**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy titled Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, and interviews, the facility failed to appropriately report an allegation of resident to resident abuse to the proper agencies. This affected one resident (Resident #73) out of three reviewed for abuse. The facility census was 102. Findings include: Review of the medical record for Resident #73 revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: diabetes mellitis type II, post-traumatic stress disorder, muscle weakness, Bipolar disorder, psychoactive substance abuse, altered mental status, dysphagia, lack of coordination, low back pain, alcohol abuse, nicotine dependence, hypertension, and gastro-esophageal reflux disease. This resident is alert and oriented and has minimal cognitive deficits according to the Minimum Data Set (MDS) assessment completed on 03/22/25. Review of nursing notes from 4/12/25 at 10:35 A.M. revealed Resident #73 reported feeling threatened by the resident located across the hall. Resident #73 stated that Resident #62 had made threatening comments towards him, including saying he doesn't like him. More seriously Resident #73 claims that Resident #62 has stated there is a hit out on him and threatened to beat him up or kill him or would have his buddies do it. Resident #73 also expressed concern that Resident #62 possesses a knife. Resident #73 states this is all over him having a girlfriend and Resident #62 not having one. Activity Director #111 immediately let the I wing nurse aware of the situation, the I wing nurse and Activity Director #111 immediately went down to Resident #62's room to ask Resident #62 if he did have a knife on his person, and the resident stated no. But the nurse had seen the knife located in his basket. Nurse immediately notified the Director of Nursing of the situation and both residents are being monitored at this time. The knife was removed and locked up in the activity directors office. This was written by Activity Director #111. Review of nursing note dated 4/12/2025 at 11:35 A.M. revealed Activity Director #111 had offered to show/ move Resident #73 to a new hallway after the incident had occurred and resident stated no he did not want to move, just hope nothing happens. This was written by Activity Director #111. Interview with Resident #73 on 04/14/25 at 02:52 P.M. stated another resident had a knife and threatened him. Resident stated he felt afraid at the time, and is still fearful. Interview with the Director of Nursing (DON) on 04/15/25 at 02:40 P.M. verified in light of the above notes from 04/12/25, both residents were both offered a room change and both declined. She agreed this incident should have been reported as this was a qualifying event under reportable incidents by the facility. Interview with Activities Director #111 on 04/15/25 at 03:24 P.M. revealed Resident #73 reported he felt threatened by another resident who had a knife. Stated the resident was fearful after the incident so she brought him to the activities room for a few hours. She stated she had notified the DON and was told to offer both residents a room change away from each other, which both declined. Review of facility policy titled Identifying Types of Abuse last revised in September 2022, revealed mental and verbal abuse include but not limited to threatening gestures or fear of a person or place. Review of the Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigation last revised in September 2022, revealed if resident abuse is suspected it will be reported immediately as required by current regulations. Review of current Self Reported Incidents on 04/16/25 at 03:31 P.M. revealed this incident has not been created as of this time. Law Enforcement has not been notified as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was accurately completed. This affected one resident (#71) out of the six residents reviewed for PASARR during the annual survey. The facility census was 102. Findings include: Record review for Resident #71 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included epilepsy, seizures, mood disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/07/25, revealed the resident was assessed to have intact cognition. Review of the residents physicians orders from 06/06/24 through 06/13/24 revealed the resident was ordered Buspar (an anti-anxiety medication) and Sertraline (an anti-depressant medication). Review of the PASARR, signed as completed on 06/13/24, revealed the resident was assessed to have not been ordered any psychotropic medications (anti-anxiety, anti-depressant, anti-psychotic, or mood stabilizers) in the past six months. Interview with the Director of Nursing (DON) on 04/16/25 at 2:40 P.M. confirmed the PASARR for Resident #71 had been completed inaccurately as the resident had been ordered psychotropic medication within the six months prior to the completion of the PASARR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide timely podiatry care and services to Resident #3. This affected one (Resident #3) of four residents reviewed for activities of daily living. The facility census was 102. Findings include: Review of the medical record for Resident #3 revealed an admission date of 01/17/25 with diagnoses including infection/inflammation reaction due to internal joint prosthesis, osteoarthritis, paint in left knee and major depressive disorder. Review of the physician orders for Resident #3 revealed an order received on admission to see podiatry as needed. Review of the Medicare 5 day Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was cognitively intact and required partial to moderate assistance to complete activities of daily living. Review of the nursing progress notes for Resident #3 revealed no documentation of the condition of Resident #3 toe nails. The progress notes did not indicate Resident #3 had been seen by a podiatrist. Review of the plan of care dated 01/25/25 revealed Resident #3 required assistance with activities of daily living. Observations on 04/14/25 at 3:06 P.M. and 04/15/25 at 10:12 A.M. revealed Resident #3 toe nails (all 10) were long, yellow and thick. The toe nails were pressing against the skin of the next toe. Interview on 04/14/25 at 3:06 P.M. with Resident #3 revealed he would like to have his toe nails trimmed and treated. Resident #3 stated he had not seen the foot doctor (podiatrist) since he had been at the facility. Interview on 04/16/25 at 3:24 P.M. with Licensed Practical Nurse (LPN) #19 confirmed Resident #3 toe nails were long, yellow and thick. LPN #19 confirmed Resident #3 had not been seen by podiatry since admission.

Based on staff interview, record review, observation, and document review the facility failed to ensure residents were free of significant medication errors when staff failed to prime an insulin pen for Resident #90. This affected one (Resident #90) of five residents reviewed for medication administration. The facility census was 102. Findings include: Record review of Resident #90 revealed an admission date of 02/03/25 with pertinent diagnoses of: sepsis, osteomyelitis, type two diabetes mellitus, hypertension, acquired absence of right and left lower leg below knee. Review of the 02/06/25 modification of admission and medicare five day Minimum Data Set (MDS) assessment revealed the resident is cognitively intact and uses a wheelchair to aid in mobility. Review of Physician Order dated 02/04/25 revealed Humalog injection solution 100 unit/milliliter (insulin Lispro) inject as per sliding scale if 150-200= 3 units; 201-250= 6 units; 251-300= 9 units; 301-350=12 units; 351-400=15 units; 401+= 18 units notify Nurse Practitioner, subcutaneously before meals and and bedtime for diabetes mellitus. Review of a Physician Order dated 02/04/25 revealed Insulin Lispro (one unit dial) 100 unit/milliliter solution pen injector inject seven units subcutaneously before meals and at bedtime related to type tow diabetes mellitus. Observation on 04/15/25 at 5:02 P.M. revealed Licensed Practical Nurse #11 (LPN) took Resident #90 blood sugar and it was 168 mg/Dl milligrams per deciliter. LPN #11 dialed the insulin Lispro pen to 10 units for seven units scheduled and three units for sliding scale. LPN #11 did not prime the insulin pen prior to administration to Resident #90. Interview with LPN #11 on 04/15/25 at 5:10 P.M. LPN #11 verified she did not prime the insulin pen prior to administering Resident #90 insulin. Review of the Humalog Kwikpen (insulin Lispro) instructions for use copyright 2007 revealed to prime before each injection. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with needle pointing up. Push the dose knob until it stops and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeating priming step no more than four times. If you still do not see insulin, change the needle and repeat priming.

Based on staff interview, record review, observation, and document review, the facility failed to appropriately clean a blood glucose monitoring machine between patient uses. This affected one (Resident #90) of five residents reviewed for medication administration. This had the potential to affect three Residents (Resident #90, #298, and #303) who resided on the E hallway and received blood sugar glucose monitoring. The facility census was 102. Findings include: Record review of Resident #90 revealed an admission date of 02/03/25 with pertinent diagnoses of: sepsis, osteomyelitis, type two diabetes mellitus, hypertension, acquired absence of right and left lower leg below knee. Review of the 02/06/25 modification of admission and medicare five day Minimum Data Set (MDS) assessment revealed the Resident is cognitively intact and uses a wheelchair to aid in mobility. Review of Physician Order dated 02/04/25 revealed Humalog injection solution 100 unit/milliliter (insulin Lispro) inject as per sliding scale if 150-200= 3 units; 201-250= 6 units; 251-300= 9 units; 301-350=12 units; 351-400=15 units; 401+= 18 units notify Nurse Practitioner, subcutaneously before meals and and bedtime for diabetes mellitus. Review of a Physician Order dated 02/04/25 revealed Insulin Lispro (one unit dial) 100 unit/milliliter solution pen injector inject seven units subcutaneously before meals and at bedtime related to type tow diabetes mellitus. Observation on 04/15/25 at 4:19 P.M. revealed Licensed Practical Nurse #11 (LPN) took Resident #303 blood sugar with an Assure Platinum blood glucose monitoring machine. LPN #11 used an alcohol wipe to clean the glucose machine. Observation on 04/15/25 at 4:45 P.M. revealed LPN #11 went into Resident #90 room to take his blood sugar. The Surveyor intervened and had her clean the blood glucose machine with a bleach wipe prior to taking Resident #90 blood glucose level. Interview with LPN #11 on 04/15/25 at 4:47 P.M. verified she was unaware that shared use glucose machines should be cleaned with bleach prior to Resident use to prevent blood borne pathogen transmission. The facility identified there was no blood borne communicable diseases for the Resident receiving blood glucose monitoring on the E Hall. Review of the revised 09/24 facility provided Arkray technical brief cleaning and disinfecting the assure platinum blood glucose monitoring system revealed the machine may only be used for testing multiple patients when standard precautions and the manufacturers disinfecting procedures are followed. The disinfecting procedure is needed to prevent the transmission of bloodborne pathogens. Arkray has tested and validated the durability and functionality of the Assure Platinum meter with the most commonly used EPA-registered wipes. Our testing confirmed the wipes listed below will not damage the functionality or performance of the meter through 3,650 cleaning and disinfecting cycles. ARKRAY recommends using these wipes to clean and disinfect the Assure Platinum meter: Clorox Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, Super Sani-Cloth Germicidal Disposable Wipe, CaviWipes, or Microdot Bleach Wipe.

