor. Findings include: Review of the menu for the current week revealed lunch on 10/23/24 was chicken dumpling soup, country fried chicken with gravy, roasted potatoes and carrots, pudding, and milk. The portion size of the chicken dumpling soup indicated an eight ounce serving and to use an orange-colored scoop. Observations of meal service on the third floor servery on 10/23/24 at 12:15 P.M. revealed staff were plating country fried steak without the gravy. During the observation Dietary Director (DD) #201 asked the staff why are you not putting gravy on the steak? Dietary Aide (DA) #202 stated the gravy is not on the meal ticket so I wasn't sure if I should put it on the steak. DD #201 stated you guys are killing me! DA #202 then stated, I don't have anything to serve the gravy with. DD #201 then directed DA #202 to use the scoop with the holes it, it should be able to keep enough gravy to cover the steak. DA #202 followed the direction provided; however, the gravy, which was watery (like an au jus), ran through the holes and did not cover the fried steak. DA #202 and DD #201 verified using the scoop with holes was not effective. Continued observations at approximately 12:17 P.M. revealed DA #203 ladling soup into small bowels using a green scoop which provided 4.5 ounces. Most of the bowels were observed to have mainly broth and little to no chicken, dumplings or vegetables. When questioned, DA #203 said I am using the correct scoop, if I fill the bowl with more chicken, dumplings and vegetables, we will run out of soup quickly. DD #201 verified the wrong scoop size was being used to portion the soup for the meal. Review of the recipe for the brown gravy revealed staff were to brown flour into shortening, add water or stock gradually, stirring constantly with a wire whip: cook until smooth and thickened. Interview on 10/23/24 at 2:14 P.M., [NAME] #200 revealed no flour was available so corn starch was used to thicken the gravy. [NAME] #200 stated I can't make it the right way if I don't have the stuff. Review of staff training dated 10/16/24 revealed [NAME] #200, DA#202 and DA #203 received education including kitchen sanitation, proper food storage, tray prep/meal prep, and proper food temperature maintenance and serving. Review of the facility census dated 10/23/24 revealed Residents #78, #80, #81, #82, #83, #86, #87, #88, #89, #91, #93, #96, #100, #101, #103, #104 #107, #108, #112, #113, #114, #115, #116, #118, #122, #123, #124, #125, and Resident #126) resided on the east wing of the third floor. This deficiency represents non-compliance investigated under Complaint Number OH00158730 and OH00157687.

Based on observations, resident interviews, staff interviews, review of facility menus, review of staff trainings, and review of policies and procedures, the facility failed to maintain appropriate and appetizing food temperatures. This had the potential to affect 29 (Resident #78, #80, #81, #82, #83, #86, #87, #88, #89, #91, #93, #96, #100, #101, #103, #104 #107, #108, #112, #113, #114, #115, #116, #118, #122, #123, #124, #125, and Resident #126) of 49 residents residing on the east wing of the third floor. Findings include: Interview on 10/23/24 at 8:37 A.M. with Resident #74 revealed foods that were supposed by hot were served warm. Interview on 10/23/24 at 8:53 A.M. with Resident #89 revealed the food was not hot. Observations of food preparation in the third floor servery on 10/23/24 at 12:22 P.M. revealed country fried steak and roasted potatoes with carrots being plated for meal delivery. After the foods were placed on a plate, a cover was placed on the plate and the plate placed on tray. Interview with Dietary Aide (DA) #202, at the time of the observation, revealed the facility stopped placing the plated meals on heating pallets. A test tray was requested. The test tray arrived onto the third floor east unit at 12:28 P.M. and was sampled at 12:39 P.M. with Wound Nurse #204. The country fried steak was salty, lukewarm and dry to taste and the potatoes and carrots were cool to taste. The temperature of the steak was 98 degrees Fahrenheit (F), and the carrots and potatoes were 78 degrees F. At the time of the test tray, Wound Nurse #204 confirmed the above findings. Interview on 10/23/24 at 1:00 P.M., with Dietary Director (DD) #201 revealed he had been working at the facility for approximately eight months. During those eight months DD #201 terminated half of the kitchen staff due to work performance. DD #201 stated he had been hiring and training staff on all aspects of kitchen procedures including storing and prepping food and infection control practices. DD #201 further revealed the kitchen staff were not conducting a tray line that was effective in keeping food warm. New procedures included taking the food to the serveries on each floor to plate, and once plated the food was covered a lid. DD #201 confirmed since the serving procedures changed, staff no longer used warming pallets. Review of staff training dated 10/16/24 revealed [NAME] #200, DA #202 and DA #203 received education including tray prep/meal prep, proper food temperature maintenance and serving. The trainings revealed the staff had either passed their orientation or demonstrated competency. Review of the facility's undated policy Guidelines for Holding Food, revealed food should be held at 135 degrees F or higher. Review of the facility's undated policy Serving Food Safely, revealed staff should follow the guidelines to maintain food at a safe temperature of 140 degrees F or above. It also indicated to remember the temperature rules to keep food hot (140 degrees F or above) with warming trays. Review of the facility census dated 10/23/24 revealed Residents #78, #80, #81, #82, #83, #86, #87, #88, #89, #91, #93, #96, #100, #101, #103, #104 #107, #108, #112, #113, #114, #115, #116, #118, #122, #123, #124, #125, and Resident #126) resided on the east wing of the third floor. This deficiency represents non-compliance investigated under Complaint Number OH00158730 and OH00157687.

