Based on medical record review, review of facility Self-Reported Incidents (SRIs), staff interview, and review of the facility policy, the facility failed to report an allegation of sexual abuse to the state survey agency. This affected one (Resident #36) of three residents reviewed for abuse. The facility census was 78. Findings include: Review of the medical record for Resident #36 revealed admission date of 10/09/23 with diagnoses including type two diabetes mellitus, atrial fibrillation, peripheral vascular disease, congestive heart failure and fracture of the right humerus. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #36 dated 04/08/24 indicated the resident had intact cognition. Review of the facility SRIs for 2024 revealed there were no reports related to Resident #36. Interview on 04/23/24 at 9:42 A.M. with the Administrator confirmed the facility investigated an allegation reported by staff on 03/26/24 of an inappropriate relationship between Licensed Practical Nuse (LPN) #10 and Resident #36. Staff had reported the relationship as inappropriate and that they had witnessed LPN #10 hug and kiss Resident #36. During the investigation of the allegation LPN #10 was placed on administrative leave. Further interview with the Administrator confirmed the facility was unable to substantiate abuse. Interview on 04/23/24 at 11:42 A.M. with State Tested Nursing Assistant (STNA) #44 confirmed the STNA had heard other staff talking about Resident #36 and LPN #10 having an inappropriate relationship. STNA #44 confirmed she had seen Resident #36 and LPN #10 exit the elevator together and they were both laughing. When the doors opened, the resident thanked the nurse and called her honey. STNA #44 confirmed she reported this to the nurse manager because she felt that something was going on between Resident #36 and LPN #10, some sort of inappropriate relationship. Interview on 04/23/24 at 11:57 A.M. with LPN #111 confirmed she had witnessed LPN #10 hug residents and/or kiss them on the cheek or the forehead, but she didn't think anything of it. LPN #11 confirmed LPN #10 was overly nice to the residents and seemed like she wanted them to like her. Interview with the Administrator and the Regional Director of Operations (RDO) confirmed the Administrator informed the RDO of the allegations made by staff on 03/26/24 regarding LPN #10 and Resident #36. The Administrator confirmed the facility investigated the allegation and did place the alleged perpetrator (AP), LPN #10 on administrative leave pending the investigation. The Administrator confirmed facility did not report the allegation regarding LPN #10 to the state agency, the Ohio Department of Health (ODH.) Review of the facility investigation regarding Resident #36 and LPN #10 dated 03/26/24 revealed the facility interviewed Resident #36 who denied an inappropriate relationship with LPN #10. The facility also interviewed LPN #10, the AP, who also denied having an inappropriate relationship with the resident. The facility interviewed other staff members but was unable to substantiate abuse or any form of mistreatment had occurred. Review of facility policy titled Abuse, Neglect and Exploitation dated 10/24/22 revealed sexual abuse was defined as nonconsensual sexual contact of any type with a resident. The policy stated all alleged violations would be reported to government agencies within specified timeframes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected three (Resident #6, Resident #40, and Resident #49) of four residents reviewed for PASRR documents. The census was 72. Findings Include: 1. Resident #6 was admitted to the facility on [DATE]. His diagnoses were dementia, schizoaffective disorder, dysphagia, falls, hyperlipidemia, myocardial infarction, depression, obstructive uropathy, chronic pain, anemia, hypertension, anxiety, dysphagia, altered mental status, acute kidney disease, cervicobrachial syndrome, and restless leg syndrome. Review of his Minimum Data Set (MDS) assessment, dated 07/09/23, revealed he was minimally impaired. Review of medical diagnoses for this resident revealed a new diagnosis of schizoaffective disorder was added on 09/14/21. Most recent PASARR was completed on 04/01/21 and does not reflect this diagnosis. A corrected PASARR was completed on 10/03/23 reflecting the new diagnosis addition. Interview with the Administrator on 10/03/23 at 02:42 P.M. verified a new PASARR should have been completed with the addition of the new diagnosis. 2. Resident #40 was admitted to the facility on [DATE]. His diagnoses were arthritis, dementia, schizoaffective disorder, atherosclerosis, hypertension, hypothyroidism, hyperlipidemia, atrial fibrillation, aortic valve insufficiency, hypokalemia, chronic kidney disease stage 4, macular degeneration, venous insufficiency, congestive heart failure, muscle weakness, abnormalities of gait and mobility, anxiety, depression, and hearing loss. Review of his MDS assessment, dated 07/11/23, revealed he was minimally to moderatelyimpaired. Review of the PASARR from 04/19/23 revealed no indications of schizoaffective disorder diagnosis from the admission PASARR. A new PASARR was not completed with the new diagnosis from 04/19/23. A correct PASARR was completed on 10/03/23 during the survey. Interview with the Administrator on 10/03/23 at 02:42 P.M. verified a new PASARR should have been completed with the addition of the new diagnosis. 3. Resident #49 was admitted to the facility on [DATE]. His diagnoses were cardiomyopathy, schizoaffective disorder, depression, osteoporosis, bipolar disorder, alopecia, anxiety, aphagia, atherosclerosis, cognitive communication deficit, diverticulosis, hypertension, mood disorder, atrial fibrillation, constipation, dementia, and falls. Review of his MDS assessment, dated 07/09/23, revealed she was rarely/never understood. Review of medical diagnoses for this resident revealed a new diagnosis of schizoaffective disorder was added on 04/21/23. Most recent PASARR was completed on 09/14/22 and does not reflect this diagnosis. A corrected PASARR was completed on 10/03/23 reflecting the new diagnosis addition. Interview with the Administrator on 10/03/23 at 02:42 P.M. verified a new PASARR should have been completed with the addition of the new diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility to adequately assess and provide treatment for Resident #64 who had red, dry, flaky scalp. This affected one (Resident #64) of two residents reviewed for activities of daily living. The facility census was 72. Findings include: Review of the medical record for Resident #64 revealed an admission date of 08/04/23 with diagnoses including rhabdomyolysis, dementia without behaviors, pain, dysphagia and fracture of unspecified part of neck of right femur. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #64 required extensive assistance of one person for personal hygiene and was totally dependent on two staff for bathing needs. Resident #64 had a surgical wound with application of dressing and application of ointment/medications other than to feet. Review of the weekly skin integrity checks for Resident #64 dated 09/11/23 indicated Resident #64 had an area to the lower part of head and back region with dry, cracked skin. The weekly skin integrity checks dated 09/13/23 and 09/20/23 revealed no changes to Resident #64 skin. Review of the physician orders for 10/2023 revealed Resident #64 was not ordered any treatment to his red, dry, flaky scalp. Review of the plan of care revealed no plan related to altered skin integrity or risk of altered skin integrity. Observations on 10/02/23 at 11:22 A.M., 10/03/23 at 11:03 A.M. and on 10/04/23 at 10:40 A.M revealed Resident #64 had red scalp with large white flakes in his hair and along his hair line. Interview on 10/03/23 at 11:08 A.M. with Registered Nurse (RN) #125 confirmed Resident #64 had large white flakes in his hair and along his hair line. Interview on 10/04/23 at 10:45 A.M. with Director of Nursing (DON) confirmed Resident #64 had impaired skin integrity as evidenced by large white flakes in his hair and along his hair line.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy revealed the facility failed to implement non-pharmacological interventions for Resident #48 prior to administering as needed narcotic pain medications. This affected one resident (Resident #48) reviewed for pain management. The facility census was 72. Findings include: Review of the medical record for Resident #48 revealed an admission date of 06/20/23 with diagnoses including nonalcoholic steathohepatitis (NASH), fatty liver, urinary retention, peripheral vascular disease, chronic kidney disease and gout in left knee. Review of the Medicare five day Minimum Data Set (MDS) dated [DATE] revealed Resident #48 was cognitively intact, required assistance with activities of daily living and had no scheduled or as needed pain medications. Resident #48 did not have any pain. Review of the physician orders dated 09/23 for Resident #48 revealed an order for hydrocodone-acetaminophen (narcotic pain medication) tablet 5-325 milligrams (mg) by mouth every six hours as needed for pain. Review of the Medication Administration Record (MAR) for 09/23 for Resident #48 revealed he received hydrocodone-acetaminophen tablet 5-325 mg by mouth at least once a day from 09/01/23 through 09/30/23. There were no non pharmacological interventions implemented or documented as provided before administering the pain medication. Review of the nursing progress notes from 09/01/23 through 09/30/23 was silent on providing non pharmacological interventions prior to administering the pain medication. Review of the plan of care dated 05/22/23 and revised on 09/18/23 revealed Resident #48 needed pain management and monitoring related to NASH, general debility and peripheral vascular disease. The Interventions included administer medication as ordered, monitor for effectiveness of medication, evaluate and establish level of pain on numeric scale, and implement Resident #48 preferred non pharmacological interventions for pain relief-rest, repositioning and relaxation. Interview on 10/02/23 at 2:29 P.M. and 10/03/23 at 9:00 A.M. with Resident #48 revealed the resident had pain and received pain medication when he requested it. Interview on 10/04/23 at 2:03 P.M. with Unit Manager #157 revealed non pharmacological interventions were in the residents care plan. Unit Manager #157 stated the nurse would document the non pharmacological interventions that were attempted on the MAR. Interview on 10/04/23 at 2:28 P.M. with the Director of Nursing confirmed Resident #48 did not receive non pharmacological interventions before administration of narcotic pain medication. Review of the facility policy titled Pain Management dated 09/29/22 revealed non pharmacological interventions would include but no limited to environmental comfort measures, loosening any constrictive bandage, clothing or device, applying splinting, physical modalities, exercises to address stiffness and prevent contractures and cognitive/behavioral interventions such as music, relaxation techniques, activities, diversions, comfort support, teaching the resident coping techniques and education about pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide care and services to address Resident #48's verbalization of being sad and depressed. This affected one resident (Resident #48) reviewed for behavioral-emotional issues. The facility census was 72. Findings include: Review of the medical record for Resident #48 revealed an admission date of 06/20/23 with diagnoses including nonalcoholic steathohepatitis (NASH), fatty liver, urinary retention, peripheral vascular disease, chronic kidney disease and gout in left knee. Review of the Medicare five day Minimum Data Set (MDS) dated [DATE] revealed Resident #48 was cognitively intact and had trouble with sleeping, feeling down, depressed and hopeless, feeling tired with no energy, poor appetite and trouble concentrating. Resident #48 scored 10 on mood assessment indicating moderate depression. Review of the physician orders dated 09/23 for Resident #48 revealed there were no orders for antidepressant medications or other mood disorder medications. There was not any orders related to psychiatric care and treatment. Review of the nursing progress notes from 09/01/23 through 09/30/23 was silent in regards to mood disorder or signs and symptoms of depression. Review of the plan of care dated 06/27/23 revealed Resident #48 felt sad, could not sleep, had no appetite or energy and felt inadequate at times. The interventions included to encourage Resident #48 to get involved in activities related to his interests, help the resident to keep in contact with family and friends, introduce the resident to others with similar interests, offer food and beverages the resident liked and take the time to discuss the residents feelings when he was feeling sad. Interview on 10/03/23 at 9:00 A.M. with Resident #48 revealed he felt down about his life and was sad. Resident #48 became tearful and expressed he was feeling sad. Interview on 10/04/23 at 3:34 P.M. with Social Services revealed she completed the mood section of the MDS assessment. Social Services stated she had visited with Resident #48 several times and he talked more about moving out of the facility and not his feelings. Social Services stated she did not document all the conversations she had with residents as their conversations were private and confidential. Social Services did not provide any documentation of conversations with Resident #48 about his feelings of depression.