Based on medical record review, resident representative interview, staff interview, and facility policy review, the facility failed to ensure resident representatives were notified of significant changes in resident status. This affected one (Resident #78) of 22 sampled residents. The facility census was 84. Findings include: Review of the medical record for Resident #78 revealed an initial admission date of 08/02/23 with diagnoses including cerebrovascular accident (CVA) with right-sided hemiplegia, osteoarthritis, subarachnoid hemorrhage, frontal lobe and executive function deficit following CVA, major depressive disorder, anxiety disorder, migraine, obstructive sleep apnea, hypertension, and hyperlipidemia. Review of the plan of care for Resident #78 dated 08/03/23 revealed the resident was at risk for impaired nutritional status related to hypertension, left hip arthroplasty, CVA, gastrostomy without tube feeding, hypertension, hyperlipidemia, obesity and weight loss. Interventions included the following: give medications for hypertension as ordered, monitor vital signs as ordered, hold medications and notify physician per parameters, give nutritional supplements as ordered, if resident shows signs/symptoms of choking notify physician and/or speech therapy (ST), monitor labs as ordered, report results to physician, provide diet as ordered, weigh monthly due to weight being stable. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #78 dated 11/06/23 revealed the resident had a severe cognitive deficit. The resident was coded for presence of a significant unplanned weight loss with a body weight of 176 pounds. Review of the weight note for Resident #78 dated 11/08/23 revealed the resident's weight was 175.5 pounds indicating a 27.8-pound weight loss in 60 days. Review of the weight note for Resident #78 dated 01/07/24 revealed the resident's weight was 177 pounds, indicating the resident had a 28-pound weight loss since admission. The resident's weight had remained stable, and the resident accepted meals and supplements. Review of the medical record for Resident #78 revealed it did not include documentation regarding notification to the resident's representative of the resident's significant weight loss of 28 pounds since admission. Interview on 01/16/24 at 3:48 P.M. with the Resident #78's representative confirmed the representative was not notified of the resident's significant weight loss. Interview on 01/17/24 at 3:36 P.M. with the Director of Nursing (DON) confirmed Resident #78's representative was not notified of the resident's significant weight loss. Review of the facility policy titled Notification of Changes dated 09/22/22 revealed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #15 revealed an admission date of 09/07/23 with diagnoses including bipolar disorder, dementia with other behavioral disturbances, and history of falling. Review of the nurse progress note for Resident #15 dated 11/10/23 revealed the resident was found lying on the right side on the floor in the dining area with no injuries noted. Review of the discharge return anticipated MDS assessment for Resident #15 dated 11/11/23 revealed the resident was coded to have had no falls since the prior assessment. Interview on 01/18/24 at 9:35 A.M. with MDS Nurse #199 confirmed Resident #15 had fallen while in the facility on 11/10/23, and the MDS assessment dated [DATE] had not been accurately coded to reflect the fall. Based on medical record review and staff interview the facility failed to ensure the accuracy of resident assessments. This affected two (Residents #15 and #60) of 22 sampled residents. The facility census was 84. Findings include: 1. Review of the medical record for Resident #60 revealed an admission date of 01/19/22 with diagnoses including quadriplegia, acute respiratory failure, aphasia, dysphagia, and severe protein calorie malnutrition Review of the care plan for Resident #60 dated 09/08/23 revealed the resident had an order for hospice care due to terminal diagnoses of intracranial hemorrhage. Interventions included the following: allow resident time and the opportunity to discuss his situation as needed, check with resident to see if he/she would like clergy visits, hospice care to be provided by hospice agency of resident's or family's choice, refer family to grieving support groups as needed, resident to be kept comfortable and as pain free as medically possible. Review of the quarterly MDS assessment for Resident #60 dated 12/14/23 revealed the resident had a moderate cognitive deficit. The assessment was coded negatively for the resident receiving hospice services. Review of the monthly physician orders for January 2024 for Resident #60 revealed the resident was admitted to hospice services with a diagnosis of intracranial hemorrhage. Interview on 01/22/24 9:37 A.M. with the Administrator confirmed the quarterly MDS for Resident #60 dated 12/14/23 was inaccurate related to the resident's enrollment with hospice services. The Administrator confirmed the resident had been receiving hospice services since admission to the facility.

Based on medical record review and staff interview, the facility failed to ensure resident Pre-admission Screening and Resident Review (PASARR) documents were accurate regarding resident current conditions and diagnoses and were completed when appropriate. This affected two (Residents #25 and #59) of four residents reviewed for PASARR documents. The census was 84. Findings include: 1.Review of the medical record for Resident #59 revealed an admission date of 08/07/21 with diagnoses including diabetes mellitus type II, drug induced subacute dyskinesia, depression, seizures, hypertension, and anxiety. Further review of the medical record revealed a diagnosis of unspecified psychosis was added for Resident #59 on 05/23/22. Review of the Minimum Data Set (MDS) assessment for Resident #59 dated 01/13/23 revealed the resident was severely impaired for cognition. Review of the PASARR document for Resident #59 dated 07/31/21 revealed it did not include any psychiatric diagnoses for the resident. Interview on 01/22/24 at 2:28 P.M. with the Administrator confirmed the facility should have completed a new PASARR for Resident #59 upon the addition of a new psychiatric diagnosis on 05/23/22. 2. Review of the medical record for Resident #25 revealed an initial admission date of 02/07/23 with the latest readmission date of 02/27/23 with diagnoses including polyneuropathy, diabetes mellitus, protein calorie malnutrition, anxiety disorder, Down's Syndrome, hypercalcemia, unstageable pressure ulcer to left hip, dislocation of left shoulder, gastro-esophageal reflux disease, anemia and psoriasis. Review of the PASARR for Resident #25 dated 05/09/23 revealed it was good for 180 days. Review of the quarterly MDS assessment for Resident #25 dated 11/28/23 revealed the resident had a severe cognitive deficit. Review of the medical record for Resident #25 revealed it did not include an updated PASARR for the resident. The only PASARR on file for Resident #25 was the one dated 05/09/23. Interview on 01/18/24 at 9:59 A.M. with the Administrator confirmed the facility had not completed a PASARR for resident since the one dated 05/09/23.

Based on medical record review and staff interview, the facility failed to ensure comprehensive care plans were developed and implemented to reflect the need for care in the area of Post Traumatic Stress Disorder (PTSD) and Preadmission Screening and Resident Review (PASARR) recommendations. This affected one (Residents #76) of 22 residents reviewed for care planning. The facility census was 84. Findings include: Review of the medical record for Resident #76 revealed an admission date of 11/01/23 with diagnoses including schizophrenia, bipolar disorder, anxiety, and PTSD. Review of the admission Minimum Data Set (MDS) assessment for Resident #76 dated 11/07/23 revealed the resident was cognitively intact. Review of the Notice of Level II PASARR Outcome for Resident #76 dated 10/16/23 revealed based on the information provided in the Level II assessment and current records, Resident #76 met inclusion criteria for serious mental illness with diagnoses of schizophrenia, bipolar disorder, nicotine dependence, anxiety disorder, and PTSD. Specialized services and support nursing facility staff were required to provide included supportive counseling from nursing facility staff, skills training, ongoing evaluation of the effectiveness of current psychotropic medications on target symptoms, mental health counseling, behaviorally based treatment plan, and structured therapeutic activities. Review of the active care plans for Resident #76 initiated 11/01/23 revealed there was not a plan of care in place that addressed the specialized services and support detailed in the residents Level II PASARR assessment nor a care plan that addressed the resident's needs related to PTSD. Interview on 01/22/24 at 9:20 A.M. with the Director of Nursing (DON) confirmed there were no care plans in place addressing the care of Resident #76 related to the Level II PASARR assessment or the resident's PTSD diagnosis.