Based on observations, interviews, staff training, and policy review, the facility failed to maintain a sanitary kitchen and failed to ensure food and liquids were stored in accordance with professional standards for food safety. This had the potential to affect all 142 residents residing in the facility and receiving food from the facility's main kitchen. Findings include: 1. Observations of the kitchen on 10/23/24 at 11:30 A.M. revealed wet and dry food debris that covered the floor of the entire kitchen. The garbage receptacle had a lid that split in the middle to allow trash to enter the can, the lid had a heavy layer of dry food debris covering the lid. The reach in refrigerator had dried food and liquid debris on the shelving. The dispensing spouts for the coffee maker had caked on dry liquid. A five-gallon bucket, which was located on the dirty side of the kitchen near the dishwasher, had broken porcelain plates and other miscellaneous items in it and it was filled with fruit flies. The observations of the kitchen were verified with Dietary Director (DD) #201. DD #201 then directed kitchen staff to start cleaning the floor. 2. Observations of the kitchen refrigerator on 10/23/24 at 11:50 A.M. with Dietary Aide (DA) #202 revealed an undated container with a small number of strawberries and grapes located at the back of the refrigerator. Interview on 10/23/24 at 11:50 A.M. with DA #202, revealed the container of strawberries and grapes were from last week and outwardly questioned why no one took it out of the refrigerator. 3. Observations of the kitchen refrigerator on 10/23/24 at 11:50 A.M. revealed eight undated containers of tomatoes and cucumbers. There were also two small individual serving sized milk containers that were opened and a half gallon of apple cider undated. The observations were verified by the Dietary Director (DD) #201. Interview on 10/23/24 at 11:50 A.M. with Dietary Aide (DA) #202 and DA #203 revealed the two small milk containers and the apple cider was from the staff. They stated the staff kept placing their personal items in the refrigerator. Review of the staff training dated 10/16/24 revealed [NAME] #200, DA #202 and DA #203 received education including kitchen sanitation and proper food storage. The trainings revealed the staff had either passed their orientation or demonstrated competency. Review of the facility policy titled, General Storage Guidelines, undated, indicated staff should label ready-to-eat foods prepped in-house that are held for more than 24-hours. Staff must label the name of the food and date by which it should be eaten or discarded. The policy also indicated that staff were to keep storage areas clean and dry, and they were to keep clean floors, walls and shelving in coolers, freezers, and dry-storage areas. This deficiency represents non-compliance investigated under Complaint Number OH00158730 and OH00157687.

Based on record review and interview, the facility failed to ensure physician's orders were followed timely to change the resident's suprapubic catheter (a catheter that drains urine from the bladder through a small incision in the abdomen). This affected one (Resident #64) of three residents reviewed for urinary catheters. The facility census was 144. Findings include: Review of the medical record for Resident #64 revealed an admission date of 01/22/21 with diagnoses including multiple sclerosis (a potentially disabling disease of the brain and spinal cord) and neuromuscular dysfunction of the bladder (a condition where the muscles in the bladder wall do not contract and relax properly causing problems with urination). Review of the physician's orders for Resident #64 revealed she had an order dated 03/01/24 to change the suprapubic catheter on evening shift every 30 days and as needed for blockage related to urinary retention. This order was discontinued on 06/11/24. Resident #64 also had an order dated 07/12/24 to change the suprapubic catheter on the evening shift every 30 days and as needed for blockage related to urinary retention. Review of the Treatment Administration Record (TAR) for Resident #64 from 05/01/24 through 07/31/24 revealed staff had changed Resident #64's catheter on 05/30/24 and 07/12/24. Interview on 09/03/24 at 9:54 A.M. with Licensed Practical Nurse (LPN) #200 verified she had changed Resident #64's catheter order on 06/11/24. She stated she spoke to the resident who wanted her suprapubic catheter order changed so that dayshift staff performed this as she did not want to be awaken at night and also because LPN #200 was on dayshift. She stated Resident #64 told her that staff changed her catheter on 06/10/24 so LPN #200 set the next catheter change for 07/12/24. She verified there was no documentation to verify Resident #64 had her catheter changed on 06/10/24 or that the physician was updated. Interview on 09/03/24 at 10:00 A.M. with Resident #64 revealed she did not ask to have her catheter change to be moved to dayshift. She stated the staff were still changing her catheter on the evening shift. She stated there were plenty of times the staff had not changed her catheter as ordered. Resident #64 stated her urologist wanted her suprapubic catheter changed every 30 days or more often as needed. This deficiency represents non-compliance investigated under Complaint Number OH00155948.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to timely report potential mistreatment or abuse to the State Agency identified for Resident #92. This affected one (Resident #92) of three residents reviewed for abuse. The facility census was 145. Findings include: Review of the medical record for Resident #92 revealed an admission date of 04/04/23 with diagnoses including hypertension, anxiety and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #92 had intact cognition. She had adequate hearing, clear speech, was able to understand others and make herself understood. Resident #92 had no behaviors and was incontinent of bowel and bladder. She required substantial to moderate assist with toileting hygiene. Review of the progress note dated 02/22/24 at 10:37 A.M. by Licensed Social Worker (LSW) #206 revealed Resident #92's daughter called stating she had concerns with something that happened during her mother's care. A family meeting was scheduled