Based on observation, interview, medical record review, and facility policy review revealed the facility failed to ensure the proper storage of nebulizer machine mask to prevent contamination and possible infection. This affected one resident (Resident #173)out of one resident reviewed for respiratory care. The facility census was 72. Findings include: Review of the medical record for Resident #173 revealed an admission date of 09/27/23 with diagnoses including acute and chronic respiratory failure with hypoxia and hypercapnia, obstructive sleep apnea, hypertension and peripheral vascular disease. The Minimum Data Set (MDS) comprehensive assessment was not complete at this time. Review of the physician orders for Resident #173 dated 09/23 revealed an order for ipratropium-albuteral solution 0.5 to 2.5 (3) milligrams (mg) per 3 milliliters (ml) inhale orally four times daily related to acute and chronic respiratory failure with hypoxia and hypercapnia. Review of the Medication Administration Record (MAR) 09/23 revealed Resident #173 received nebulizer respiratory medication as ordered. The plan of care was silent related to providing protective barrier to nebulizer machine breathing mask. Observations made during the annual survey on 10/02/23 at 8:51 A.M., 10/03/23 at 11:14 A.M. and 10/04/23 at 1:18 P.M. revealed Resident #173 nebulizer machine was on the bedside table. The tubing was not dated and the mask was hanging over the side of the table. Interview on 10/04/23 at 1:18 P.M. with Resident #173 revealed the mask did not have a protective barrier to prevent contamination since she had been at the facility. Interview on 10/04/23 at 1:19 P.M. with State Tested Nursing Assistant (STNA) #83 confirmed the nebulizer mask was not in a protective barrier for infection control. STNA #83 also confirmed there was not a date on the mask tubing. Review of the facility policy titles Oxygen Administration dated 09/29/22 revealed to change nebulizer tubing and delivery devices weekly and as needed if become soiled or contaminated. Also stated to keep deliver devices covered in plastic bag when not in use.

Based on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to place call lights within resident reach. This affected two (Resident's #39 and #28) of two residents reviewed for call lights. The facility census was 59. Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 10/15/21. Diagnoses included malignant neoplasm of an unspecified part of the right bronchus or lung, malignant neoplasm of the heart, acute and chronic respiratory failure with hypoxia, schizoaffective disorder bipolar type, dementia without behavioral disturbance, anxiety disorder, vertigo of the central origin, hyperlipidemia, hypothyroidism, protein-calorie malnutrition, bipolar disorder, and adult failure to thrive. Review of the care plan dated 01/14/22 revealed Resident #39 was at risk for falls related to being in a new environment, vertigo, general weakness, debility, non-compliance with asking for help, and a history of falls. Interventions included Call Don't Fall sign on the wall and call light within reach. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/16/22, revealed Resident #39 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of 15 (severe cognitive impairment). Resident #39 exhibited behaviors such as inattention and disorganized thinking. Resident #39 required limited to extensive assistance of one to two staff or more for all activities of daily living (ADL) except eating which required set-up and supervision. Resident #39 was occasionally incontinent of bladder and was always incontinent of bowels. Further review of the MDS revealed Resident #39 did not have a pressure injury/ulcer, was at risk for pressure ulcers, and did not have any unhealed pressure ulcers. The MDS revealed Resident #39 had a pressure reducing device for the bed but no other skin and ulcer/injury treatments. Observation and interview on 03/07/22 at 10:40 A.M. revealed Resident #39's call light was in her night stand top drawer and she revealed she was unsure where her call light was located. Observation on 03/08/22 at 8:57 A.M. revealed Resident #39 was resting in bed with her call light pinned to the bed above her right shoulder and a sign on wall across from her read use call light for assistance. Interview and observation on 03/08/22 at 3:52 P.M. with Licensed Practical Nurse (LPN) #999 confirmed Resident #39's call light was pinned to the right of her. LPN #999 stated in the mind set the resident was in on 03/08/22, she would not be able to look and locate her call light to use it. 2. Review of the medical record for Resident #28 revealed an admission date of 01/03/22. Diagnoses included chronic obstructive pulmonary disease (COPD), heart failure, Stage IV chronic kidney disease (CKD IV), reduced mobility, obstructive sleep apnea (OSA), insomnia, major depressive disorder, nicotine dependence, hypertension (HTN), type two diabetes mellitus (DM II), gastro-esophageal reflux (GERD), hyperlipidemia, repeated falls, muscle weakness, benign prostatic hyperplasia (BPH), rhabdomyolysis, weakness, orthostatic hypotension, syncope and collapse, obesity, and atherosclerotic heart disease of the native coronary artery without angina pectoris. Review of the admission MDS 3.0 assessment, dated 01/09/22, revealed Resident #28 had intact cognition with a BIMS score of 15 out of 15 (no impairment). The resident did not have any documented behaviors. Resident #28 required extensive assistance of one to two or more staff for all ADL except eating which he required supervision and one-person physical assistance. Review of the plan of care dated 01/12/22 revealed Resident #28 was at risk for falls related to a new environment, use of medication, history of syncope/collapse, sleep apnea, depression, HTN, COPD, incontinence, weakness, oxygen use, DM II, decreased mobility, and history of falls with injury. Interventions included call light within reach. Interview and observation on 03/08/22 at 3:47 P.M. revealed Resident #28 asked to hand him the television (tv) remote, his call light was pinned to his bed sheet above his right shoulder. Resident #28 stated he was unable to reach his call light to call for assistance. Interview and observation on 03/08/22 at 3:49 P.M. with Human Resources (HR) #90 confirmed Resident #28's call light was pinned to his bed sheet on his right side and above her shoulder. Resident #28 attempted to reach his call light and was unable to. Resident #28 and HR #90 confirmed the resident was unable to reach his call light. Interview on 03/10/22 at 10:33 A.M. with the Administrator revealed the facility did not have a call light policy. She confirmed call lights should be within reach of each resident. This deficiency substantiates Master Complaint Number OH00130892.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to complete a correct Preadmission Screening and Record Review (PASARR). This affected one (Resident #39) of one resident reviewed for PASARR completion. The facility census was 59. Findings include: Review of the medical record for Resident #39 revealed an admission date of 10/15/21. Diagnoses included malignant neoplasm of an unspecified part of the right bronchus or lung, malignant neoplasm of the heart, acute and chronic respiratory failure with hypoxia, schizoaffective disorder bipolar type, dementia without behavioral disturbance, anxiety disorder, vertigo of the central origin, hyperlipidemia, hypothyroidism, protein-calorie malnutrition, bipolar disorder, and adult failure to thrive. Review of Resident #39's diagnoses revealed she was diagnosed on [DATE] with schizoaffective disorder, bipolar type, anxiety disorder, major depressive disorder, and bipolar disorder. Review of the Preadmission Screening and Resident Review Result Notice dated 10/14/21 revealed no indications of serious mental illness and/or developmental disability effective 10/14/21. Further review of the notice revealed no referral had been made for a level II evaluation and antianxiety medication was the only medication marked. Review of the plan of care dated 01/14/22 revealed the resident had the potential for drug related complications associated with use of anti-anxiety medication and anti-psychotic medication. Interventions included monitoring for side effects of the medication and providing the medication as ordered. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/16/22, revealed Resident #39 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of 15 (severe cognitive impairment). The resident exhibited behaviors such as inattention and disorganized thinking. The resident required limited to extensive assistance of one to two staff or more staff for all activities of daily living (ADL) except eating which required set-up and supervision. Resident #39 was occasionally incontinent of bladder and was always incontinent of bowels. Further review of the MDS revealed the resident did not have a pressure injury/ulcer, was at risk for pressure ulcers (ulcer), and did not have any unhealed ulcers. The MDS revealed the resident had a pressure reducing device for the bed but no other skin and ulcer/injury treatments. Review of the physician orders for March 2022 revealed an order dated 10/19/21 to administer 600 milligrams (mg) of Seroquel (antipsychotic) for schizoaffective disorder, bipolar type. Further review of the orders revealed an order dated 10/21/21 for 200 mg of lamotrigine (bipolar therapy agent) to be administered in the morning for bipolar disorder. Interview on 03/08/22 at 3:27 P.M. with the Administrator confirmed there were no mental disorders marked in section E of the PASSAR dated 10/14/21 and section E revealed Resident #39 did not have a diagnosis of any of the mental disorders listed (schizophrenia, mood disorders, panic or other severe anxiety disorder, personality disorders, or other psychotic disorders). She also confirmed Resident #39 had listed diagnoses that included schizoaffective disorder bipolar type, dementia without behavioral disturbance, anxiety disorder, and bipolar disorder. She stated she believed the PASARR was completed in the hospital and the facility did not complete a new PASSAR but instead used the hospital PASARR. She revealed she would check to verify that was correct but believed it was. Interview on 03/08/22 at 4:34 P.M. with Regional Registered Nurse (RN) #888 and the Administrator revealed the PASSAR was only redone if there was a significant change, which the resident had not had. Interview on 03/09/22 at 11:15 A.M. with the Regional RN #888 revealed the PASSAR for Resident #39 was not updated because it was legal for the hospital to do it for the facility. She confirmed the resident's diagnoses were not listed on the PASSAR nor was the medication she was taking marked on the PASSAR except for antianxiety medication. She also stated the facility did not have a PASSAR policy. Interview on 03/09/22 at 1:01 P.M. with Regional RN #888 revealed she did not complete PASSARs and could not answer as to whether the PASSAR should have been redone since the hospital's PASSAR did not have any of resident's psychologic diagnosis. Interview on 03/09/22 at 4:45 P.M. with the Administrator revealed there was no PASARR policy. Interview on 03/10/22 9:50 A.M. with Social Services #256 revealed Resident #39's PASARR should have been completed correctly upon her admission. She also stated the PASARR was not redone if the resident had a new diagnosis of a mental illness while residing at the facility since level II's were only initiated with a psych hospitalization.