Based on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure staff provided assistance with nail care and routine shaving for dependent residents. This affected two (Residents #38 and #78) of four residents reviewed for activities of daily living (ADLs). The facility census was 84. Findings Include: 1. Review of the medical record for Resident #38 revealed an admission date of 10/12/23 with diagnoses including fracture of lumbar vertebra, cardiac arrest, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus, morbid obesity, hypertension, constipation, gastro-esophageal reflux disease, hyperlipidemia, chronic kidney disease, atrial fibrillation, congestive heart failure, osteoarthritis, anemia, anxiety disorder, and major depressive disorder. Review of the plan of care for Resident #38 dated 10/26/23 revealed the resident had a self-care deficit related to COPD. Interventions included the following: therapy evaluation and treat as needed, refuses care/risk and benefits with encouragement given, set-up bath items and put out clothes as needed, toileting with one assist, transfers with one assist and shave daily as needed. Review of the Minimum Data Set (MDS) assessment for Resident #38 dated 11/06/23 revealed the resident was cognitively intact. Review of the mood and behavior section of the MDS revealed the resident displayed verbal behaviors directed towards others, behaviors not directed towards others and rejection of care. Review of the progress notes for Resident #38 dated 10/12/23 to 01/17/24 revealed there was no documentation regarding refusal of care. Observation on 01/16/24 at 12:34 P.M. of Resident #38 revealed the resident was holding her hands in fists and her long and jagged fingernails were cutting into the palm of her hands. The resident was unable to open her hands completely on request. Observation on 01/17/24 at 9:30 A.M. of Resident #38 revealed the resident's fingernails were long and jagged with visible debris underneath and she had untrimmed hairs to her chin. Observation on 01/17/24 at 1:45 P.M. of Resident #38 revealed the resident's fingernails were long and jagged with visible debris underneath and she had untrimmed hairs to her chin. Interview on 01/17/24 at 1:47 P.M. with State Tested Nursing Assistant (STNA) #163 confirmed Resident #38's fingernails were long and jagged with visible debris underneath and should be trimmed and cleaned. STNA #163 further confirmed Resident #38's chin hair was long and needed to be trimmed. Review of the facility policy titled Grooming a Resident's Facial Hair dated 2017 revealed it was the practice of the facility to assist residents with grooming facial hair to help maintain proper hygiene as per current standards of practice. 2. Review of the medical record for Resident #78 revealed an admission date of 08/02/23 with diagnoses including cerebrovascular accident (CVA) with right sided hemiplegia, osteoarthritis, nontraumatic subarachnoid hemorrhage, frontal lobe and executive function deficit following CVA, major depressive disorder, anxiety disorder, migraine, nicotine dependence, obstructive sleep apnea, hypertension, and hyperlipidemia. Review of the plan of care for Resident #78 dated 08/15/23 revealed the resident had a self-care deficit related to CVA, history of fracture, hemiplegia, impaired mobility, incontinence, pain, poor health management, weakness and osteoarthritis. Interventions included staff to assist with grooming and hygiene and to provide nail care weekly and as needed. Review of the MDS assessment for Resident #78 dated 11/06/23 revealed the resident had a severe cognitive deficit. Observations on 01/17/24 at 8:19 A.M. and 10:45 A.M. of Resident #78 revealed the resident's fingernails were long with visible debris underneath. Interview on 01/17/24 at 12:45 P.M. with the Administrator confirmed Resident #78's fingernails were long with visible debris underneath and staff should clean and trim the resident's nails. Review of the facility policy titled Nail Care dated 2023 revealed routine cleaning and inspection of nails would be provided during ADL care on an ongoing basis. Routine nail care included trimming and filing on a regular schedule. Nail care should be provided between scheduled occasions as the need arises. This deficiency represents non-compliance investigated under Complaint Number OH00149963.

Based on medical record review, observation, staff interview, facility policy review, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure pressure ulcers were thoroughly assessed and failed to ensure treatments for pressure ulcers were completed as ordered. This affected one (Resident #57) of five residents reviewed for pressure ulcers. The facility census was 84. Findings include: Review of the medical record for Resident #57 revealed an initial admission date of 06/19/23 with the latest readmission of 11/07/23 with diagnoses including severe protein calorie malnutrition, chronic respiratory failure, severe morbid obesity, diabetes mellitus, chronic obstructive pulmonary disease (COPD), stage IV pressure ulcer sacral region, chronic kidney disease, hypertension, hyperlipidemia, and congestive heart failure. Review of the admission assessment for Resident #57 dated 06/20/23 revealed the resident was admitted to the facility with an unstageable pressure ulcer to the sacrum measuring 1.5 centimeters (cm) by 1.0 in length by 0.5 cm in width. The assessment did not include any additional description of the wound. Review of the readmission assessment for Resident #57 dated 09/06/23 revealed the resident was readmitted to the facility with a stage IV pressure ulcer to the sacrum measuring 8.0 cm in length by 6.0 cm in width by 0.5 cm in depth, a suspected deep tissue issues (SDTI) to the left lateral foot measuring 1.0 cm, and an unstageable pressure ulcer to the right heel measuring 4.5 cm in length by 4.6 cm in width. The assessment did not include any additional description of the wounds. Review of the plan of care for Resident #57 dated 09/12/23 revealed the resident was at risk for skin breakdown related to impaired mobility, stage IV pressure ulcer wound to the sacrum and stage IV pressure ulcer to the right heel. Interventions included the following: low air loss mattress with lateral supports, observe skin for redness or open areas, notify the nurse, observe skin with showers/care, notify nurse of any new areas of skin breakdown, off-loading boots, may remove for hygiene and skin checks, pressure reducing/relieving cushion to chair, supplements per order, treat left distal lateral foot as ordered, weekly head to toe skin assessment, document and report abnormal findings to physician. Review of the readmission assessment for Resident #57 dated 11/07/23 revealed the resident was readmitted with wounds and to see the full description. The area on the assessment for detailed wound documentation was blank. Further review of the medical record revealed it did not include an assessment of Resident #57's wounds upon readmission to the facility. Review of the pressure ulcer risk assessment for Resident #57 dated 11/08/23 revealed the resident was at risk for skin breakdown. Review of the weekly pressure ulcer assessment for Resident #57 dated 11/14/23 revealed the resident had a stage IV pressure ulcer to the sacrum which measured 1.4 cm in length by 0.6 cm in width by 0.1 cm in depth. The resident had an area to the right heel which measured 3.8 cm in length by 4.1 cm in width. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 11/21/23 revealed the stage IV pressure ulcer to the resident's sacrum measured 2.6 cm in length by 2.3 cm in width by 0.3 cm in depth. The resident had an area to the right heel which measured 2.4 cm in length by 2.2 cm in width. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 11/28/23 revealed the stage IV pressure ulcer to the resident's sacrum measured 2.2 cm in length by 1.8 cm in width by 0.2 cm in depth with no description of the wound. The wound to the resident's right heel measured 4.5 cm in length by 4.8 cm in width. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 12/05/23 revealed the stage IV pressure ulcer to the resident's sacrum measured 2.1 cm in length by 1.7 cm in width by 0.1 cm in depth with no description of the wound. The right heel wound measured 6.0 cm in length by 5.2 cm in width. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 12/19/23 revealed the stage IV pressure ulcer to the sacrum measured 2.3 cm in length by 1.4 cm in width by 0.2 cm in depth with no description of the wound. The right heel wound measured 4.2 cm in length by 4.3 cm in width by 0.4 cm in depth. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 12/26/23 revealed the stage IV pressure ulcer to the sacrum measured 1.8 cm in length by 1.0 cm in width by 0.2 cm in depth with no description of the wound. The right heel wound measured 4.4 cm in length by 4.2 cm in width by 0.4 cm in depth. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 01/02/24 revealed the stage IV pressure ulcer to the sacrum measured 3.4 cm in length by 1.6 cm in width by 0.3 cm in depth with no description of the wound. The right heel wound measured 4.5 cm in length by 4.3 cm in width by 0.4 cm in depth. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 01/09/24 revealed the stage IV pressure ulcer to the sacrum measured 1.2 cm in length by 1.3 cm in width by 0.3 cm in depth with no description of the wound. The right heel wound measured 4.8 cm in length by 4.6 cm in width by 0.4 cm in depth. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the weekly pressure ulcer assessment for Resident #57 dated 01/16/24 revealed the stage IV pressure ulcer to the sacrum measured 1.8 cm in length by 0.6 cm in width by 0.2 cm in depth with no description of the wound. The right heel wound measured 3.6 cm in length by 3.4 cm in width by 0.4 cm in depth. The assessment included a description which indicated the wound bed was granulation tissue with serous exudate and maceration to the peri-wound, but it did not indicate to which wound this description applied. The assessment did not indicate what stage and/or type of wound was present to the resident's right heel. The assessment did not indicate if the wounds had improved, declined or were unchanged. Review of the Treatment Administration Record (TAR) for Resident #57 dated December 2023 revealed the physician ordered treatment to the stage IV pressure ulcer to the sacrum (cleanse wound to sacrum with soap and water and pat dry, apply calcium alginate and Alleyn border foam dressing and change once daily) was not signed off as completed on the following dates: 12/03/23, 12/07/23, 12/11/23 and 12/12/23. The physician ordered treatment to the stage IV pressure ulcer to the heel (cleanse wound to right heel with soap and water, pat dry, apply calcium alginate and cover with border gauze once daily) was not signed off as completed on 12/12/23, 12/13/23 and 12/27/23. Review of the monthly physician's orders for Resident #57 for January 2024 revealed orders dated 01/17/24 to cleanse the stage IV pressure wound to the sacrum with wound wash or normal saline (NS), apply calcium alginate with silver and cover with border gauze daily and to cleanse the stage IV pressure wound to right heel with wound wash or NS, and to apply calcium with silver and border gauze daily. Observation on 01/17/24 at 1:10 P.M. of wound care for Resident #57 per Licensed Practical Nurse (LPN) #190 and State Tested Nursing Assistant (STNA) #219 revealed the staff completed the treatment to the pressure ulcers to the resident's sacrum and the resident's right heel. The resident had a dime-sized pressure ulcer to the sacrum which had visible necrotic tissue to the wound bed and a pressure ulcer to the right heel which was the size of a fifty-cent coin with visible slough to the wound bed. Interview on 01/18/24 at 8:25 A.M. with the Director of Nursing (DON) confirmed the facility staff did not conduct thorough wound assessments of Resident #57's stage IV pressure ulcer to the sacrum and the unstageable pressure ulcer to the right heel. The DON confirmed the facility measured the wounds weekly, but the assessments did not include a specific description of each wound and did not indicate whether or not the condition of the wound was improving or deteriorating and/or if the wound treatment needed to be changed. Further interview with the DON confirmed Resident #57 did not receive wound care as ordered to the right sacrum on 12/03/23, 12/07/23, 12/11/23 and 12/12/23 and did not receive wound care as ordered to the right heel on 12/12/23, 12/13/23 and 12/27/23. Review of the facility policy titled Wound Treatment Management dated 09/22/22 revealed wound treatments would be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change. Review of the NPUAP guidelines dated 2014 at (https://npiap.com/general/custom.asp?page=2014Guidelines) pages 151 and 152 revealed pressure ulcers should be assessed initially and the re-assessed at least weekly. The nurse should document the results of all wound assessments. The assessment and documentation of the physical characteristics of the wound should include the following: location, category/stage, size, tissue type(s), color, peri wound condition, wound edges, sinus tracts, undermining, tunneling, exudate, odor. The staff should use the findings of the pressure ulcer assessment to plan and document interventions that will best promote wound healing.