for 02/27/24 at 12:30 P.M. This was later changed to 02/27/24 at 10:00 A.M. Review of the facility Self-Reported Investigation (SRI) #244615 dated 02/27/24 revealed the facility was investigating the potential for neglect and mistreatment. Findings were as follows: -Statement from the Director of Nursing (DON) stated on 02/22/24 she was updated about a care concern with Resident #92. The DON spoke to Resident #92 who stated she did not like the way the State Tested Nurse Aide (STNA) provided perineal care (cleaning of the perineal area after toileting). Resident #92 was unsure of what day this had happened but stated it was three days prior. She did not know the name of the STNA but provided a physical description of her. Resident #92 stated to the DON she had asked the STNA why she was cleaning her a certain way and the STNA stated that because she wore an incontinent brief and was incontinent, that urine would get up there (meaning the vagina). The STNA stated to the resident that she needed to open the folds in the perineal area to clean her properly. Resident #92 asked her to stop the care and the STNA complied. The DON discovered it was STNA #203 that had taken care of Resident #92. There was no evidence an SRI was filed on this day. -STNA #203's statement dated 02/23/24 revealed she had provided care for Resident #92. She stated during care the resident had stated ouch and told the aide that she did not have to do that during care. STNA #203 stated she explained to Resident #92 that she needed to be washed, rinsed and dried because she had been sitting in urine. Resident #92 stated to STNA #203 that she didn't need to put her finger there. STNA #203 stated to the resident that there was a proper way of being cleaned and you could not just take the wash cloth over the perineal area and call it clean. She denied placing her finger in Resident #92's vagina. -Administrator's statement dated 02/27/24 revealed he had attended a family care conference for Resident #92 as they had concerns with the care being provided. Resident #92's daughter asked if the police were updated and he stated that they had not because Resident #92 said she did not feel it was abuse, but rather a care issue. Resident #92's daughter stated she felt it was abuse as the STNA had put her fingers into her mother's vagina without any use of wipes or Vaseline. The Administrator stated during his interview with STNA #203 she had stated she was using a washcloth and actually had asked Resident #92 on her preference to wipes or a washcloth. The Administrator stated STNA #203 was on administrative leave pending the outcome of his investigation. -Licensed Practical Nurse (LPN) #202 statement dated 02/27/24 stated an STNA reported to her that Resident #92 wanted to speak with her. She talked to the resident with the resident's daughter in the room. Resident #92 stated she did not like the way one of the STNA's cleaned her up and she did not wish for her to take care of her any longer. LPN #202 assured her that the STNA would not be placed on her assignment. LPN #202 stated the resident and family were in agreement and were satisfied. Interview on 02/27/24 at 9:15 A.M. with Resident #92 revealed she felt she had never been abused while at the facility. She stated she felt STNA #203 had taken liberties during care and that herself and her daughters were having a care conference with the facility regarding the issue. Resident #92 stated she did not tell staff for a couple of days about what had happened and then decided to speak to the nursing manager on 02/21/24. She stated on 02/21/24 she spoke to LPN #202 related to the care provided by STNA #203. She stated she told her that during incontinence care, STNA #203 put her finger into her vagina while cleaning her. STNA #203 had told her she had bowel there and she wanted to clean her properly. When this surveyor asked her if she felt the STNA did not know how to properly perform perineal care or if she felt it was sexual abuse, Resident #92 stated she never thought about it being sexual abuse. Resident #92 felt that STNA #203 did not know how to properly clean residents. Interview on 02/27/24 at 11:07 A.M. with LPN #202 revealed she had spoken to Resident #92 on 02/21/24 about care performed by an STNA. LPN #202 stated Resident #92 had stated to her that an aide (she did not know which STNA it was or her name) was attempting to clean her and perform perineal care and while doing so had put her finger into her vagina. Resident #92 had stated to LPN #202 she didn't think it was done purposely but did not like how she was cleaning her. LPN #202 stated she did not update the DON until 02/22/24 on this concern. Interview on 02/27/24 at 11:20 P.M. with the DON revealed she had spoken to Resident #92 on 02/22/24 and she felt it was more of a care concern because the resident did not like the way the STNA had cleaned her up. The DON stated she had been interviewing staff and residents related to care and abuse since 02/22/24 and ensured STNA #203 was not on the schedule. Although the DON was investigating the incident since 02/22/24, there was no evidence a SRI was submitted to the State Agency untin 02/27/24. Interview on 02/27/24 at 11:20 A.M. with the Administrator revealed he did not report the incident with Resident #92 to the police or the State Agency as Resident #92 did not state it was abuse. He believed it was more of a care concern with STNA #203 not performing appropriate perineal care. The Administrator stated during the care conference held with the resident, family and other staff members earlier in the day, Resident #92's daughter stated she felt it was abuse and he was going to file an SRI with the State Agency and continue the investigation. Review of facility policy titled Abuse, Neglect and Exploitation, revised 03/07/18 revealed the facility response would be to complete a full body assessment of the resident, provide medical treatment if necessary, initiate an investigation immediately, notify the attending physician and resident's family and the medical director, obtain statements, place the accused associate on leave and contact the State Agency and local Ombudsman to report the alleged abuse. This deficiency represents non-compliance investigated under Complaint Number OH00151374.