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review the facility failed to create baseline care plans upon admission to the facility. This affected three (Resident's #53, #272 and #273) of the five newly admitted residents reviewed who still resided in the facility. The facility census was 59. Findings include: 1. Record review revealed Resident #53 was admitted to the facility on [DATE] and had diagnoses including venous insufficiency, hypertension, and angina pectoris. Review of the medical record for Resident #53 revealed a baseline care plan was not completed. 2. Record review revealed Resident #272 was admitted to the facility on [DATE] and had diagnoses including dementia without behavioral disturbances, chronic obstructive pulmonary disease, and anxiety disorder. Review of the medical record for Resident #272 revealed a baseline care plan was not completed. 3. Record review revealed Resident #273 was admitted to the facility on [DATE] and had diagnoses including type two diabetes mellitus, chronic obstructive pulmonary disorder, and asthma. Review of the medical record for Resident #273 revealed a baseline care plan was not completed. Interview with Registered Nurse (RN) #801 on 03/08/22 at 4:10 P.M. verified Resident's #53, #272 and #273 did not have a baseline care plan started or completed in their medical record. Interview with Regional Nurse #888 on 03/09/22 at 1:10 P.M. revealed residents newly admitted to the facility were to have baseline care plans implemented and completed within 48 hours of the admission. Review of the facility policy titled Baseline Care Plan and Summary, revised 01/2020, revealed upon admission the admitting clinical team will develop an initial plan of care based on information upon admission. The other members will review and add to the baseline care plan within the first 48 hours of admission. This includes and is not limited to dietary, social services, activities, therapy, and other clinical staff. Within 48 hours the resident, family, and/or responsible party will be given a summary review of the baseline care plan and a copy will be given to the resident, family, and/or responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, acute and chronic respiratory failure with hypoxia, malignant neoplasm of bladder, diarrhea, hypertension, and obstructive sleep apnea. Resident #26 had allergies to penicillin. Review of the nurse's progress notes, dated 01/01/22, revealed Resident #26 required oxygen at two liters per minute (LPM). Review of the nurse's progress notes, dated 02/03/22, revealed Resident #26 complaining of chest congestion, oxygen saturations were 95 percent (%) to 98% on oxygen at two LPM via nasal cannula. Resident #26 was assisted onto the left side for resting, explained the importance of lying face down with COVID-19 but Resident #26 stated she can't sleep on her stomach, she did agree to stay on her side for a while. Resident #26 was alert and oriented to person, place, and time, was eating and drinking on her own, stated her throat was sore with a hoarse voice noted. Nursing will continue to monitor, and the call light was within reach. Review of the MDS 3.0 assessment, dated 02/07/22, revealed Resident #26 had no impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 14. Resident #26 was assessed to require two staff assist with mobility, transfers, and toileting. Review of the physician's order for Resident #26, dated 02/07/22, revealed oxygen vial nasal cannula at two LPM as needed for shortness of breath and cough status post COVID-19. Review of the care plan revealed no information addressing Resident #26 having any respiratory issues that warranted administering oxygen. Interview on 03/09/22 at 2:10 P.M. with Regional Registered Nurse #888 confirmed there was no care plan in place addressing Resident #26's respiratory issues or use of oxygen. Review of the facility policy titled Care Plan Preparation revealed a nursing care plan should be written for each patient, preferably within 24 hours of admission, and should be updated and revised throughout the patient stay, based on residents' response. The policy further revealed that the care plan serves as a database for planning assignment, giving change of shift report, conferring to the practitioner or other members of the healthcare team, and documenting patient care. Based on observation, record review, staff interview and policy review, the facility failed to develop a comprehensive plan of care in the area of hospice and oxygen use for two (Resident's #9 and #26). This affected two of 22 sampled residents. The facility census was 59. Findings include: 1. Review of Resident #9's medical record revealed an initial admission date of 07/26/21 with the latest readmission of 11/03/21. Diagnoses included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), Parkinson's disease, dementia, atrial fibrillation, major depressive disorder, hypertension, gastro-esophageal reflux disease, sleep apnea, retention of urine, schizoaffective disorder, anxiety disorder, seizures, insomnia, and hyperlipidemia. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 had clear speech, sometimes understood others, usually made herself understood and had a moderate cognitive deficit. Review of the mood and behavior section of the MDS revealed Resident #9 displayed no behaviors, including rejection of care. Resident #9 required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. The assessment indicated Resident #9 was always incontinent of both bowel and bladder. Review of Resident #9's monthly physician's orders for March 2022 identified an order dated 03/02/22 to admitted under hospice care effective 03/02/22. Review of the plan of care dated 03/03/22 revealed the resident is on hospice care related to end of life care. Interventions included respect patient and family wishes. On 03/09/22 at 1:51 P.M. interview with Registered Nurse (RN) #301 verified the care plan addressing the resident's hospice service was not comprehensive.

Based on observation, staff interview, resident interview, medical record review, and facility policy review, the facility failed to update Resident #33's care plan. This affected one (Residents #33) of two residents reviewed for care plans. The facility census was 59. Findings include: Review of the medical record for Resident #33 revealed an initial admission date of 09/09/13 and a re-admission date of 04/06/17. Diagnoses included dementia, history of falling, type two diabetes, psychosis, dysphagia, macular degeneration, cholecystitis, agnosia (loss of the ability to identify objects using one or more senses), restless and agitation, hypertension, Alzheimer's disease, major depressive disorder, gastro-esophageal reflux disease, and benign prostatic hyperplasia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/12/22, revealed Resident #33 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of 15 (severe cognitive impairment). He exhibited behaviors such as inattention and disorganized thinking. Resident #33 required extensive assistance of one staff member for all activities of daily living (ADL) except eating which required set-up and supervision. Review of the plan of care dated 01/19/22 revealed Resident #33 had impaired communication due to impaired cognition, was alert and oriented with periods of confusion and/or forgetfulness due to dementia, hard of hearing (HOH), dysphagia, macular degeneration, and cognition. Interventions included ensure placement and offer encouragement of hearing aids as needed due to his refusal to leave hearing aids in, hearing consultation as needed, and nonverbal cues as needed. Interview and observation on 03/07/22 at 10:35 A.M. with Resident #33 revealed he was HOH, required the Surveyor to speak directly into his ear, and repeat questions several times before he was able to hear and understand the questions being asked. He did not have hearing aids in his ears, denied having owned hearing aids, and was unable to recall the last time he was evaluated by an audiologist. Interview and observation on 03/08/22 at 4:18 P.M. with Resident #33 revealed he was HOH, required the Surveyor to speak directly into his ear, and repeat questions several times before he was able to hear and understand the questions being asked. State Tested Nurse Aide (STNA) #508 was present and when she was asked if Resident #33 had hearing aids, she revealed she was not sure. Interview on 03/08/22 at 4:18 P.M. with Licensed Practical Nurse (LPN) #888 and Human Resources/STNA #90 revealed Resident #33 used to wear hearing aids but threatened to throw his hearing aids out the window, so his Power of Attorney (POA)/ Receptionist #92 took them home. Interview on 03/08/22 at 4:28 P.M. with Receptionist #92 revealed she was the wife of the resident's POA. She revealed Resident #33 had hearing aids that made him hear too good, so he threatened to throw them out. She revealed he last wore them about two to three years ago. Interview on 03/08/22 at 4:34 P.M. with Regional Registered Nurse (RN) #888 and the Administrator confirmed Resident #33 had a care plan stating he had minimal difficulty hearing and hearing aids. They did not deny Resident #33 had greater than minimal hearing difficulty. Review of the undated policy titled Care Plan Preparation revealed a care plan directs a residents nursing care from admission to discharge and was based on nursing diagnosis. The care plan was to be updated and revised throughout the residents stay based on the resident response. Further review of the policy revealed the care plan served as a database used for caring for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and policy review the facility failed to administer insulin as ordered by the physician. This affected one Resident (#273) of the five residents reviewed for unnecessary medications. Additionally, the facility failed to identify, assess, and monitor one Resident's (#9) multiple bruising to face and bilateral arms. This affected one Resident (#9) of one resident reviewed for anticoagulant medication side effects. The facility census was 59. Findings include: Record review revealed Resident #273 was admitted to the facility on [DATE] with diagnosis including type two diabetes mellitus. 