Based on medical record review, observation, and staff interview the facility failed to ensure accurate monitoring regarding resident consumption of physician ordered snacks. This affected one (Resident #54) of the three residents reviewed for nutrition. The facility census was 84. Findings include: Review of the medical record for Resident #54 revealed an admission date of 12/06/21 with diagnoses including dementia, aphasia, psychosis, aphasia, vitamin B12 deficiency, and altered mental status. Review of the annual Minimum Data Set (MDS) assessment for Resident #54 dated 12/06/23 revealed the resident was cognitively impaired, was coded negative for significant weight loss, and received a mechanically altered diet. Review of the care plan for Resident #54 revised 01/12/24 revealed the resident was at risk for impaired nutritional status. Interventions included staff should provide snacks three times a day. Review of the physician orders for Resident #54 revealed an order dated 08/16/23 for the resident to receive three snacks a day. Review of the Medication Administration Record (MAR) for Resident #54 for January 2024 revealed on 01/16/24 the resident was documented as having consumed 100 percent of the morning snack and 100 percent of the lunch snack. On 01/17/24 Resident #54 was documented as having consumed 50 percent of morning snack and 100 percent of the lunch time snack. On 01/18/24 Resident #54 was documented as having consumed 50 percent of the morning snack. Review of the nutritional risk assessment for Resident #54 dated 12/12/23 revealed the resident received peanut butter sandwiches for snacks because they provided increased protein. Observation on 01/16/23 at 4:15 P.M. revealed Resident #54 was lying in bed sleeping. There was half of a peanut butter sandwich lying on the resident bedside table in plastic bag which had not been opened or consumed. The bag was labeled with the resident's name and a date of 01/16/24. Observation on 01/17/24 at 8:45 A.M. revealed Resident #54 was lying in bed sleeping. There was half of a peanut butter sandwich on the residents bedside table in a plastic bag which had not been opened. The bag was labeled with the resident's name and was dated 01/17/24. Interview on 01/17/24 at 8:51 A.M. with State Tested Nursing Assistant (STNA) #126 confirmed the morning snack for Resident #54 was unopened and had not been consumed. STNA #126 stated Resident #54 frequently refused her snacks. Observation on 01/17/24 at 2:10 P.M. revealed Resident #54 was up ambulating in the room. There was half of a peanut butter sandwich on the residents bedside table in a plastic bag which had not been opened. The bag was labeled with the resident's name and was dated 01/17/24. Interview on 01/17/24 at 2:15 P.M with STNA #126 confirmed the snack for Resident #54 was unopened and had not been consumed. STNA #126 stated the resident had again refused the snack. Observation on 01/18/24 at 10:23 A.M. revealed Resident #54 was lying in bed sleeping. There was half of a peanut butter sandwich on the residents bedside table in a plastic bag which had not been opened. The bag was labeled with the resident's name and was dated 01/18/24. Interview 01/18/24 at 10:39 A.M. with STNA #126 confirmed the morning snack for Resident #54 was unopened and had not been consumed and the resident had refused the snack. STNA #126 further stated the nurse on duty documented the percentage of the residents' snacks consumed. Interview on 01/18/24 at 10:34 A.M with Dietary Supervisor (DS) #120 on 01/18/24 at 10:34 A.M. confirmed the kitchen provided Resident #54 with a snack of half of a peanut butter sandwich in the morning, at lunch time, and in the evening to fulfill the physician's order of a snack three times a day. Interview on 01/18/24 at 10:42 A.M. with Licensed Practical Nurse (LPN) #102 confirmed nurses documented the percentage of snacks consumed by residents in the MAR and relied on the STNAs to tell the nurses the percentage of the snacks consumed by the resident.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure oxygen saturation levels and respiratory rates were monitored as ordered by the physician for residents with impaired respiratory status. This affected one (Resident #21) of two residents reviewed for respiratory care. The facility census was 84. Findings include: Review of the medical record for Resident #21 revealed an admission date of 07/16/23 with diagnoses including vascular dementia, shortness of breath, chronic obstructive pulmonary disease (COPD), and nicotine dependence. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #21 dated 10/20/23 revealed the resident was mildly cognitively impaired. Review of the care plan for Resident #21 dated 07/28/23 revealed the resident was at risk for impaired gas exchange related to shortness of breath and COPD. Interventions included monitor oxygen saturation as ordered and as needed. Review of the physician's orders for Resident #21 revealed an order dated 08/29/23 to obtain vital signs every Wednesday on night shift. Review of the vital sign records for Resident #21 from October 2023 to January 2024 revealed the last recorded oxygen saturation levels for the resident was done on 10/25/23 and the resident's record did not include any subsequent assessments of oxygen saturation. Review of the vital sign records for Resident #21 from November 2023 to January 2023 revealed the last documented respiration rate for the resident was done on 11/17/23 and the resident's record did not include any subsequent assessments of respiratory rates. Interview on 01/18/24 at 8:28 A.M. with Licensed Practical Nurse (LPN) #190 confirmed Resident #21 had a physician's order for vital signs to be obtained every week on Wednesday on night shift. LPN #190 further confirmed the last recorded oxygen saturation level for Resident #21 was done on 10/25/23 and the last recorded respiratory rate for Resident #21 was done on 11/17/23. Review of the facility policy titled Vital Signs undated revealed vital signs were indicators of health status and included temperature, pulse, respiratory rate, blood pressure, oxygen saturation level, and pain level. Licensed nurses were responsible for knowing the usual range of a resident's vital signs, analyzing and interpreting routine vital signs, and notifying the physician of abnormal findings.