Based on observation, interview, and record review the facility failed to provide palatable meals and failed to ensure food was served at adequate temperatures. This had the potential to affect all residents residing in the facility. The facility census was 151. Findings include: Interviews on 12/13/23 from 9:18 A.M. to 9:55 A.M. with Resident #128 and Resident #14 revealed their meals were cold at times. Interview on 12/13/23 at 3:11 P.M. with Resident #141 revealed his meals were almost always cold, including his soups and coffee. Interview 12/13/23 at 3:16 P.M. with State Tested Nursing Assistants (STNAs) #208 and #210 revealed they were aware of multiple concerns related to cold foods. Interview on 12/13/23 at 3:20 P.M. with Resident #109 revealed his food was often cold. Resident #109 stated his family often provided him with food, and he had a microwave in his room to heat the food his family brought. Resident #109 stated, If it wasn't for my family, I would starve. Observation of meal service on 12/13/23 beginning at 4:45 P.M. revealed a pan of cut up chicken that was in chicken broth, a pan of cooked hamburgers that appeared to be old and dry, and a pan of golf ball sized dinner rolls that appeared to be dry and hard. Interview with Supervisor of Dining Services (SDS) #212 revealed meal plating usually began about 4:30 P.M. and she stated she had already obtained the temperatures of the food. Observation revealed a clipboard with no recorded temperature for the chicken or hamburgers, a temperature of 195 degrees Fahrenheit (F) for the soup, and the salad temperature of 35 degrees F. SDS #212 stated she had not written down the temperatures of the chicken; however, it was 183 degrees F, and she had not taken the temperature of the hamburgers or the pureed items. SDS #212 stated she was aware of concerns related to food temperatures and taste. A test tray was requested at 5:33 P.M. and was plated at 6:08 P.M., test tray consisted of a hamburger with a piece of unmelted cheese, French fries, and a bowl of soup. Test tray arrived to the floor at 6:12 P.M. and was received at 6:28 P.M. after the last resident tray was served. The temperature of the cheeseburger was 95 degrees F, French fries were 80 degrees F, and soup was 97 degrees F. Temperatures were verified by STNA #211. The test tray food was cold and lacking taste. Review of Resident Council Minutes for September and October 2023 revealed concerns related to cold food. This deficiency represents non-compliance investigated under Master Complaint Number OH00148622.

Based on observation, record review, and interview the facility failed to ensure timely meal service. This had the potential to affect all residents residing in the facility. The facility census was 151. Findings include: Review of the mealtime schedule revealed breakfast was served from 7:30 A.M. to 9:00 A.M., lunch was served from 12:00 P.M. to 1:00 P.M., and dinner was served from 5:00 P.M. to 6:30 P.M. Interviews on 12/13/23 from 9:18 A.M. to 9:55 A.M. with Resident #128 and Resident #14 revealed their meals were often late. Interview on 12/13/23 at 3:11 P.M. with Resident #141 revealed his meals were almost never on time. Interview on 12/13/23 at 3:16 P.M. with State Tested Nursing Assistants (STNAs) #208 and #210 stated they worked from 7:00 A.M. to 7:00 P.M., and meals were often late. STNAs #208 and #210 stated there were occasions when the dinner meals were not served until between 6:30 P.M. and 6:45 P.M. Interview on 12/13/23 at 3:20 P.M. with Resident #109 revealed his meals were always late. At time of interview STNA #211 entered Resident #109's room to take his dinner order and stated the meals were always late. STNA #211 stated the dinner meals were served between 6:30 P.M. and 7:00 P.M. at times. Interview on 12/13/23 at 4:45 P.M. with Supervisor of Dining Services (SDS) #212 revealed meal plating usually began about 4:30 P.M.; however, the meal was behind today due to the lettuce she was going to use spoiled, and she had to cut new lettuce. SDS #212 stated meals were late on occasion. Dishwasher #213 stated on 12/12/23, he and SDS #212 were the only staff members present to prepare the meals. Observation on 12/13/23 at 6:42 P.M. revealed dinner trays were continuing to be served on the first floor. This deficiency represents non-compliance investigated under Master Complaint Number OH00148622.