1. Review of the active physician order, dated 03/06/22, revealed Resident #273 was to be administered 20 units of insulin glargine in the morning for diabetes. There was an absence of a physician's order to hold the medication for low blood sugar results. Review of the Medication Administration Record (MAR) documentation, dated 03/07/22 and signed by Registered Nurse (RN) #801, revealed the morning dose of 20 units of insulin glargine was held due to a blood sugar result of 83. Interview on 03/09/22 at 11:12 A.M. with RN #801 verified the morning dose of insulin glargine was held due to a blood sugar result of 83 and verified there were no physician's orders to hold the insulin if blood sugar levels were below a certain reading. RN #801 verified the morning blood sugar result for Resident #273 on 03/09/22 was 68 and the insulin glargine was administered as ordered with no adverse side effects. RN #801 verified the physician was not notified the morning dose of insulin glargine was held on 03/07/22. Review of the facility policy titled Medication Administration General Guidelines, dated 01/2021, revealed medications were to be administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition the nurse call the provider pharmacy for clarification prior to the administration of the medication. If necessary, the nurse contacts the prescriber for clarification. 2. Review of Resident #9's medical record revealed an initial admission date of 07/26/21 with the latest readmission of 11/03/21. Diagnoses included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), Parkinson's disease, dementia, atrial fibrillation, major depressive disorder, hypertension, gastro-esophageal reflux disease, sleep apnea, retention of urine, schizoaffective disorder, anxiety disorder, seizures, insomnia, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 had clear speech, sometimes understood others, usually made herself understood and had a moderate cognitive deficit. Review of the mood and behavior section of the MDS revealed Resident #9 displayed no behaviors, including rejection of care. Resident #9 required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. Review of the plan of care dated 08/02/21 revealed Resident #9 was at risk for complications, increased bleeding, excessive bruising related to anticoagulant use. Interventions included apply prolonged pressure to venipuncture sites, monitor medication regimen for medications which increase effects of bleeding and bruising and notify physician if noted, observe for signs and symptoms of bleeding, and obtain and monitor lab/diagnostic work as ordered, report results to physician for follow up as indicated. Review of Resident #9's monthly physician's orders for March 2022 identified orders dated 08/26/21 to observe for signs and symptoms of bleeding during each nursing shift. Notify the physician if the resident has dark/discolored urine, black tarry stools, nose bleeds, vomiting and or coughing up blood or other signs/symptoms of bleeding. An order dated 09/22/21 for weekly skin review, and an order dated 12/03/21 for Rivaroxaban (medication used to thin blood) 20 milligrams (mg) by mouth in the evening for clot prevention. Review of Resident #9's medical record revealed no current wound/skin condition documentation for the bruising to the left side of the resident's face and the multiple bruises to the resident's bilateral arms. On 03/07/22 at 10:20 A.M. an observation of Resident #9 revealed a bruise on the left side of her face next to the left ear and multiple bruises to both arms that were dark red to purple in various stages of healing. On 03/09/22 at 1:34 P.M. interview with Registered Nurse (RN) #301 verified the presence of bruising with no documented identification, assessment, and monitoring of the bruising in the medical record. Review of the nurse's note dated 03/09/21 at 3:40 P.M. revealed a bruise to Resident #9's right dorsal forearm measured 6.5 centimeters (cm) by 9.0 cm and a small bruise to the left cheek and the left hand, middle finger. Physician #888 was also informed of the bruising, and monitoring was initiated. Hospice was to be updated as well.

Based on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to arrange audiology care for Resident #33 who was hard of hearing (HOH). This affected one Resident (#33) of two residents reviewed for ancillary services (hearing/vision). The facility census was 59. Findings include: Review of the medical record for Resident #33 revealed an initial admission date of 09/09/13 and a re-admission date of 04/06/17. Diagnoses included dementia, history of falling, type two diabetes, psychosis, dysphagia, macular degeneration, cholecystitis, agnosia (loss of the ability to identify objects using one or more senses), restless and agitation, hypertension, Alzheimer's disease, major depressive disorder, gastro-esophageal reflux disease, and benign prostatic hyperplasia. Review of the physician orders for March 2022 revealed an order dated 07/12/18 for Resident #33 to see the dentist, optometrist, psychiatrist, or podiatrist as needed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/12/22, revealed Resident #33 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of 15 (severe cognitive impairment). He exhibited behaviors such as inattention and disorganized thinking. Resident #33 required extensive assistance of one staff member for all activities of daily living (ADL) except eating which he required set-up and supervision. Review of the plan of care dated 01/19/22 revealed Resident #33 had impaired communication due to impaired cognition, was alert and oriented with periods of confusion and/or forgetfulness due to dementia, HOH, dysphagia, and macular degeneration. Interventions included ensure placement and offer encouragement of hearing aids as needed due to his refusal to leave hearing aids in, hearing consultation as needed, and nonverbal cues as needed. Review of the plan of care dated 01/19/22 revealed Resident #33 had behaviors/mood which include signs and symptoms of depression, sad facial expression, agitation, stays in his room, sometimes he got agitated and became verbally aggressive, history of sexual activity in inappropriate places related to dementia and depression, refusal of care at times, sexually verbal comments at times, sexual comments and acts toward staff observed, noted increase in behaviors, physical abuse towards staff, agitation, restlessness and wandering. Interventions included medications as ordered, avoidance of situations/people that are upsetting, notify the physician, and offering a diversion. Interview and observation on 03/07/22 at 10:35 A.M. with Resident #33 revealed he was HOH, required the Surveyor to speak directly into his ear, and repeat questions several times before he was able to hear and understand the questions being asked. He did not have hearing aids in his ears, denied having owned hearing aids, and was unable to recall the last time he was evaluated by an audiologist. Interview and observation on 03/08/22 at 4:18 P.M. with Resident #33 revealed he was HOH, required the Surveyor to speak directly into his ear, and repeat questions several times before he was able to hear and understand the questions being asked. State Tested Nurse Aide (STNA) #508 was present and did not deny Resident #33 was HOH and needed hearing aids. When she was asked if the resident had hearing aids, she revealed she was not sure. Interview on 03/08/22 at 4:18 P.M. with Licensed Practical Nurse (LPN) #999 and Human Resources/STNA #90 revealed Resident #33 used to wear hearing aids but threatened to throw his hearing aids out the window, so his Power of Attorney (POA) Receptionist #92 took them home. Interview on 03/08/22 at 4:28 P.M. with Receptionist #92 revealed she was the wife of the resident's POA. She revealed Resident #33 had hearing aids that made him hear too good, so he threatened to throw them out. She revealed he last wore them about two to three years ago, was seen by an ear doctor within the last year, had not retried the hearing aids for a long time but the specific length of time was unknown, and there was no difficulty communicating with him as far as she knew. She confirmed Resident #33 had behaviors and was uncertain if the behaviors could be related to lack of communication due to his hearing impairment. She stated she would find the hearing aids and see if Resident #33 would like to wear them. Interview on 03/08/22 at 4:34 P.M. with Regional Registered Nurse (RN) #888 and the Administrator confirmed Resident #33 had a care plan stating he had minimal difficulty hearing and hearing aids. They did not deny Resident #33 had greater than minimal hearing difficulty. Interview on 03/09/22 at 4:45 P.M. with the Administrator revealed Resident #33 had not been seen by an audiologist since 2021. Interview on 03/10/22 at 10:33 A.M. with the Administrator revealed there was no policy for ancillary services (audiology).