Based on medical record review and staff interviews the facility failed to ensure residents with post-traumatic stress disorder (PTSD) were appropriately assessed with care plans implemented to minimize triggers and/or re-traumatization. This affected one (Resident #76) of two facility-identified residents with PTSD/history of trauma. The facility census was 84. Findings include: Review of the medical record for Resident #76 revealed an admission date of 11/01/23 with diagnoses including PTSD, schizophrenia, bipolar disorder, and anxiety. Review of the admission Minimum Data Set (MDS) assessment for Resident #76 dated 11/07/23 revealed the resident was cognitively intact and was coded for an active and current diagnosis of PTSD. Review of the care plan for Resident #76 initiated 11/01/23 revealed the plan did not identify the cause of the resident's PTSD, triggers which could cause re-traumatization and/or interventions to reduce the risk of re-traumatization and provide care for PTSD symptoms. Interview on 01/22/24 at 9:20 A.M. with the Director of Nursing (DON) confirmed the facility had not conducted an assessment regarding the source of Resident #76's PTSD and the possible triggers which could cause re-traumatization for the resident. The DON further confirmed the facility had not implemented a care plan for Resident #76 to minimize the risk of re-traumatization and care for PTSD symptoms.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident (#54) out of the five residents reviewed for unnecessary medications. The facility census was 84. Findings include: Review of the medical record for Resident #54 revealed an admission date of 12/06/21 with diagnoses including dementia, psychosis, and hypothyroidism. Review of the physician's orders for Resident #54 revealed an order dated 07/28/23 for 100 micrograms (mcg) of levothyroxine sodium (a thyroid hormone) once a day for hypothyroidism. Review of the laboratory results for Resident #54 dated 11/27/23 revealed the resident had a thyroid stimulating hormone (TSH) level of 0.139 milliunits per liter (mU/L) which was a below normal result indicating the need for decreased thyroid hormone. The normal range was 0.4 to 4.0 mU/L. Further review revealed Nurse Practitioner (NP) #500 reviewed the laboratory result on 11/29/23 and documented an order at the bottom of the page to decrease the dose of levothyroxine sodium for Resident #54 to 50 mcg per day and to recheck the resident's TSH level in eight weeks. Review of the physician's orders for Resident #54 revealed an order dated 11/29/23 to administer 50 mcg of levothyroxine sodium once a day for hypothyroidism. Review of the consultant pharmacist's Medication Regimen Review (MRR) recommendation for Resident #54 dated 12/05/23 revealed on 11/29/23 a new order for levothyroxine 50 mcg was added and the order for levothyroxine 100 mcg was still active. Further review revealed there were no progress notes or lab work related to the new order and it was unclear if the new order reflected an increased or decreased dose of levothyroxine. The Director of Nursing (DON) had written on the bottom of the MRR recommendation form that the time of administration had been updated. Review of the annual Minimum Data Set (MDS) assessment for Resident #54 dated 12/06/23 revealed the resident was cognitively impaired. Review of the December 2023 and January 2024 Medication Administration Records (MARs) for Resident #54 revealed the resident was administered a 100-mcg dose and a 50-mcg dose of levothyroxine sodium daily from 12/06/23 to 01/17/24 for a total of 150 mcg per day. Review of the TSH results for Resident #54 dated 01/19/24 revealed the resident had a low TSH level of 0.030 mU/L. Interview with the DON on 01/22/24 at 9:05 A.M. confirmed Resident #54's TSH level on 11/27/23 was low. The DON confirmed NP #500 gave an order on 11/29/23 to decrease the dose of levothyroxine from 100 mcg per day to 50 mcg per day. The DON further confirmed the facility staff did not discontinue the 100-mcg dose of levothyroxine, and the nurses had administered 150 mcg per day of levothyroxine to Resident #54 rather than the reduced dose of 50 mcg per day ordered by NP #500. DON further confirmed this was a medication error identified by the surveyor. Interview with NP #500 on 01/22/24 at 10:49 A.M. confirmed she wrote an order on 11/29/23 to decrease Resident #54's levothyroxine sodium from 100 mcg per day to 50 mcg per because the resident's TSH level was low on 11/27/23 which indicated a need for a decreased dose of the medication. NP #500 confirmed the surveyor identified a medication error which resulted in the resident receiving an increased dose of levothyroxine sodium. NP #500 further confirmed the increased dose of levothyroxine could result in increased confusion and lethargy for the resident. Review of the facility policy titled Medication Errors dated 09/29/23 revealed significant medication errors included errors which caused the resident discomfort or jeopardized his/her safety. The facility should ensure residents were free from significant medication errors. This deficiency represents non-compliance investigated under Complaint Number OH00149963.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure physician visit notes were accurately documented in the resident medical record. This affected one (Resident #15) of 22 resident records sampled. The facility census was 84. Findings include: Record of the medical record for Resident #15 revealed an admission date of 09/07/23 with diagnoses including bipolar disorder, dementia with behavioral disturbance, and history of falling. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #15 dated 12/20/23 revealed the resident had mildly impaired cognition. Review of the nurse progress notes for Resident #15 revealed the resident was sent to the emergency room and was admitted to hospital on [DATE]. The resident was readmitted to the facility on [DATE]. Review of the physician progress note for Resident #15 dated 11/16/23 revealed the physician examined the resident in the facility for a 60-day regulatory visit. Interview on 01/18/24 at 8:00 A.M with the Director of Nursing (DON) confirmed Resident #15 was admitted to the hospital on [DATE] and did not return to the facility until 11/29/23. The DON further confirmed Physician #400 would not have been able to conduct a visit with Resident #15 in the facility on 11/16/23 as the resident was admitted to the hospital at that time. Telephone interview with Physician #400 on 01/22/24 at 4:00 P.M. confirmed the physician progress note for Resident #15 dated 11/16/23 had been documented in error. Physician #400 confirmed he had not examined the resident on that date.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure target behaviors were identified and monitored in conjunction with the use of anti-psychotic medications. This affected four (Residents #15, #54, #59, and #76) of 22 facility-identified residents with orders for anti-psychotic medications. The facility census was 84. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 09/07/23 with diagnoses including bipolar disorder, dementia with other behavioral disturbances, and hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #15 dated 12/20/23, revealed the resident was mildly cognitively impaired and received anti-psychotic medication on a routine basis. Review of the physician's orders for Resident #15 revealed an order dated 11/30/23 for Seroquel (an anti-psychotic medication) 300 milligrams (mg) once a day in the evening related to bipolar disorder. Review of the care plan for Resident #15 initiated 09/07/23 revealed the care plan did not include documentation regarding target behaviors being treated by use of the anti-psychotic medication. Interview on 01/18/24 at 8:00 A.M with the Director of Nursing (DON) confirmed the facility had not identified target behaviors or monitored behaviors related to the use of anti-psychotic medication for Resident #15. 2. Review of the medical record for Resident #54 revealed an admission date of 12/06/21 with diagnoses including dementia with other behavioral disturbances, psychosis, and anxiety disorder. Review of the annual MDS assessment for Resident #54 dated 12/06/23 revealed the resident was cognitively impaired and received anti-psychotic medication on a routine basis. Review of the physician's orders for Resident #54 revealed an order dated 07/26/23 for the Zyprexa 7.5 mg once daily for unspecified psychosis. Review of the care plan for Resident #54 initiated 12/06/21 revealed the care plan did not include documentation regarding target behaviors being treated by use of the anti-psychotic medication. Interview on 01/18/24 at 8:00 A.M with the DON confirmed the facility had not identified target behaviors or monitored behaviors related to the use of anti-psychotic medication for Resident #54. 3. Review of the medical record for Resident #76 revealed an admission date of 11/01/23 with diagnoses including schizophrenia, bipolar disorder, and post-traumatic stress disorder (PTSD). Review of the admission MDS assessment for Resident #76 dated 11/07/23 revealed the resident was cognitively intact and received anti-psychotic medication on a routine basis. Review of the physician's orders for Resident #76 revealed an order dated 11/07/23 for loxapine succinate 55 mg twice daily for schizophrenia. Review of the care plan for Resident #76 initiated 11/01/23 revealed the care plan did not include documentation regarding target behaviors being treated by use of the anti-psychotic medication. Interview on 01/18/24 at 8:00 A.M with the DON confirmed the facility had not identified target behaviors or monitored behaviors related to the use of anti-psychotic medication for Resident #76. 4. Review of the medical record for Resident #59 revealed an admission date of 08/07/21 with diagnoses including dementia with behavioral disturbance, diabetes mellitus, drug induced subacute dyskinesia, psychosis, major depressive disorder, insomnia, and anxiety disorder. Review of the physician's orders for Resident #59 revealed an order dated 07/25/23 for Risperdal 0.25 mg and 0.5 mg once daily for psychosis. Review of the care plan for Resident #59 initiated 08/07/21 revealed the care plan did not include documentation regarding target behaviors being treated by use of the anti-psychotic medication. Interview on 01/22/24 at 2:35 P.M with the DON confirmed the facility had not identified target behaviors or monitored behaviors related to the use of anti-psychotic medication for Resident #59 Review of the facility policy titled Unnecessary Drugs-Without Adequate Indications for Use undated revealed the facility would manage each residents' drug regimen and would monitor the medications to promote or maintain the residents highest practicable mental, physical and psychosocial well-being free from unnecessary drugs.