Based on observation, interview and record review the facility failed to ensure medications were not left unattended at the resident bedside. This affected one ( Resident #79) of 135 residents observed for environmental safety. The census was 135. Findings Included: Review of the medical record for Resident #79 revealed an admission date of 08/12/21 and diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and emphysema. Review of orders for June 2022 revealed Ventolin HFA Aerosol solution 90 micromilligram (mcg)/Actuation Breath Activated Powder Inhaler (ACT) (used to treat wheezing and shortness of breath ) two puff inhale orally four times a day for shortness of breath (SOB) and one puff inhale orally every four hours as needed for SOB. Additional orders included Fluticasone/salmeterol 100/50 mcg inhaler (improve breathing and control symptoms of asthma) one puff inhale orally two times a day for COPD and Spiriva Handihaler (Bronchodilator) one capsule inhale orally one time a day for COPD. There was no order to leave medications at bedside. Observation on 06/06/22 at 11:21 A.M. of Resident #79 revealed Ventolin HFA Aerosol, Fluticason/salmeterol and Spiriva handihaler sitting on the bedside table and the nurse was not in room. Interview at time of observation with Resident #79 revealed the nurse brought in his three inhalers in the morning and would come back and pick them up later in the day. Resident #79 verified the nurse did not watch him take his inhalers. Interview on 06/06/22 at 12:38 P.M. with the Director of Nursing (DON) verified three inhalers were sitting on the bedside table in Resident #79's room. The DON verified Resident #79 did not have orders to self-administer medications or inhalers could be left at bedside. Review of the Facility policy Medication Storage in the Facility, dated 01/09/17 revealed bedside medication storage was permitted for residents who wished to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the resident assessment team.

Based on observations, staff interview, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure staff wore eye protection to prevent the spread of Covid-19. This had the potential to affect 135 residents residing at the facility. The facility also failed to ensure oxygen tubing was changed weekly affecting Resident #33, #67 and #79 out of 38 residents receiving oxygen. The facility also failed to ensure the proper use of gloves during meal pass. This affected 135 residents in the facility. 1. Observation on 06/06/22 at 11:30 A.M. of State Tested Nursing Assistant (STNA) #791 walking out of a resident's room revealed STNA #791 was wearing an N95 mask and no eyewear. Interview at this time, with STNA #791 revealed she was an agency nurse and the facility gave her an N95 mask to wear at the start of her shift. Observation and interview on 06/06/22 of STNA #791 at 2:39 P.M., revealed she was wearing an N95 and eye protection. STNA#791 stated at 2:00 P.M. she was given eye protection to wear for the rest of her shift. Observation and interview on 06/06/22 of LPN #714 at 2:41 P.M. revealed she was wearing an N95 and eye protection. Interview at this time with LPN #714 revealed about an hour prior she was given eye protection wear. Interview on 06/06/22 at 3:04 P.M. with the Director of Nursing (DON) verified the findings and stated the facility followed the CDC guidelines and eye protection was required during direct care. Observation and interview on 06/07/22 at 9:57 A M. revealed STNA #707 walking down the 220-hallway wearing an N95 mask with no eye protection. STNA #707 verified the lack of eye protection and said the facility allowed the use of eye protection when needed. Observation and interview at 06/07/22 10:37A.M with Licensed Practical Nurse (LPN) # 714 revealed she was sitting at the nurses' station wearing an N95 mask and no eye protection. Interview at this time with LPN #714 stated she had not worn eye protection in several month. Interview on 06/08/22 at 1:00 P.M. with the facility Infection Control Preventionist (ICP) revealed the facility was in outbreak status due a positive staff on 05/31/22 and 06/06/22 and would continue outbreak status through 06/23/22. Review of the facility's COVID-19 staff tracking list revealed Occupational Therapist #790 tested positive on 05/31/22 and laundry staff #578 tested positive on 06/06/22. Review of the Cuyahoga County community transmission rate at data.cms.gov on 06/06/22 revealed the county transmission rate for COVID-19 was high for week of 06/01/22 through 06/07/22. Review of the CDC Covid-19 guidance updated 02/02/22 revealed health care providers (HCP) working in facilities located in areas with substantial or high transmission should wear eye protection (goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. Review of the facility policy titled COVID-19 infection control in long term care facilities revealed all heath care personnel must wear eye protection when caring for residents in transmission-based precautions (TBP). Fully vaccinated health care personnel may choose not to wear eye-protection regardless of the county positivity rates, unless a resident is in TBP due to symptoms of COVID-19 exposure or positive diagnosis. 2. Record review of Resident #33 revealed and admission date of 03/15/21. Diagnosis including Chronic Obstructive Pulmonary Disease (COPD). Review of the physician orders for June 2022 revealed an order to change cannula and tubing for oxygen one time a day on Monday. Observation on 06/06/22 at 10:00 A.M. revealed Resident #33's oxygen tubing was not dated. Resident #33 had oxygen in place via nasal cannula. Record review of Resident #67 revealed admission date of 11/01/11. Diagnosis orthopnea (difficulty breathing when lying down) and shortness of breath upon exertion. Review of the physician orders from June 2022 revealed change oxygen tubing very night shift on Mondays. Observation on 06/06/22 at 10:10 A.M. revealed Resident #67's oxygen tubing was not dated. Resident #67 had oxygen in place via nasal cannula. Record review of Resident #79 admission date of 08/12/21. Diagnosis included COPD and emphysema. Review of the physician orders from June 2022 revealed change oxygen tubing every night shift on Mondays. Observation on 06/06/22 at 11:21 A.M. revealed Resident #79's oxygen tubing was not dated. Resident #79 had oxygen in place via nasal cannula. Interview on 06/06/22 at 12:38 P.M. with Director of Nursing (DON) verified Resident #33, #67 and #79 oxygen tubing were not dated. DON verified oxygen tubing was to be changed weekly and dated on Monday night shift. 