Based on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed apply a WanderGuard (a device to prevent wander-prone residents from leaving unattended) to Resident #33 per physician orders. This affected one Resident (#33) of one resident reviewed for WanderGuards. The facility census was 59. Findings include: Review of the medical record for Resident #33 revealed an initial admission date of 09/09/13 and a re-admission date of 04/06/17. Diagnoses included dementia, history of falling, type two diabetes, psychosis, dysphagia, macular degeneration, cholecystitis, agnosia (loss of the ability to identify objects using one or more senses), restless and agitation, hypertension, Alzheimer's disease, major depressive disorder, gastro-esophageal reflux disease, and benign prostatic hyperplasia. Review of the physician orders for March 2022 revealed an order dated 12/09/21 to check placement and function of the secure alert (WanderGuard) every shift. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/12/22, revealed Resident #33 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of 15 (severe cognitive impairment). He exhibited behaviors such as inattention and disorganized thinking. Resident #33 required extensive assistance of one staff member for all activities of daily living (ADL) except eating which he required set-up and supervision. Review of the plan of care dated 01/19/22 revealed Resident #33 was at risk for elopement related to attempts to leave the living center and wandering. Interventions included secure care (WanderGuard) placement and check placement and functioning per orders. Interview and observation on 03/07/22 at 10:35 A.M. revealed Resident #33 resting in bed with no WanderGuard in place on his person, wheelchair, or walker. He confirmed he did not know of a WanderGuard being placed on him or his assistive devices. Interview and observation on 03/08/22 at 4:18 PM there was no WanderGuard in place on Resident #33's persons, wheelchair, or walker. He confirmed he did not know of a wander guard being placed on him or his assistive devices. Observation on 03/09/22 at 9:28 A.M. revealed Resident #33 resting in bed without a WanderGuard. Interview on 03/09/22 at 9:51 A.M. with Licensed Practical Nurse (LPN) #315 and Assistant Director of Nursing (ADON) #301 confirmed there was no WanderGuard in place on Resident #33's body, wheelchair, or walker, and he had an order for it. They stated it was there but could not locate it during the observation. Review of the facility policy titled Elopement Risk, revised 12/19, revealed if a resident was an elopement risk, the care plan will reflect the interventions (WanderGuard).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observations, medical record review, and facility policy review, the facility failed to administer oxygen per physician orders for Resident #26 and failed to store the BiPAP (bilevel positive airway pressure) mask properly for Resident #9. This affected two residents (Resident's #9 and #26) of four residents reviewed for respiratory care. The facility census was 59. Finding include: 1. Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, acute and chronic respiratory failure with hypoxia, malignant neoplasm of the bladder, diarrhea, hypertension, and obstructive sleep apnea (OSA). Resident #26 was allergic to penicillin. Review of the nurse's progress note, dated 01/01/22, revealed Resident #26 required two liters of oxygen per minute. Review of the nurse's progress note, dated 02/03/22, revealed Resident #26 complaining of chest congestion, oxygen saturations were 95 percent (%) to 98% on two liters of oxygen per minute via nasal cannula. Resident #26 was assisted onto her left side for resting. Nursing explained the importance of lying face down with COVID-19, Resident #26 stated she can't sleep on her stomach. Resident #26 agreed to stay on her side for a while. Resident #26's blood sugars ranged from 66 to 98 this shift. Resident #26 was alert and oriented to person, place, and time, and was eating and drinking on her own. Resident #26 stated her throat was sore with a hoarse voice noted. Nursing would continue to monitor, and the call light was within reach. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 02/07/22, revealed Resident #26 had no impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Resident #26 was required two-staff assistance with mobility, transfers, and toileting. Review of the physician's order for Resident #26, dated 02/07/22, revealed oxygen vial nasal cannula at two liters per minute as needed for shortness of breath and cough status post COVID-19. Review of the care plan for Resident #26 revealed no documented information related to the resident having respiratory issues that warranted administering oxygen. Observation on 03/07/22 at 10:41 A.M. revealed Resident #26 lying in bed with oxygen on via nasal cannula set at four liters per minute. Observation on 03/08/22 at 9:48 A.M. revealed Resident #26 lying in bed with oxygen on via nasal cannula set at four liters per minute. Observation with License Practical Nurse (LPN) #313 on 03/08/22 at 10:27 A.M. Resident #26 was on four liters of oxygen via nasal cannula. LPN #313 revealed she had been off work for a couple of days, and the report she received from the outgoing nurse was Resident #26 was not feeling well and was required to be on oxygen via nasal cannula between two and four liters per minutes. During the interview LPN #313 verified reviewing the physician's order that Resident #26 should be on two liters of oxygen per minute, not four liters. Review of the facility policy titled Oxygen Administration revealed verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed. 2. Review of Resident #9's medical record revealed an initial admission date of 07/26/21 with the latest readmission of 11/03/21. Diagnoses included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), Parkinson's disease, dementia, atrial fibrillation, major depressive disorder, hypertension, gastro-esophageal reflux disease, sleep apnea, retention of urine, schizoaffective disorder, anxiety disorder, seizures, insomnia, and hyperlipidemia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #9 had clear speech, sometimes understood others, usually made herself understood and had a moderate cognitive deficit. Review of the mood and behavior section of the MDS revealed Resident #9 displayed no behaviors, including rejection of care. Resident #9 required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. The assessment indicated Resident #9 was always incontinent of both bowel and bladder. Review of the plan of care dated 08/11/21 revealed Resident #9 had an alteration in respiratory status due to COPD, non-compliant with BiPAP and oxygen use. Interventions included administer medications as ordered, observe labs, response to medication and treatments, apply BiPAP/oxygen per physician order, monitor oxygen saturations on room air and/or oxygen as ordered and as needed, monitor oxygen flow rate and response, explain risks and benefits of non-compliance and encourage compliance, elevate head of bed to alleviate shortness of breath, labs per physician order for change in condition and/or manifestation of clinical signs or symptoms, observe and document vital signs, specifically respiratory pattern, rate, rhythm, effort and use of accessory muscles. Review of Resident #9's monthly physician's orders for March 2022 identified orders dated 09/08/21 family may bring in mask for BiPAP if one at home, otherwise consult BiPAP vendor for proper fitting mask, 12/25/21 oxygen per nasal cannula per BiPAP at two to three liters continuously, resident to wear BiPAP with all activities/sleep with exception of eating, bathing, and therapy, check every two hours for proper placement with settings at 16/10, backup rate 12 with fiO2 30% on at two to three liters per minute. On 03/07/22 at 10:22 A.M. observation of Resident #9's BiPAP machine revealed the mask was uncovered and wedged between the nightstand and the wall. On 03/08/22 at 4:27 P.M. observation of Resident #9's BiPAP machine revealed the mask was uncovered and wedged between the nightstand and the wall. On 03/09/22 at 9:22 A.M. observation of Resident #9's BiPAP machine revealed the mask was uncovered and wedged between the nightstand and the wall. On 03/09/22 at 1:34 P.M. interview with Registered Nurse (RN) #301 verified the improper storage of the BiPAP mask.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to provide nail care, shaving, and haircuts, showers, and mouth care to residents who needed assistance. This affected five (Resident's #5, #9, #33, #28 and #36) of seven residents reviewed for activities of daily living (ADL). The facility census was 59. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 11/10/20. Diagnoses included dementia, metabolic encephalopathy, rhabdomyolysis, adult failure to thrive, muscle weakness, abnormalities of gait and mobility, emphysema, right hip osteoarthritis, major depressive disorder, hypertension, benign prostatic hyperplasia, and gastro-esophageal reflux disease. Review of the plan of care dated 01/25/22 revealed Resident #5 had a physical functioning deficit related to mobility impairment, self-care impairment due to osteoarthritis, decreased mobility, weakness, rhabdomyolysis, edema, history of a deep vein thrombosis (DVT), depression, failure to thrive, and dementia. Interventions included encourage choices with care, nail care as needed, and personal hygiene assistance of one as needed. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/25/22, revealed Resident #5 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of nine out of 15 (moderate cognitive impairment). Resident #5 exhibited behaviors such as inattention, disorganized thinking, and rejection of care. He required extensive assistance of one to two or more staff for all ADL except eating which he required set-up and supervision. Interview and observation on 03/07/22 at 10:12 A.M. with Resident #5 revealed his mustache was grown over his upper lip and was in his mouth. He confirmed he was tired of eating hair from his overgrown mustache. He confirmed he wanted a clean-shaven neck as he pointed out the long hair on his neck and under his chin. He stopped talking to spread his mustache apart and to get the mustache hair out of his mouth before he proceeded to state he was unsure why he had not been shaven or offered to be shaven. This was confirmed with State Tested Nursing Assistant (STNA) #742 who was present in the room during the interview with the approval of the resident. Interview and observation on 03/08/22 at 8:54 A.M. with Resident #5 revealed he had not been shaven or offered to be shaven. Interview and observation on 03/08/22 at 4:03 P.M. with STNA #508 of Resident #5 confirmed he was verbally stating he would like to have his neck shaved and his mustache trimmed so the hair did not get into his mouth. Interview and observation 03/09/22 9:30 A.M. with Resident #5 revealed his mustache hair remained over his upper lip, in his mouth, and his neck hair remained. He confirmed he was still waiting for his mustache to be trimmed and his neck hair to be shaved. Interview on 03/09/22 at 11:15 A.M. with the Regional Registered Nurse (RN) #888 revealed there was not an area where shaving was documented in residents' charts, but shaving and facial hair maintenance was to be performed as needed. 