Based on observation and staff interview the facility failed to maintain a clean and functional environment with evidence of poor repair to five rooms that required wall repairs, room heater repairs, and painting. This affected five residents in rooms numbered B-1, B-5, B-8, B-12, and F-64. The facility census was 84. Findings include: Observation on 01/17/24 at 2:30 P.M. of Room B-12 with the Administrator revealed a large hole in the wall between the outside window and the wall heater. Cold air from outside was blowing into the room through the hole. Areas behind both beds had exposed dry wall and other exposed areas from missing paint with large holes in the drywall observed. The vent screen on the heating unit was visibly rusty and unpainted. Observation on 01/17/24 at 2:35 P.M. of Room B-8 with the Administrator revealed there were large, unrepaired holes in the drywall behind both resident beds and holes under the clock and across the room in the middle of the wall. There were some areas of exposed dry wall between the beds. Observation on 01/17/24 at 2:40 P.M. of Room B-5 with the Administrator revealed there were two large water stains on the ceiling above the sink. The vent screen on the heating unit was visibly rusty and unpainted. Observation on 01/17/24 at 2:45 P.M. of Room B-1 with the Administrator revealed there was a large area of stained flooring under the resident's bed. The vent screen on the heating unit was visibly rusty and unpainted. Observation on 01/17/24 at 2:52 P.M. of Room #F-64 with the Administrator revealed the metal cover on the heating unit was not properly installed and was leaning against the wall. Dry wall was exposed in multiple areas where the paint was peeling away. Interview on 01/17/24 at 3:00 P.M. with the Administrator confirmed the area identified during the observations of Rooms B-1, B-5, B-8, B12, and F-64 needed to be repaired. This deficiency represents non-compliance investigated under Complaint Number OH00149963.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, plumbing company interview and, review of plumbing invoices and quotes, this facility failed to timely fix/replace a non-working hot water heater that was used to provided hot water to the facility's laundry room. This had the potential to affect all residents residing in the facility at this time. The facility census was 81. Findings included: Review of the provided Quote from a local Plumbing, Heating and Cooling Company #1 dated 02/28/23 revealed the facility was provided a quote for the cost of $18,125.25 to replace the water heater in the facility ' s laundry room and for the labor to complete this work. Summary of work included: 1. Backordered - Expected May 26, 2023, through August 24, 2023. 2. Remove the existing water heater. 3. Install new AO [NAME] BRT - 365, 85 Gallon, 365,000 Gas Water Heater. 4. New heater to be ASME Construction. 5. Company providing the quote to supply State Permit and State Inspection. 6. Clean job site and leave water heater in good working order. Interview on 04/14/23 at 10:30 A.M. with the Administrator revealed the hot water tank located in the laundry room has not been functioning for a little over a month now. The Administrator claimed the facility had been in contact with plumbing companies obtaining quotes to have the hot water tank replaced and the work completed but each company they contact claim the hot water tank that is needed is on backorder and will take a few months to get in. The Administrator did not confirm during this time if a company was officially contracted to order the needed hot water tank and complete the work. The Administrator denied receiving any complaints or concerns from any of the residents or their family members regarding the facility's hot water temperatures. Interview on 04/14/23 at 10:12 A.M. with Laundry Aide #10 confirmed the hot water tank that provided hot water to the facility's laundry room was not working properly and had not been working for a few months now, but she could not recall how long it had been exactly. Interview on 04/14/23 from 11:50 A.M. through 12:30 P.M. with Maintenance Director #5 confirmed the hot water tank located in the facility's laundry room was not currently working and has not been working for almost two months now. Review of the provided Quote from Plumbing, Heating and Cooling Company #1 dated 04/18/23 revealed a estimate for labor and material to install a new water heater in the laundry room with an estimated cost of $13,299.00. This estimated quote was noted to be approved on 04/18/23 by the facility for replace hot water heater to be ordered for replacement and for the plumbing company to complete the labor. Interview on 04/18/23 at 2:40 P.M. with Secretary/Dispatcher #100 revealed their Plumbing, Heating and Cooling Company #1 had first provided the facility with a Quote back in February 2023 for labor and parts to replace the hot water broiler system in the facility' s laundry room. Claimed the facility ' s cooperate staff had gone back and forth with their company regarding different prices and quotes including the facility just purchasing the equipment form the company and installing it themselves. The Plumbing company claimed they informed the facility that to properly install this size and type of water heater, they are required to obtain a permit. It was not until 04/18/23 that the facility finally agreed and signed off on a Quote for the company to provide the replacement equipment and labor. This deficiency represents non-compliance investigated under Complaint Number OH00142006.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to communicate with therapy about range of motion and assistive device recommendations for Resident #23 and failed to ensure restorative range of motion was provided as ordered and addressed in the plan of care for the resident. This affected one resident (#23) of five residents reviewed for range of motion. Findings Include: Review of the medical record for Resident #23 revealed an admission date of 06/02/16 with diagnoses including chronic pulmonary edema, aphasia, mixed hyperlipidemia, sequelae of protein-calorie malnutrition, Alzheimer's disease, dysphagia, contracture of right ankle and right hand, major depression disorder, anorexia, hemiplegia affecting right side, cognitive communication deficit and cerebral infarction. Review of the restorative plan of care, dated 03/15/21 revealed Resident #23 was at risk for a decline in functional range of motion related to limited mobility. A decline was expected due to diagnoses. Interventions included completing passive range of motion ten repetitions of three to bilateral lower extremities six to seven days a week for at least 15 minutes a day, completing passive range of motion to bilateral upper repetitions with ten repetitions for 15 minutes or more for six to seven days a week, the nurse was to be informed of any changes in Resident #23's ability to participate or of any pain, and if the resident refused it should be offered again at a later time. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/06/22 revealed Resident #23 had severely impaired cognition, required extensive assistance from one person for bed mobility and transfers, walking and locomotion did not occur during the look back period and the resident was totally dependent on one person for eating. The assessment revealed the resident had range of motion impairment of the bilateral upper and lower extremities on one side. Review of Resident #23's physician's orders revealed she had an order for restorative passive range of motion to her right lower extremity according to the plan of care starting 05/11/22. Further review revealed an order for active range of motion to left lower extremity according to the plan of care starting 05/11/22. Review of the restorative task documentation Passive range of motion to bilateral lower extremity six to seven days a week for at least 15 minutes per day from 04/19/22 to 05/17/22, revealed they were not done consistently. Documentation indicated range of motion was done on 04/22/22, 04/27/22, 04/28/22, 04/29/22, 05/02/22, 05/06/22 and 05/07/22. Range of motion was refused on 04/23/22 and 05/10/22 and listed as 'not applicable' on 05/14/22. Review of the restorative task documentation Passive range of motion to bilateral upper extremities. Staff to perform range of motion to bilateral upper extremities six to seven days per week for 10 repetitions for 15 minutes or more from 04/19/22 to 05/17/22, revealed they were not done consistently. Documentation indicated range of motion was done on 04/22/22, 04/27/22, 04/28/22, 04/29/22, 05/02/22, 05/06/22 and 05/07/22. Range of motion was refused on 04/23/22 and 05/10/22 and listed as 'not applicable' on 05/14/22. Review of the physical therapy Discharge summary, dated [DATE] revealed Resident #23 received physical therapy from 03/01/22 to 05/06/22. The summary indicated a restorative program was not indicated at that time. Review of the occupational therapy Discharge summary, dated [DATE] revealed Resident #23 received occupational therapy from 02/28/22 to 05/06/22. The summary indicated a restorative program was not indicated at that time; she had a good prognosis with consistent staff follow-through. On 05/16/22 at 11:50 A.M., 12:38 P.M. and 1:22 P.M. and on 05/17/22 at 9:06 A.M. and 4:05 P.M. Resident #23's right hand was observed to be tightly contracted and her fingers were not visible. At each observation a soft palm protector was observed on the resident's bedside table. On 05/18/22 at 12:08 P.M. Resident #23's right hand was observed to be tightly contracted. A soft palm protector was resting on her chest above her hand. Agency Certified Nurse Aide (CNA) #77 attempted to unclench Resident #23's hand to view it. At that time, she was unable to open it enough to view the palm as Resident #23 was using her left hand to attempt to get her to stop opening her right hand. However, Resident #23's nails were observed to extend around half a centimeter past her fingertips. All nails on her right hand were black from the tip to halfway down her fingernail. On 05/18/22 at 12:08 P.M. interview with Agency CNA #77 confirmed Resident #23's nails were black and needed clipped and the hand protector had not been on. Agency CNA #77 reported completing restorative programs were hit or miss. She reported she made sure Resident #23 was wearing the palm protector but declined to comment on other aides. On 05/18/22 at 11:58 A.M. interview with Occupational Therapist (OT) #420 revealed Resident #23's contractures were not going to get better. She previously had a splint for her right hand, however, it no longer worked for her. She reported they then switched to the palm protectors, which she should wear a majority of the time. She revealed she had not gotten an order for the protector. OT #420 reported she made an