3. The meal delivery was observed for the lunch meal on 3 East beginning on 06/06/22 at 12:32 P.M. STNA #659 was observed delivering room trays. STNA #659 donned disposable gloves and began to deliver trays to Resident's #119, #23 and #11 without removing the gloves or washing her hands. STNA #659 then went to the kitchen to obtain a pitcher of juice and returned wearing the same gloves and proceeded to deliver trays to Resident #52. STNA #659 headed back to the kitchen to obtain milk and continued to pass trays to Resident #103 all wearing the same gloves. Then STNA #659 passed a tray to Resident #188 with the same gloves. STNA #659 moved Resident #103's over bed table closer and raised the head of the bed using the controls. STNA #659 exited the room to obtain help by STNA #788. STNA #788 informed STNA #659 Resident #188 was on contact precautions for Clostridium difficile (C-diff severe diarrhea and inflammation of the colon) bacterium that was highly contagious. STNA #659 said she was not aware the resident was in contact isolation despite the cart with the contact precautions sign posted. STNA #659 was educated by STNA #788 on not wearing gloves when delivering trays to residents and using alcohol based hand rub or washing the hands between trays and to wear the gown and gloves when delivering to residents in rooms while on contact precautions and removing the personal protective equipment prior to leaving the room. Observations on 06/06/22 at 12:04 P.M. revealed Resident #188 was in contact isolation for C-diff. Resident #188's son and daughter in law were in the room only wearing surgical masks. They were sitting down in chairs. Interview with LPN #512 reported the family should have been wearing gowns and gloves when in the room. LPN #512 went down to the room and educated the family. Review of the note dated 06/06/22 indicated LPN #645 was on 3 East and observed family members in Resident #188's room. Resident #188 was on contact precautions. The proper sign was displayed and appropriate personal protective equipment was available for staff and visitors to utilize. The family was observed without PPE on while in Resident #188's room. LPN #645 educated the family on what contact precautions were and what PPE needed to be worn. On 06/07/22 a note to all staff was written by the director of nursing related to personal protective equipment use in isolation rooms. Interview with the director of nursing on 06/07/22 10:50 A.M. reported STNA #659 was educated this morning on appropriate glove use and use of personal protective equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify and involve Resident #35's power of attorney in care conferences and care planning. This affected one of one resident reviewed for participation in care planning. The facility census was 139. Findings include: Review of the medical record for Resident #35 revealed he was admitted on [DATE] with diagnoses of Alzheimer's disease, vascular dementia, and unspecified mood disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. Review of advanced directives revealed Resident #35 had a valid power of attorney in place identifying his daughter as his decision maker. Review of the nurses note dated 07/07/19 at 9:23 P.M., Resident #35's daughter was noted to express concerns of not being invited to care conferences. Interview with Medical Records #500 on 07/17/19 at 8:15 A.M. confirmed Resident #35's daughter did not receive mailed care conference notices due to not being listed as a responsible party, even though she was the power of attorney.

Based on record review and staff interview, the facility failed to implement its abuse policy related to an allegation of verbal abuse by Resident #82's family. This affected one of two residents reviewed for abuse (Resident #82). The facility census was 139. Findings Include: Resident #82 was admitted the facility on 05/23/19 with diagnoses including multiple sclerosis, broken internal left knee prosthesis and chronic heart failure. Interview with the family member of Resident #82 on 07/16/19 at 2:30 P.M. revealed on 06/28/19 Physical Therapy Assistant (PTA) #900, while completing treatment with family present, began to speak to Resident #82 in a way that was not appropriate to Resident #82's family. Per Resident #82's family from the moment PTA #900 entered Resident #82's room PTA #900 had an unfriendly tone and was verbally abusive to Resident #82 regarding her home going situation and progress in therapy. PTA #900 stated the resident was going backwards and no one in her family could help her with homegoing therapy training (Resident #82 lives at home with 24-hour assistance from her husband). Per Resident #82's family member Resident #82 began to cry due to PTA #900's aggressive tone and demeaning words regarding her therapy progress and homegoing status. Interview with Resident #82 on 07/16/19 at 3:30 P.M. revealed on the evening of 06/28/19 she felt she was treated in a way no one should ever be treated by PTA #900 Review of the email provided by Resident #82's family dated 06/28/19 at 5:29 P.M. to the facilities rehab director revealed As you know, we have had a concern about the PTA, PTA #900. Today, she came in to my moms room with both me and my mom's roommate, Resident #118, present. From the moment she entered, she was curt, combative, and demeaning to the point of near verbal abuse. In an effort to diffuse the situation, I continued to try to redirect her because I could see my mother start to tear up. Interview with the facilities Administrator and Rehab Director #901 on 07/16/19 at 3:30 P.M. verified Rehab Director #901 received the email allegation of abuse by Resident #82's family. Rehab Director #901 and the Administrator also verified the facility did not conduct an investigation into the allegation of abuse or notify the state agency of the allegation of abuse. Review of the facilities Abuse/Neglect policy dated 03/27/17, revealed when suspicion of abuse, neglect or exploitation occur, an investigation is immediately warranted and to Contact the State Agency and the local ombudsman office to report the alleged abuse.