error in the discharge summary and stated she had recommended the passive range of motion restorative program continue for Resident #23. On 05/19/22 at 9:30 A.M. interview with Physical Therapy (PT) Aide #210 revealed they had recommended no splints or restorative program for Resident #23's bilateral lower extremities upon discharge from therapy. On 05/19/22 at 10:00 A.M. interview with the Director of Nursing (DON) confirmed the remaining orders for range of motion to lower extremities, the plan of care interventions for bilateral upper and lower extremities, and the missing documentation for the restorative program as listed in the plan of care. She reported there seemed to be a communication problem. Review of the undated policy titled Restorative Nursing Documentation revealed treatment provided as part of a restorative nursing program was to be documented on a daily basis by the restorative aide or other trained individual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure fall interventions were in place for Resident #50 to prevent falls. This affected one resident (#50) of three residents reviewed for falls. Findings include: Review of the medical record for Resident #50 revealed the resident was admitted to the facility on [DATE] with diagnoses including hyperlipidemia, type two diabetes mellitus, dysphagia, chronic obstructive pulmonary disease, hemiplegia and hemiparesis affecting right dominant side, mood disorder, aphasia, cerebral infarction, cognitive communication deficit and major depression. Review of the plan of care, initiated 08/31/20 revealed Resident #50 was at risk for falls related to impaired balance, impaired mobility, hemiplegia, incontinence, pain, seizures, dizziness, and history of falls. Resident #50 had been educated and encouraged related to safety needs however, she continued to self-transfer and self-ambulate without asking for assistance. Interventions included anti-roll backs to wheelchair, perimeter mattress, extensive assistance of two staff members for transfers, encourage the resident to wear non-skid footwear, keep bed in lowest position, nonskid strips in front of the toilet, starting 09/16/20 Dycem to cushion in wheelchair, starting 11/18/21 Dycem to wheelchair, and starting 05/06/22 there was an intervention check the wheelchair had Dycem when getting the resident out of bed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/15/22, revealed Resident #50 had intact cognition, functional limitation in range of motion on one side to both upper and lower extremities, required extensive assist of one person for bed mobility and dressing and extensive assistance of two persons for transfers. Resident #50 had one fall since prior assessment without injury. Review of the progress note, dated 05/06/22 revealed Resident #50 was observed laying on her left side on the floor in front of her wheelchair. She stated she had slid out on her butt and fell over. The resident denied hitting her head, denied any pain or discomfort and no injuries were noted. Resident #50 was helped up by two staff without difficulty. There was no Dycem in wheelchair but there was a pillow on it. The new intervention was to check that the wheelchair had Dycem in it when getting the resident out of bed. Review of the fall investigation report, dated 05/06/22 revealed it repeated the information in Resident #50's progress note. Resident #50 was found on the floor, she stated she slid out of her wheelchair, and there was no Dycem noted in the wheelchair. The new intervention was to check that the wheelchair had Dycem in it when getting the resident out of bed. On 05/16/22 at 9:10 A.M. and on 05/18/22 at 12:08 P.M. observation revealed Resident #50 did not have a perimeter mattress in place. This was confirmed by Agency Certified Nurse Aide (CNA) #77 on 05/18/22 at 12:08 P.M. On 05/18/22 at 3:40 P.M. and 4:30 P.M. interview with the Director of Nursing (DON) confirmed the use of the Dycem was addressed multiple times in Resident #50's plan of care. She reported the first time the intervention was to put it in the wheelchair, the second time was to put the Dycem on the cushion in the chair and the third time the Dycem had not been in place. She additionally confirmed Resident #50 had an order for a perimeter mattress and it was in her plan of care, however, it was not in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to monitor meal and supplement intake for Resident #23 who had a significant weight loss. This affected one resident (#23) of seven residents reviewed for nutrition. Findings Include: Review of the medical record for Resident #23 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic pulmonary edema, aphasia, mixed hyperlipidemia, sequelae of protein-calorie malnutrition, Alzheimer's disease, dysphagia, contracture right ankle and right hand, major depression disorder, anorexia, hemiplegia affecting right side, cognitive communication deficit and cerebral infarction. Review of the plan of care, dated 11/03/21 revealed Resident #23 was at nutritional risk related to diagnoses of depression, dementia, dysphagia, hyperlipidemia, hypertension, and malnutrition, and poor meal intakes, weight fluctuations related to variable meal intakes, refusing meals at times and history of significant weight loss. Interventions included providing the diet as ordered, weighing the resident as ordered, encouraging meal and fluid acceptance, give medication to stimulate appetite, give nutritional supplements as ordered and ice cream with lunch and supper. Review of Resident #23's physician's orders revealed Resident #23 had an order for facility nourishment with meals and snacks starting 05/11/21, fortified juice with meals starting 05/02/22, Med pass (supplement) 90 milliliters (ml) twice a day starting 05/05/22 and increased to 200 ml on 05/12/22. Review of Resident #23's weight records revealed on 11/04/21 the resident weighed 116 pounds, on 12/02/21 the resident weighed 112 pounds, on 01/06/22 the resident weighed 108.6 pounds, on 02/03/22 she weighed 105 pounds, on 03/03/22 she weighed 106 pounds, on 04/07/22 she weighed 103.2 pounds, on 04/14/22, she weighed 101.4 pounds, on 04/21/22 she weighed 104 pounds, on 04/28/22 she weighed 102 pounds, and on 05/05/22 she weighed 102.4 pounds. Residents weight of 102.4 pounds indicated a clinically significant weight loss of 11.7% since 11/04/21. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/06/22 revealed Resident #23 had severely impaired cognition and was totally dependent on one person for eating. Resident #23 was 59 inches tall and weighed 102 pounds, she had lost weight while not on a weight-loss regimen. Review of the nutritional risk assessment, dated 05/09/22 revealed Resident #23 weighed 102 pounds which was a significant weight loss of 12% over 180 days. The resident's usual weight was 120-130 pounds. The resident was assessed to have total calorie needs as 1202 to 1740 calories a day, 46 to 55 grams of protein a day, and 1202 to 1740 ml of fluids per day. The resident was on a mechanical soft diet, her supplements and snacks included facility nourishment, juice, Med pass and ice cream which she had varied intake of. The dietitian indicated the resident had poor solid food intake; she consumed from 25-50% of meals. Foods, fluids, and interventions were to be encouraged. The dietitian indicated the resident liked liquids better than solid foods but had varied intake. Review of Resident #23's documentation for meal intake from 04/19/22 to 05/18/22 revealed three intakes were documented on 04/20/22, 04/22/22, 04/27/22, 05/06/22 and 05/07/22. Only two intakes were documented on 04/23/22, 04/28/22, 04/29/22, 05/02/22, 05/10/22, 05/14/22 and 05/17/22. Only one intake was documented on 05/11/22. No meal documentation was entered on 04/19/22, 04/21/22, 04/24/22, 04/25/22, 04/26/22, 04/30/22, 05/01/22, 05/03/22, 05/04/22, 05/08/22, 05/09/22, 05/12/22, 05/13/22, 05/15/22, 05/15/22 or 05/18/22. Review of Resident #23's documentation for intake of fortified juice with meals from 05/02/22 to 05/18/22 revealed there were no days where three intakes with meals were documented. Only two intakes were documented on 05/02/22, 05/06/22, 05/07/22, 05/10/22 and 05/14/22. Only one intake was documented on 05/05/22 and 05/11/22. No intakes were documented on 05/03/22, 05/04/22, 05/08/22, 05/09/22, 05/12/22, 05/13/22, 05/15/22, 05/16/22, 05/17/22 or 05/18/22. Review of Resident #23's documentation for intake of facility nourishment at all three meals from 04/19/22 to 05/18/22 revealed there were three intakes documented on 04/22/22 and 04/27/22. Only two intakes were documented on 04/23/22, 04/28/22, 04/29/22, 05/02/22, 05/06/22, 05/07/22, 05/10/22, and 05/14/22. Only one intake was documented on 04/20/22, 05/05/22, and 05/11/22. No intakes were documented on 04/19/22, 04/21/22, 04/24/22, 04/25/22, 04/26/22, 04/30/22, 05/01/22, 05/03/22, 05/04/22, 05/08/22, 05/09/22, 05/12/22, 05/13/22, 05/15/22, 05/16/22, 05/17/22 or 05/18/22. Review of Resident #23's documentation for facility nourishment with snacks three times a day from 04/19/22 to 05/18/22 revealed there were three intakes documented on 05/02/22. Two intakes were documented on 04/22/22, 04/23/22, 04/27/22, 04/28/22, 04/29/22, 05/06/22, 05/07/22, 05/10/22, and 05/14/22. One intake was documented on 04/20/22, 05/05/22, and 05/11/22. No intakes were documented on 04/19/22, 04/21/22, 04/24/22, 04/25/22, 04/26/22, 04/30/22, 05/01/22, 05/03/22, 05/04/22, 05/08/22, 05/09/22, 05/12/22, 05/13/22, 05/15/22, 05/16/22, 05/17/22 or 05/18/22. Interview on 05/19/22 at 10:34 A.M. with Registered Dietitian (RD) #95 revealed she had been following Resident #23 closely. She reported they had adjusted her Med pass supplement amount frequency due to changing intakes. RD #95 reported they had multiple interventions in place including juice and other liquid supplements. She confirmed documentation for meal and supplement intake outside of the Medication Administration Record was a problem. She reported she would have to ask multiple facility staff to determine her true intake. Interview on 05/19/22 at 1:20 P.M. with the Director of Nursing (DON) confirmed meal intake and supplement intake were not documented according to when they should have been given. She reported this was due to agency staff. The DON said they were aware of the problem but by the time they realized the documentation had not occurred the agency staff had left. Review of the undated facility policy titled Nutritional and Dietary Supplements revealed due to the possible interactions with some medications, the resident's intake should be documented in the clinical record. Review of the undated facility policy titled Weight Monitoring revealed nutrition interventions were to be identified, implemented, monitored and modified consistent with the resident's assessed needs and current professional standards.