Based on record review and staff interview, the facility failed to ensure an allegation of verbal abuse was reported to the state agency as required. This affected one of two residents reviewed for abuse (Resident #82). The facility census was 139. Findings Include: Resident #82 was admitted the facility on 05/23/19 with diagnoses including multiple sclerosis, broken internal left knee prosthesis and chronic heart failure. Interview with the family member of Resident #82 on 07/16/19 at 2:30 P.M. revealed on 06/28/19 Physical Therapy Assistant (PTA) #900, while completing treatment with family present, began to speak to Resident #82 in a way that was not appropriate to Resident #82's family. Per Resident #82's family from the moment PTA #900 entered Resident #82's room PTA #900 had an unfriendly tone and was verbally abusive to Resident #82 regarding her home going situation and progress in therapy. PTA #900 stated the resident was going backwards and no one in her family could help her with homegoing therapy training (Resident #82 lives at home with 24-hour assistance from her husband). Per Resident #82's family member Resident #82 began to cry due to PTA #900's aggressive tone and demeaning words regarding her therapy progress and homegoing status. Interview with Resident #82 on 07/16/19 3:30 P.M. revealed on 06/28/19 she felt she was treated in a way no one should ever be treated by PTA #900. Review of the email provided by Resident #82's family dated 06/28/19 at 5:29 P.M. to the facilities rehab director revealed As you know, we have had a concern about the PTA, PTA #900. Today, she came in to my moms room with both me and my mom's roommate, Resident #118, present. From the moment she entered, she was curt, combative, and demeaning to the point of near verbal abuse. In an effort to diffuse the situation, I continued to try to redirect her because I could see my mother start to tear up. Review of the Ohio Department of Health's Gateway system revealed no self-reported incident related to the allegation of verbal abuse by Resident #82's family. Interview with the facilities Administrator and Rehab Director #901 on 07/16/19 at 3:30 P.M. verified the facility received the email complaint of verbal abuse by Resident #82's family, and no self-reported incident was submitted to the state agency as required. Review of the facilities Abuse/Neglect policy dated 03/27/17 revealed the facility upon receiving an allegation of abuse shall Contact the State Agency and the local ombudsman office to report the alleged abuse.

Based on record review and staff interview, the facility failed to complete an investigation of an allegation of verbal abuse. This affected one of two residents reviewed for abuse (Resident #82). The facility census was 139. Findings Include: Resident #82 was admitted the facility on 05/23/19 with diagnoses including multiple sclerosis, broken internal left knee prosthesis and chronic heart failure. Interview with the family member of Resident #82 on 07/16/19 at 2:30 P.M. revealed on 06/28/19 Physical Therapy Assistant (PTA) #900, while completing treatment with family present, began to speak to Resident #82 in a way that was not appropriate to Resident #82's family. Per Resident #82's family from the moment PTA #900 entered Resident #82's room PTA #900 had an unfriendly tone and was verbally abusive to Resident #82 regarding her home going situation and progress in therapy. PTA #900 stated the resident was going backwards and no one in her family could help her with homegoing therapy training (Resident #82 lives at home with 24-hour assistance from her husband). Per Resident #82's family member Resident #82 began to cry due to PTA #900's aggressive tone and demeaning words regarding her therapy progress and homegoing status. Interview with Resident #82 on 07/16/19 3:30 P.M. revealed on 06/28/19 she felt she was treated in a way no one should ever be treated by PTA #900. Review of the email provided by Resident #82's family dated 06/28/19 at 5:29 P.M. to the facilities rehab director revealed As you know, we have had a concern about the PTA, PTA #900. Today, she came in to my moms room with both me and my mom's roommate, Resident #118, present. From the moment she entered, she was curt, combative, and demeaning to the point of near verbal abuse. In an effort to diffuse the situation, I continued to try to redirect her because I could see my mother start to tear up. Interview with the facilities Administrator and Rehab Director #901 on 07/16/19 at 3:30 P.M. verified the facility received the email complaint of verbal abuse by Resident #82's family, and no investigation was completed by the facility in regards to the allegation of verbal abuse. Review of the facilities Abuse/Neglect policy dated 03/27/17 revealed when suspicion of abuse, neglect or exploitation occur, an investigation is immediately warranted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #7 revealed he was admitted on [DATE] with poliomyelitis, weakness, and chronic obstructive pulmonary disease. Review of the MDS 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating no cognitive impairment, and impairment to the upper extremity on one side requiring extensive assistance with