Based on observation, record review and interview the facility failed to develop and implement a comprehensive and individualized behavior management plan to address the total care needs of Resident #45 and to decrease and/or eliminate yelling behaviors the resident was exhibiting. This affected one resident (#45) of one resident reviewed for accommodation of needs. Findings Include: A review of the medical record for Resident #45 revealed an admission date of 01/25/21 with diagnoses including paraplegia, hemiplegia to left hand, end stage renal disease, paralytic syndrome and chronic respiratory failure. A review of the resident's care plans revealed no plan of care related to or addressing behaviors or difficulty with range of motion to the resident's upper and lower extremities. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/04/22 revealed Resident #45 was alert and oriented, able to make decisions, was dependent on staff for mobility and had a pressure injury wound to his sacrum. The MDS assessment also revealed Resident #45 had impaired range of motion to both upper and both lower extremities and had a history of verbal behavior towards others but not enough to significantly intrude on others privacy. An occupational therapy evaluation, dated 05/10/22 revealed Resident #45 had a significant decline in functional mobility and generalized weakness after multiple recent hospital stays. Review of an occupational note for Resident #45, dated 05/13/22 revealed Resident #45 had impaired mobility in all four extremities including all fingers on his right and left hand. It also revealed he was dependent (on staff) for bed mobility, eating and transfers. On 05/16/22 at 9:35 A.M. interview with Resident #2 revealed he had a complaint about Resident #45 always yelling. Resident #2 stated Resident #45 was keeping him awake because he yells 12 hours per day. Resident #2 further stated he had told several staff about the noise, but nothing had changed. On 05/18/22 at 9:20 A.M. a follow up interview requested by Resident #2 was conducted. Resident #2 revealed he was concerned Resident #64 might hurt Resident #45 because the resident (#45) had been yelling all night again. Resident #2 did not state when or how Resident #64 would hurt Resident #45. On 05/18/22 from 9:24 A.M. through 9:30 A.M. an observation revealed Resident #45, who was in his room was yelling and could be heard up to four rooms away. The call light for Resident #45 was not ringing or lit up at the time. Resident #45 was repeatedly yelling out statements that included I am burning up, oh God, and Help. Resident #64 was heard yelling at Resident #45 to shut up, knock it off, and turn it down! Resident #64 also called Resident #45 an inconsiderate brat. On 05/18/22 at 9:30 A.M. interview with Resident #64 confirmed he was upset with Resident #45 and stated he (Resident #45) yells all night interrupting his sleep. Resident #64 stated he had no intention of hurting anyone but wanted his roommate to stop the nonsense. Resident #64 stated he had reported this to the social worker and thought they were working on a new room for him. Resident #64 further revealed the nurses had not done anything but call him (Resident #45) a screamer when he had reported his frustration to them. On 05/18/22 at 9:35 A.M. an observation of Resident #45's call light revealed it was right next to his left hand. The call light was a flat pancake style. Resident #45 became visibly angry when he was asked to show he was unable to ring his call light. Resident #45 began yelling again and stated, How many hundreds of times do I have to tell you I CAN'T!!! Resident #45 then stated the wound on his bottom was burning and requested cream be placed on it. Resident #45 began crying and stated, Why do I have to keep telling people I can't do it? An interview with State Tested Nursing Assistant (STNA) #310 on 05/18/22 at 9:45 A.M. revealed STNA #310 stated she had always heard Resident #45 yelling and had never seen him use a call light. On 05/18/22 at 9:48 A.M. an observation between Resident #45 and Licensed Practical Nurse (LPN) #970 was conducted. When LPN #970 asked Resident #45 to use his left hand to press the call light, Resident #45 stated he couldn't. LPN #970 was observed rolling her eyes. When Resident #45 began yelling he stated he couldn't push the button because he was paralyzed, LPN #970 moved the call light to the right side and asked Resident #45 to try pressing the call light with his right hand. Resident #45 yelled again stating he couldn't. On 05/18/22 at 9:50 A.M. interview with LPN #970 confirmed Resident #45 always yelled and complained about his bottom hurting. LPN #970 revealed Resident #45's inability to press the call light was a behavior and he needed to see psychology services. LPN #970 revealed she was aware of the pressure ulcer on Resident #45's sacrum and that he had complained of it burning. LPN #970 revealed Resident #45 shouldn't be having much pain there because the wound was almost healed. LPN #970 further stated she had never seen the resident use his call light except one time maybe a few weeks ago. LPN #970 stated she did not know the process for evaluating the ability of resident's use of call lights. On 05/18/22 at 10:00 A.M. an interview with Resident #19 revealed she had sometimes heard someone yelling and pointed to the doorway. Resident #19 revealed the noise occurred at random times. On 05/18/22 at 10:05 A.M. an interview with Resident #329 revealed she always hears a gentleman yelling and it wakes her up at night. Resident #329 further revealed she had tried to ignore it but couldn't always help it. Resident #329 also stated she felt bad for whomever was yelling. On 05/18/22 at 10:20 A.M. interview with Resident #75 revealed she was often awakened by someone yelling at night. Resident #75 further revealed she was not for certain if it was a man or woman who yelled, but it did worry her when she heard it. On 05/18/22 at 12:00 P.M. interview with Occupational Therapist (OT) #420 revealed Resident #45 always wants to be picked up for occupational and physical therapy, but he couldn't do much. OT #420 revealed Resident #45 was a yeller and did not like when they tried stretching his hands in the past because it was painful for him. On 05/18/22 at 1:45 P.M. interview with Social Worker #430 revealed she was aware of multiple resident complaints including Resident #64 and Resident #2 about Resident #45's yelling. Social Worker #430 further stated she had made several attempts to make accommodations for residents who had complaints about the noise. Social Worker #430 stated she was frustrated because every time she tried to make a room change for Resident #64 and Resident #2, she was not able to. Social Worker #430 stated the Director of Nursing (DON) and Administrator would not allow her to move residents to other rooms. Social Worker #430 had suggested using an empty room or the empty hall in the facility but was told she could not because of staffing concerns. Social Worker #430 revealed multiple emails had been ignored when trying to advocate for residents with complaints about Resident #45. Social worker #430 also confirmed there was no plan of care for Resident #45 about his yelling behavior. On 05/18/22 at 2:00 P.M. interview with the DON confirmed staff were aware of resident complaints about Resident #45 yelling. The DON revealed she believed Resident #45 knew how to use a call light and had behaviors. There was no evidence the behaviors had been comprehensively assessed or addressed to manage, decrease or prevent. The DON revealed she was not aware there was no care plan for behaviors in Resident #45's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide an appropriate diagnosis for the use of antipsychotic medication for Resident #51. This affected one resident (#51) of five residents reviewed for unnecessary medication use. Findings Include: Record review for Resident #51 revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, depression, hypertension, anxiety, insomnia, Vitamin D deficiency, seizures, dementia, falls and diabetes mellitus type II. Review of the Minimum Data Set (MDS) 3.0 assessment, completed on 02/09/22 revealed the resident had severe cognitive impairment. Review of physician's orders revealed the resident had an order for the psychoactive medication, Seroquel 50 milligrams (mg) by mouth daily for unspecified dementia, anxiety and depression and Risperdone three mg by mouth daily at bedtime for unspecified dementia. Interview with the Director of Nursing on 05/18/22 at 02:35 P.M. verified unspecified dementia was not an acceptable diagnosis for the use of Seroquel or Risperdone. Also verified the resident received the medications on a daily basis.

Based on observation and interview the facility failed to provide residents a comfortable and homelike environment. This affected five residents (#2, #19, #329, #75 and #64) of five residents interviewed regarding the environment. Findings Include: On 05/16/22 at 9:35 A.M. interview with Resident #2 revealed he had a complaint about Resident #45 always yelling. Resident #2 stated Resident #45 was keeping him awake because he yells 12 hours per day. Resident #2 further stated he had told several staff about the noise, but nothing had changed. On 05/18/22 at 9:20 A.M. a follow up interview requested by Resident #2 was conducted. Resident #2 revealed he was concerned Resident #64 might hurt Resident #45 because the resident (#45) had been yelling all night again. Resident #2 did not state when or how Resident #64 would hurt Resident #45. On 05/18/22 from 9:24 A.M. through 9:30 A.M. an observation revealed Resident #45, who was in his room was yelling and could be heard up to four rooms away. The call light for Resident #45 was not ringing or lit up at the time. Resident #45 was repeatedly yelling out statements that included I am burning up, oh God, and Help. Resident #64 was heard yelling at Resident #45 to shut up, knock it off, and turn it down! Resident #64 also called Resident #45 an inconsiderate brat. On 05/18/22 at 9:30 A.M. interview with Resident #64 confirmed he was upset with Resident #45 and stated he (Resident #45) yells all night interrupting his sleep. Resident #64 stated he had no intention of hurting anyone but wanted his roommate to stop the nonsense. Resident #64 stated he had reported this to the social worker and thought they were working on a new room for him. Resident #64 further revealed the nurses had not done anything but call him (Resident #45) a screamer when he had reported his frustration to them. An interview with State Tested Nursing Assistant (STNA) #310 on 05/18/22 at 9:45 A.M. revealed STNA #310 stated she had always heard Resident #45 yelling and had never seen him use a call light. On 05/18/22 at 10:00 A.M. an interview with Resident #19 revealed she had sometimes heard someone yelling and pointed to the doorway. Resident #19 revealed the noise occurred at random times. On 05/18/22 at 10:05 A.M. an interview with Resident #329 revealed she always hears a gentleman yelling and it wakes her up at night. Resident #329 further revealed she had tried to ignore it but couldn't always help it. Resident #329 also stated she felt bad for whomever was yelling. On 05/18/22 at 10:20 A.M. interview with Resident #75 revealed she was often awakened by someone yelling at night. Resident #75 further revealed she was not for certain if it was a man or woman who yelled, but it did worry her when she heard it. On 05/18/22 at 12:00 P.M. interview with Occupational Therapist (OT) #420 revealed Resident #45 always wants to be picked up for occupational and physical therapy, but he couldn't do much. OT #420 revealed Resident #45 was a yeller. On 05/18/22 at 1:45 P.M. interview with Social Worker #430 revealed she was aware of multiple resident complaints including Resident #64 and Resident #2 about Resident #45's yelling. Social Worker #430 further stated she had made several attempts to make accommodations for residents who had complaints about the noise. Social Worker #430 stated she was frustrated because every time she tried to make a room change for Resident #64 and Resident #2, she was not able to. Social Worker #430 stated the Director of Nursing (DON) and Administrator would not allow her to move residents to other rooms. Social Worker #430 had suggested using an empty room or the empty hall in the facility but was told she could not because of staffing concerns. Social Worker #430 revealed multiple emails had been ignored when trying to advocate for residents with complaints about Resident #45. On 05/18/22 at 2:00 P.M. interview with the DON confirmed staff were aware of resident complaints about Resident #45 yelling. The facility failed to provide additional information related to how a comfortable and homelike environment was provided for Resident #2, #19, #329, #64 and #75 related to Resident #45 yelling at random and ongoing times throughout each day.

Based on record review and staff interview the facility failed to ensure quarterly Quality Assessment and Assurance (QAA) meetings were conducted. This had the potential to affect all 84 residents residing in the facility. Findings Include: Review of the QAA sign in sheets from 2021 and 2022 revealed meetings were held on 07/29/21 and 11/19/21. The facility failed to provide any additional sign in sheets to reflect quarterly meetings being conducted. Interview with the Administrator on 05/19/22 at 1:50 P.M. verified no further meeting sign in sheets could be found or provided as the only records were from meetings held on 07/29/21 and 11/19/21.