dressing, toileting, personal hygiene, transfers, bed mobility, and locomotion. During an initial facility tour on 07/15/19 at 11:37 A.M., Resident #7 was observed with a left hand contracture and without a splint or brace applied. Review of the care plan for Resident #7 revealed no problem area to address limited range of motion (ROM) of the left hand contracture. Interview on 07/17/19 at 10:51 A.M. with Rehab Director #901 verified Resident #7 was admitted with a left hand contracture and completed physical and occupational therapy on 04/02/19 with a recommendation to use a foam roll in the hand. Interview on 07/17/19 at 12:08 P.M. with Unit Manager #502 confirmed the care plan for Resident #7 effective 03/06/19 did not contain a problem area to address limited ROM of the left hand contracture. Based on record review and interview the facility failed to ensure Resident #76 and #7's care plan. This affected two of 31 residents reviewed for care plans. The facility census was 139. Findings include: 1. Record review of Resident #76 revealed an admission date of 03/24/19. Diagnoses included unspecified dementia with behavioral disturbance, lymphedema, heart failure, and localized edema. The annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition. Review of the current care plan was silent for edema. Review of the physician's note dated 02/27/19 revealed Resident #76 had severe pedal edema and purplish discoloration. It was explained to Resident #76 that since she refused the compression stockings she needed to elevate her lower extremities. The plan was to encourage frequent elevation of the lower extremities. Another physician's note dated 06/19/19 revealed Resident #76 exhibited edema. Observation on 07/16/19 at 9:29 A.M. revealed Resident #76 was observed sitting in her wheelchair in her room. Resident #76's were both very swollen, she had no socks on, and her feet were flat on the ground. Interview on 07/17/19 at 8:52 A.M. with Resident #76 revealed the her feet are alwys swollen, and staff do encourage her to elevate them. Resident #76 stated her feet were fine as they were. Resident #76 stated she just didn't want to have them propped up doing nothing. Interview on 07/17/19 at 3:42 P.M. with Unit Manager (UM) #505 revealed the unit managers managed the care plans. UM #505 stated Resident #76 had ongoing issues with edema and refused treatment and elevation of her feet. UM #505 verified Resident #76 did not have a care plan regarding her edema.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the care plan for Resident #30. This affected one resident of two residents reviewed for non-pressure skin conditions. The facility census was 139. Findings include: Record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including weakness, hypertension, and hypothyroidism. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed impaired cognition. Resident #30 required extensive assistance of two staff for bed mobility and extensive assistance of one staff for transfers and toilet use. Review of the physician's notes dated 07/05/19 revealed Resident #30 had complained of a itchy rash that started a month ago. Physical exam revealed a patch of scattered macules (flat, distinct, discolored area of skin). Resident #30 was treated with Triamcinlone cream (treatment for itchiness and redness). Review of the care plan dated 04/22/19 for pressure sores and skin was silent for the rash and the treatment of the rash. Interview on 07/15/19 at 3:36 P.M. with Resident #30 revealed she had a rash on stomach for about two months, and it had gotten worse and had spread. Resident #30 stated as of this day she was told she was being referred to see a dermatologist. Interview on 07/17/19 at 3:31 P.M. and at 3:35 P.M. with State Tested Nurse Aide (STNA) #507 and Registered Nurse (RN) #506 revealed Resident #76 has had a rash that came and went in different areas of her body, but the current rash had worsen and spread. Interview on 07/17/19 at 3:48 P.M. with Unit Manager (UM) #505 stated he was aware of Resident #30's rash and confirmed he had not revised her care plan.

Based on record review and interview, the facility failed to ensure the Medical Director (MD) and the Administrator attended the Quality Assessment and Assurance (QAA) and the Quality Assurance Performance Improvement (QAPI) meetings quarterly. This had the potential to affect all 139 residents residing in the facility. Findings include: Interview on 07/18/19 at 1:40 P.M. with Administrator, Director of Nursing (DON), and the Director Resident Services (DRS) #503 revealed the QAA and QAPI meetings are conducted monthly with facility department directors, DON,and Administrator, but the Medical Director and contracted services staff attend quarterly. Review of the sign in sheets titled, Monthly QAA and Ethics Committee Meeting Sign-In Sheet dated 07/23/18, 01/22/19, and 04/29/19 revealed only on 04/29/19 the Administrator and Medical Director were in attendance. Interview on 07/18/19 at 1:57 P.M. and 2:15 P.M. the DRS #503 confirmed the Medical Director and the Administrator were not in attendance for the QAA and QAPI meetings on 07/23/18 and 01/22/19. DRS #503 stated she didn't have a sign in sheet for the October 2018 meeting.