2. Review of the medical record for Resident #33 revealed an initial admission date of 09/09/13 and a re-admission date of 04/06/17. Diagnoses included dementia, history of falling, type two diabetes, psychosis, dysphagia, macular degeneration, cholecystitis, agnosia (loss of the ability to identify objects using one or more senses), restless and agitation, hypertension, Alzheimer's disease, major depressive disorder, gastro-esophageal reflux disease, and benign prostatic hyperplasia. Review of the quarterly MDS 3.0 assessment, dated 01/12/22, revealed Resident #33 had impaired cognition with a BIMS score of three out of 15 (severe cognitive impairment). He exhibited behaviors such as inattention and disorganized thinking. Resident #33 required extensive assistance of one staff member for all ADL except eating which he required set-up and supervision. Review of the plan of care dated 01/19/22 revealed Resident #33 had a physical functioning deficit related to fluctuation with mobility impairment, self-care impairment related to weakness, cognition, depression, restless/agitation at times, history of falling, dementia, and agnosia. Interventions included encourage choices with care, nail care as needed, and personal hygiene assistance of one as needed. Interview and observation on 03/07/22 at 10:35 A.M. with Resident #33 revealed his nails were grown past the tips of his fingers, were jagged, had dirt underneath them, and he confirmed he would like his nails cut/trimmed and cleaned. He had mustache hair stubble and confirmed he needed to shave but had not been offered assistance with shaving. Interview and observation on 03/08/22 at 3:59 P.M. with Human Resources (HR)/STNA #90 confirmed Resident #33 had long, jagged, dirty nails, and had facial hair stubble. Observation on 03/08/22 at 4:18 P.M. revealed STNA #508 was clipping and cleaning Resident #33's fingernails after Surveyor intervention. Observation on 03/09/22 at 9:28 A.M. revealed Resident #33 was resting in bed with eyes closed and the facial hair stubble remained. Observation on 03/09/22 at 12:44 P.M. revealed Resident #33 lying in bed with his facial hair stubble remaining. 3. Review of the medical record for Resident #28 revealed an admission date of 01/03/22. Diagnoses included chronic obstructive pulmonary disease (COPD), heart failure, Stage IV chronic kidney disease (CKD IV), reduced mobility, obstructive sleep apnea (OSA), insomnia, major depressive disorder, nicotine dependence, hypertension (HTN), type two diabetes mellitus (DM II), gastro-esophageal reflux (GERD), hyperlipidemia, repeated falls, muscle weakness, benign prostatic hyperplasia (BPH), rhabdomyolysis, weakness, orthostatic hypotension, syncope and collapse, obesity, and atherosclerotic heart disease of the native coronary artery without angina pectoris. Review of the admission MDS 3.0 assessment, dated 01/09/22, revealed Resident #28 had intact cognition with a BIMS score of 15 out of 15 (no impairment). The resident did not have any documented behaviors. The resident required extensive assistance of one to two or more staff for all ADL except eating which he required supervision and one-staff physical assistance. Review of the plan of care dated 01/12/22 revealed Resident #28 had a physical functioning deficit related to mobility impairment, self-care impairment due to decreased mobility, emphysema, depression, history of syncope/collapse, decreased mobility, weakness, history of falls, cardiac issues, obesity, OSA, CKD IV, and chronic respiratory failure with hypoxia. Interventions included assistance with ADL as needed and nail care as needed. Interview and observation on 03/07/22 at 10:26 A.M. of Resident #28 revealed his hair was long, approximately to his shoulders, and he stated he was supposed to get his hair cut on 03/07/22. His nails were very long, grown past the tips of his fingers, and he confirmed he would like them to cut. Interview and observation on 03/07/22 at 11:46 A.M. of Resident #28 with STNA #742 confirmed Resident #28's nails needed trimmed, and his hair had grown to approximately shoulder length. Observation on 03/07/22 at 11:55 A.M. revealed STNA #742 clipped Resident #28's nails after Surveyor intervention. Observation on 03/08/22 at 8:56 A.M. of Resident #28 revealed his hair remained grown past his ears approximately to his shoulders. Observation on 03/09/22 at 9:25 A.M. of Resident #28 revealed his hair remained grown past his ears approximately to his shoulders. 4. Review of the medical record for Resident #36 revealed an admission date of 10/22/18. Diagnoses included atrial fibrillation, diabetes mellitus due to underlying condition with diabetic polyneuropathy, muscle weakness, major depressive disorder, Alzheimer's disease, dementia without behavioral disturbance, hyperlipidemia, arthropathy, hypertension. Review of the plan of care dated 01/07/22 revealed Resident #36 required assistance with mobility and self-care due to increased weakness, frequent non-compliance with care, mobility needs, frequently refused to stand or assist with mobility needs, and fluctuated in assistance needs. Interventions included assistance with ADL, assistive devices including a wheelchair and wheeled walker at bedside, trapeze to his bed as desired, nail care as needed, right resting hand splint as ordered, and passive range of motion (PROM) to the right hand with care as tolerated. Review of the quarterly MDS 3.0 assessment, dated 01/10/22, revealed Resident #36 had impaired cognition with a BIMS score of seven out of 15 (severe cognitive impairment). The resident exhibited behaviors such as inattention. The resident required extensive assistance of one to two or more staff for all ADL except eating which he required set-up and supervision. Interview and observation on 03/07/22 at 10:25 A.M. with Resident #36 revealed he was up in his wheelchair waiting on a haircut. His hair had grown past his ears. His nails were orange and were very long, past the tips of his fingers. He confirmed he would like his nails cleaned and cut. Interview on 03/07/22 at 11:44 A.M. with STNA #743 confirmed Resident #36's nails were to be clipped weekly and as needed. Interview and observation on 03/07/22 at 11:46 A.M. with STNA #742 confirmed Resident #36's nails needed trimmed and were orange as a result of him eating cheesy popcorn. Observation on 03/07/22 at approximately 11:54 A.M. revealed STNA #742 was assisting Resident #36 with nail care after Surveyor intervention. Interview on 03/09/22 at 9:26 A.M. with Resident #36 revealed no one was available to cut his hair. Interview on 03/09/22 at 9:37 A.M. with Human Resources and STNA #90 revealed the beautician was available every Monday to cut residents' hair. She revealed residents could request to be seen by the beautician or if the staff thought a resident needed a haircut, they could inform the beautician. She revealed males should have their hair cut every two to three weeks and hair past a male residents' ears would not be acceptable. She also confirmed a male resident should be shaved daily, mustache and beards should be kept clean and trimmed, and facial hair should not be over their lip and in their mouth. Interview on 03/09/22 at 12:59 P.M. with the Administrator revealed haircuts were provided based on resident and family preferences. She stated the beauty shop just reopened after COVID-19 and the hairdresser/beautician came to the facility on Tuesdays but was unable to come to the facility the week of 03/07/22. She stated she was unsure of the last hair cut provided for Resident's #28 and #36. She also stated resident families were permitted to take the residents out of the facility to obtain haircuts. Interview on 03/09/22 at 1:39 P.M. with the Administrator revealed Resident #28 did not have a facility managed account. She continued by stating she spoke with his daughter who confirmed money would be brought into the facility to get the residents haircut. She stated she would check the list for the beauty shop dated 03/09/22 to confirm Resident #36 was on the beautician list because she was unaware that he had been in his wheelchair waiting for a haircut on 03/07/22. Interview on 03/09/22 at 1:51 P.M. with the Administrator revealed the facility had not had beauty care services since March of 2020. She revealed after the facility began allowing visitors according to Centers for Disease Control (CDC) recommendations and after they relicensed and found a beautician, it was around Valentine's Day in 2022 when the beautician started. She stated she was unsure if families were notified of the facility no longer offering hair care services but stated the families were verbally encouraged to take residents out for haircuts/care. The Administrator confirmed Resident #36 was on the list for a haircut but Resident #28 was not. She stated she was not able to provide documentation of either residents last haircut and did not have a haircut or beauty shop policy. Review of the undated facility policy titled Hair Care revealed the frequency of hair care depends on the length and texture of the resident's hair, the duration of the admission, and the resident's condition. Review of the undated facility policy titled Shaving revealed shaving was part of the male resident's usual daily care. Shaving not only reduced bacterial growth on the face but also promoted resident comfort by removing facial hair that can itch and irritate the skin and produce an unkempt appearance. Review of the undated facility provided list titled Beautician Worksheet revealed Resident #36 was listed as wanting a haircut. 5. Review of Resident #9's medical record revealed an initial admission date of 07/26/21 with the latest readmission of 11/03/21. Diagnoses included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), Parkinson's disease, dementia, atrial fibrillation, major depressive disorder, hypertension, gastro-esophageal reflux disease, sleep apnea, retention of urine, schizoaffective disorder, anxiety disorder, seizures, insomnia, and hyperlipidemia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #9 had clear speech, sometimes understood others, usually made herself understood and had a moderate cognitive deficit. Review of the mood and behavior section of the MDS revealed Resident #9 displayed no behaviors, including rejection of care. Resident #9 required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene. Review of the plan of care dated 08/02/21 revealed Resident #9 had a mobility and self-care impairment related to Parkinson's disease, generalized weakness and fluctuations in need of assist. Interventions included oral care twice daily and as needed, dental exams as necessary and provide extensive assist with hygiene, bathing, toileting, and dressing, may require increased assist at times. Review of Resident #9's medical record revealed the resident's scheduled showers were on Monday and Thursday on night shift. Review of Resident #9's February 2022 bathing documentation revealed the resident had not received scheduled bathing on 02/21/22 and 02/24/22. Further review revealed Resident #9 received bed baths; however, the resident's power of attorney (POA) requested showers. Review of the resident's March 2022 bathing documentation revealed Resident #9 had not received scheduled bathing on 03/03/22 and 03/07/22. Further review revealed the resident received bed baths; however, the resident's POA requested showers. On 03/07/22 at 11:20 A.M. interview with Resident #9's POA revealed she has spoken with the facility on multiple occasions regarding the lack of mouth care and the resident receiving showers instead of bed baths. On 03/07/22 at 11:24 A.M. observation of Resident #9 revealed a large amount of whitish debris on her teeth. On 03/08/22 at 4:27 P.M. observation of Resident #9 revealed a large amount of whitish debris on her teeth. On 03/09/22 at 9:22 A.M. observation of Resident #9 revealed a large amount of whitish debris on her teeth. On 03/09/22 at 1:51 P.M. interview with Registered Nurse (RN) #301 verified the large build-up of white debris on Resident #9's teeth. Review of the nurse's note dated 03/09/21 at 3:40 P.M. revealed Resident #9's POA requested she would like her mother to have frequent mouth care/teeth brushing. On 03/10/22 at 11:56 A.M. interview with Regional Nurse #888 verified Resident #9 had not received scheduled bathing and showers as preferred. Review of the undated facility policy titled Oral Care revealed oral care is commonly performed in the morning, at bedtime and after meals. Oral care removes soft plaque deposits and calculus from the teeth, cleans and massages the gums, reduces mouth odor, and provides comfort and reduces the risk of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, observations, medical record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines the facility failed to provide hand hygiene between resident care, while passing meal trays, and to wear gloves with direct resident care. This directly affected eleven Resident's (#36, #1, #29, #22, #28, #39, #272, #273, #53, #270, #271) but had the potential to affect all 59 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 02/21/20. Diagnoses included chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), dementia, major depressive disorder, hypertension (HTN), gastro-esophageal reflux disease (GERD), and anxiety. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/01/22, revealed Resident #1 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 14 out of 15 (no cognitive impairment). Resident #1 exhibited behaviors such as verbal behavioral symptoms directed towards others. Resident #1 required limited to extensive assistance of one to two or more staff members for all activities of daily living (ADL) except eating which required set-up and supervision. Review of the care plan dated 02/28/22 revealed Resident #1 had a rectal abscess infection and pneumonia. Interventions included medications as ordered and observation of signs and symptoms of continued or unresolved infection and report to the physician as appropriate. 2. Review of the medical record for Resident #29 revealed an admission date of 07/03/20. Diagnoses included major depressive disorder, GERD, fibromyalgia, necrotizing fasciitis, and Alzheimer's disease. Review of the quarterly MDS 3.0 assessment, dated 01/15/22, revealed Resident #29 had impaired cognition with a BIMS score of four out of 15 (severe cognitive impairment). Resident #29 exhibited behaviors such as inattention, disorganized thinking, and rejection of care. Resident #29 required limited to extensive assistance of one to two or more staff members for all ADL except eating which required set-up and supervision. Review of the care plan dated 01/12/22 revealed Resident #29 had an actual infection and was at risk for infection related to history of cellulitis and necrotizing fasciitis. Interventions included antibiotics as ordered and following of the standard precautions according to the facility's infection control manual. Observation on 03/07/22 at 12:17 P.M. revealed blood was drawn from Resident #29's left arm without gloves by Phlebotomist #777 from a contracted laboratory company. She was observed exiting the resident's room without preforming hand hygiene and entering the nurse's station where she was observed filing paperwork into a binder. Phlebotomist #777 then proceeded to exit the facility. Interview on 03/07/22 at 12:22 P.M with Phlebotomist #777 revealed she immediately removed used gloves from her travel lab bag and stated those were the gloves she used to draw blood on Resident #29 but did not clarify why the gloves were not disposed of in the resident's room or why hand hygiene was not preformed prior to exiting the room immediately thereafter. 3. Review of the medical record for Resident #36 revealed an admission date of 10/22/18. Diagnoses included atrial fibrillation, diabetes mellitus due to underlying condition with diabetic polyneuropathy, muscle weakness, major depressive disorder, Alzheimer's disease, dementia without behavioral disturbance, hyperlipidemia, arthropathy, and hypertension. Review of the plan of care dated 01/07/22 revealed Resident #36 required assistance with mobility and self-care due to increased weakness, frequent non-compliance with care, mobility needs, frequently refused to stand or assist with mobility needs, and fluctuated in assistance needs. Interventions included assistance with ADL, assistive devices including a wheelchair and wheeled walker at bedside, trapeze to the bed as desired, nail care as needed, right resting hand splint as ordered, and passive range of motion (PROM) to the right hand with care as tolerated. Review of the quarterly MDS 3.0 assessment, dated 01/10/22, revealed Resident #36 had impaired cognition with a BIMS score of seven out of 15 (severe cognitive impairment). Resident #36 exhibited behaviors such as inattention. Resident #36 required extensive assistance of one to two or more staff for all ADL except eating which required set-up and supervision. 4. Review of the medical record for Resident #39 revealed an admission date of 10/15/21. Diagnoses included malignant neoplasm of an unspecified part of the right bronchus or lung, malignant neoplasm of the heart, acute and chronic respiratory failure with hypoxia, schizoaffective disorder bipolar type, dementia without behavioral disturbance, anxiety disorder, vertigo of the central origin, hyperlipidemia, hypothyroidism, protein-calorie malnutrition, bipolar disorder, and adult failure to thrive. Review of the quarterly MDS assessment, dated 01/16/22, revealed Resident #39 had impaired cognition with a BIMS score of three out of 15 (severe cognitive impairment). Resident #39 exhibited behaviors such as inattention and disorganized thinking. Resident #39 required limited to extensive assistance of one to two staff or more staff for all ADL except eating which required set-up and supervision. Resident #39 was occasionally incontinent of bladder and was always incontinent of bowels. Further review of the MDS revealed Resident #39 did not have a pressure injury/ulcer, was at risk for pressure ulcers (ulcer), and did not have any unhealed ulcers. The MDS revealed Resident #39 had a pressure reducing device for the bed but no other skin and ulcer/injury treatments. Observation on 03/07/22 at 11:54 A.M. of State Tested Nursing Assistant (STNA) #743 revealed she assisted Resident #39 with drinking water, exited her room then entered Resident #36's room to assist with a Hoyer (mechanical lift) transfer without preforming hand hygiene. Observation on 03/07/22 at 12:01 P.M. of STNA #743 revealed no hand hygiene was preformed after exiting Resident #36's room, before entering Resident #1's room, before assisting Resident #1, after exiting Resident #1's room, or re-entering Resident #1's room once again. Observation on 03/07/22 at 11:55 A.M. with STNA #742 revealed she clipped Resident #28's nails wearing gloves, removed the gloves without preforming hand hygiene, and then proceeded to assist Resident #36 to bed. Observation on 03/07/22 at 12:00 P.M. with STNA #742 revealed new gloves were applied without preforming hand hygiene and care was provided to Resident #28. Interview on 03/07/22 12:01 P.M. with STNA #743 confirmed no hand hygiene was performed before entering Resident #39's, after assisting her with drinking, after exiting Resident #39's room, before or after exiting Resident #36's room, before entering Resident #1's room, or after exiting Resident #1's room, and reentering. Interview on 03/07/22 at 12:10 P.M. with STNA #742 revealed hand hygiene was to be performed before and after entering or exiting a room. She also confirmed she did not perform hand hygiene prior to or after caring for Residents #36 or #28 nor was hand hygiene preformed in between their care. 5. Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery, disorder of circulatory system, peripheral vascular angioplasty status, type two diabetes, and essential hypertension. Resident #22 had allergies to tetracycline, Bactrim, and Sulfa antibiotics. Review of the quarterly MDS 3.0 assessment, dated 01/01/22, revealed Resident #22 was cognitively intact evidenced by a BIMS score of 12. Resident #22 was assessed to require one to two staff assist with transfers, toileting, and mobility. Review of the care plan dated 04/22/21 revealed Resident #22 was at risk for complications related to anticoagulant and antiplatelet medication due to decreased mobility peripheral vascular disease (PVD), and diabetes. Interventions included observe for signs and symptoms of bleeding and apply prolonged pressure venipuncture sites. Observation on 03/07/22 at 10:20 A.M. during facility tour on the third floor revealed Resident #22 came out of his room in his wheelchair with a bloody towel on his right forearm telling STNA #1000 that he was bleeding from a skin tear. STNA #1000 proceeded to take the bloody towel with bare hands from Resident #22. Interview with STNA #1000 on 03/07/22 at 10:20 A.M. revealed she should have had gloves on before touching the towel. STNA #1000 confirmed that was not ideal to be touching the bloody towel with bare hands. 6. Record review revealed Resident #273 was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus, chronic obstructive pulmonary disorder, and asthma. Review of the active physician order, dated 03/07/22, revealed Resident #273 was to be on transmission-based precautions. Record review revealed Resident #272 was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbances, chronic obstructive pulmonary disease, and anxiety disorder. Review of the active physician order, dated 03/07/22, revealed Resident #272 was to be on transmission-based precautions. Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including venous insufficiency, hypertension, and angina pectoris. Review of the active physician order, dated 03/07/22, revealed Resident #53 was to be on transmission-based precautions. Record review revealed Resident #270 was admitted to the facility on [DATE] with diagnoses including rhabdomyolysis, venous insufficiency, and hypertension. Review of the active physician order, dated 03/07/22, revealed Resident #270 was to be on transmission-based precautions. Record review revealed Resident #271 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease, muscle weakness, and type two diabetes mellitus. Review of the active physician order, dated 03/07/22, revealed Resident #271 was to be on transmission-based precautions. Observation on 03/07/22 at 11:40 A.M. of the lunch meal being served to five residents (Resident's #53, #270, #271, #272 and #273) residing on the COVID-19 observation unit revealed Hospitality Aide #259 was observed to don a gown, gloves, shoe covers, a face shield, and an N-95 respirator mask with a surgical mask placed over the N-95 mask before entering the COVID-19 observation unit through a plastic barrier. Hospitality Aide #259 then removed a lunch meal tray and entered the room of Resident #53 to deliver the meal. Hospitality Aide #259 then exited the room of Resident #53, removed another lunch meal tray from the cart, and entered the room of Resident #273 to deliver the tray without changing the N-95 mask, surgical mask, gown, gloves, or shoe covers or cleaning the face shield the employee was wearing. Hospitality Aide #259 then exited the room of Resident #273, removed another lunch meal tray from the cart, and entered the room of Resident #271 to deliver the tray without changing the N-95 mask, surgical mask, gown, gloves, or shoe covers or cleaning the face shield the employee was wearing. Hospitality Aide #259 then exited the room of Resident #271, removed another lunch meal tray from the cart, and entered the room of Resident #270 to deliver the tray without changing the N-95 mask, surgical mask, gown, gloves, or shoe covers or cleaning the face shield the employee was wearing. Hospitality Aide #259 then exited the room of Resident #270, removed another lunch meal tray from the cart, and entered the room of Resident #272 to deliver the tray without changing the N-95 mask, surgical mask, gown, gloves, or shoe covers or cleaning the face shield the employee was wearing. Interview with Hospitality Aide #259 on 03/07/22 at 12:05 P.M. verified the employee had donned Personal Protective Equipment (PPE) which included an N-95 respirator mask with a surgical mask placed over it, a gown, gloves, shoe covers, and a face shield prior to entering the COVID-19 observation unit and had not changed the PPE or cleaned the face shield between delivering the lunch meal trays to Resident's #53, #270, #271, #272 and #273. Hospitality Aide #259 stated the residents on the COVID-19 observation unit did not have confirmed infections of COVID-19 and PPE only needed to be changed between residents with active infection with the COVID-19 virus. Interview with Regional Nurse #888 on 03/07/22 at 12:50 P.M. verified Resident's #53, #270, #271, #272 and #273 resided on the COVID-19 observation unit and were on transmission-based precautions due to being newly admitted to the facility and not being up to date with COVID-19 vaccinations per the Centers for Disease Control (CDC) most recent recommendations. Regional Nurse #888 verified PPE including N-95 masks, gowns, gloves, and shoe covers should be changed and face shields cleaned upon exiting the room of each resident residing on the COVID-19 observation unit. Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated 02/02/22, revealed empiric use of transmission-based precautions (quarantine) was recommended for residents who were newly admitted to the facility if they were not up to date with all recommended COVID-19 vaccine doses. Review of the CDC guidance titled COVID-19, updated 01/16/22, revealed up to date meant a person had received all recommended COVID-19 vaccines, including any booster dose(s) when eligible. Review of the facility policy titled Hand Washing Technique, dated 02/17 revealed all personnel will wash before beginning the treatment/care of a resident and upon completion of such tasks, to prevent the spread of nosocomial infections. Hands should be washed after the removal of gloves or other personal protective barrier equipment. Review of the facility policy titled Disposable Non-Sterile Gloves, dated 02/17, revealed personnel will wear disposable gloves when a barrier between the resident and health care provider was necessary to prevent the transmission of blood and bodily fluids or when handling soiled articles or equipment. Gloves were also to be worn when touching mucous membranes or non-intact skin areas. Review of the facility policy titled Disposable Non-Sterile Gloves, dated February 2017, revealed personnel will wear disposable non-sterile gloves when a barrier between the resident and the health care provider is necessary to prevent the transmission of blood and bodily fluids or when handling soiled articles or equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure a seat belt restraint was properly assessed, used as the least restrictive device and released every two hours for one resident (Resident #78). This affected one of three residents reviewed for restraints. Findings include: Record review revealed Resident #78 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, convulsions, schizophrenia, repeated falls, aphasia, dementia without behavioral disturbance, hypertension and bipolar disorder. Review of the quarterly 12/16/19 Minimum Data Set (MDS) 3.0 assessment revealed the resident's cognitive level test was unable to be completed. The assessment revealed Resident #78 required extensive assistance from staff for bed mobility, transfers, to walk in room, dressing, eating, toileting and personal hygiene. The resident's balance during transitions and walking was coded as not steady; only able to stabilize with assistance. The assessment revealed the resident used a wheelchair to aid in mobility, was always incontinent of bladder, frequently incontinent of bowel and was coded as not using any physical restraints. Observation of Resident #78 on 01/06/20 at 3:08 P.M. revealed she was sitting in a wheelchair with a seat belt on around her waist. Interview with State Tested Nursing Assistant (STNA) #9 on 01/06/20 at 3:08 P.M. revealed the STNA was unsure if Resident #78 could unbuckle her seat belt. STNA #9 asked Resident #78 to unbuckle the seat belt multiple times and the resident would not comply. Observation of Resident #78 on 01/09/20 at 9:11 A.M. revealed she was in the activity room in her wheelchair with a seat belt around her waist. During an interview with Registered Nurse (RN) #59 on 01/09/20 at 9:12 A.M., the RN asked Resident #78 to unbuckle her seat belt multiple times and the resident would not comply. Observation on 01/09/20 at 11:35 A.M. revealed STNA #9 and Licensed Practical Nurse (LPN) #54 assisted Resident #78 to transfer from her wheelchair to the toilet. Resident #78 used the grab bar and stood up with little to no weight bearing assistance from the staff. Interview on 01/09/20 at 11:37 A.M. with STNA #9 verified Resident #78 did the transfer herself and required minimal to no weigh bearing assistance from her or LPN #54. Review of Resident #78's medical record revealed no documented evidence staff were removing the resident's seat belt every two hours. Interview with the Director of Nursing (DON) on 01/09/20 at 2:48 P.M. verified there was no evidence staff were removing/releasing the resident's seat belt every two hours as per the facility policy. In addition, the DON was unable to provide evidence the use of the seat belt was the least restrictive device for the resident and verified the MDS assessment was not accurate to reflect the use of the restraint as the resident was unable to independently remove the belt. Review of the facility Physical Restraint and Reduction policy, dated 02/01/17 revealed staff would directly observe a restraint every 30 minutes, would provide exercise every two hours and as needed and release the restraint for at least 10 minutes. Restraint use was to be documented in the care plan and nurse's note. Documentation must include the resident response to restraint, time of removal and response, and observation of the restraint every 30 minutes and exercise every two hour and release of the restraint for at least 10 minutes.

Based on record review and staff interview the facility failed to ensure pharmacy recommendations for Resident #60 were addressed timely by the physician. This affected one of five residents reviewed for unnecessary medications use. Findings include: Record review for Resident #60 revealed an admission date of 04/27/18 with diagnoses including heart failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus, major depressive disorder, obsessive compulsive disorder and anxiety disorder. Review of the 12/04/19 five day Minimum Data Set (MDS) 3.0 assessment revealed the resident was cognitively intact and required extensive assistance from staff for bed mobility, transfers, toilet use and personal hygiene. The resident used a wheelchair and a walker to aid in mobility. Resident #60 was frequently incontinent of bladder and occasionally incontinent of bowel. Review of the physician's orders revealed an order dated 07/26/19 for Imipramine (a tricyclic antidepressant) 25 milligrams (mg), give one tablet by mouth three times a day for depression. Review of the 08/01/19, 10/03/19, and 11/06/19 pharmacy recommendation summary revealed all three pharmacy recommendations indicated the resident was receiving Amitriptyline (a tricyclic antidepressant) 25 mg one tablet three times a day by mouth. Current clinical guidelines indicated this medication was potentially inappropriate for use in the elderly because of its strong anticholinergic and sedating properties. Please consider a selective serotonin reuptake inhibitor (SSRI) antidepressant that was more appropriate for the elderly with less side effects. Review of the pharmacy recommendation summary, dated 12/06/19 revealed Resident #60 had recommendations to add a physician's order to monitor for bleeding and thromboembolism (obstruction of a blood vessel by a blood clot) for the medication Plavix (an anticoagulant). Review of Resident #60's medical record revealed no evidence the pharmacy recommendations from 08/01/19, 10/03/19, 11/06/19 and 12/06/19 had been addressed or signed by the physician. Interview with the Director of Nursing (DON) on 01/09/20 at 2:33 P.M. verified the facility was unable to provide evidence the pharmacy recommendations had been reviewed and addressed by the physician from 08/01/19, 10/03/19, 11/06/19 and 12/06/19. Interview with Consultant Pharmacist (CP) #200 on 01/09/20 at 4:47 P.M. revealed she did the medication review for Resident #60 on 08/01/19, 10/03/19, and 11/06/19. CP #200 verified Resident #60 was not on the medication Amitriptyline but was on Imipramine. She stated the two medications were in the same drug class (tricyclic antidepressants) and the three recommendations were meant for the medication Imipramine.

Based on record review and interview the facility failed to ensure the justified use of the psychoactive medication, Seroquel for Resident #75. This affected one of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #75's medical record revealed a readmission date of 10/22/19 with diagnoses including diabetes mellitus, insomnia, Parkinson's disease, anxiety, major depressive disorder and psychosis. Review of the plan of care, dated 08/08/19 revealed the resident sometimes had behaviors which included refusal of care and verbal abuse at times. Interventions included to administer medications as ordered. Review of the resident's quarterly MDS 3.0 assessment, dated 12/20/19 revealed the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit as indicated by a BIMS score of 12. Review of the mood and behavior section revealed the resident displayed symptoms of depression. The assessment indicated he received antipsychotic and antianxiety medications. He received the antipsychotic medications on a regular basis and a GDR was not attempted. Review of the resident's monthly physician's orders for January 2020 revealed an order dated 11/20/19 for Seroquel 25 mg by mouth at bedtime with Seroquel 50 mg by mouth for a total dose of 75 mg. Review of the resident's progress notes from 07/26/19 to 01/07/19 revealed no documented evidence of psychosis or behaviors to support the use of the medication Seroquel. On 01/09/20 at 3:53 P.M. interview with the Assistant Director of Nursing (ADON) verified the resident's medical record lacked documented justification to support the use of the medication Seroquel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #67 was provided timely services from a urologist as ordered following an acute care hospital stay. This affected one of one resident reviewed for urinary catheters. Findings include: Review of Resident #67's medical record revealed an admission date of 08/06/19 with a latest readmission of 09/12/19. The resident had admitting diagnoses of constipation, insomnia, anxiety, major depressive disorder and hypothyroidism. Review of the hospital discharge papers, dated 08/20/19 revealed the resident was noted to have a fecal impaction and urinary retention. The urinary retention was possibly from the fecal impaction versus a neurogenic bladder. The paperwork revealed a urology consult for the resident as an outpatient. Review of the resident's physician's orders identified an order, dated 08/22/19 for a consult with a consulting urologist in two weeks for the indwelling Foley catheter. Review of the resident's plan of care, dated 08/23/19 revealed the resident had a urinary catheter in place and was at risk for infection, pain and obstruction. Interventions included to change Foley catheter per protocol and as needed, check catheter tubing for proper drainage and positioning, consult urology as ordered, Foley catheter to straight drainage, size as ordered, indwelling urinary catheter every shift and as needed, keep drainage bag of catheter below the level of the bladder at all times and off the floor, change collection bag every week and as needed, labs as ordered and monitor for signs and symptoms of a urinary tract infection (UTI). Review of the nursing note, dated 08/26/19 at 10:26 A.M. and authored by Registered Nurse (RN) #150 revealed the RN called and scheduled the consulting urology appointment for 09/10/19 at 10:30 A.M. Review of the medical record revealed the resident was admitted to the local hospital intensive care unit (ICU) for diagnosis of cardiac ischemia on 09/09/19. The resident was re-admitted to the facility on [DATE]. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, had a hearing impairment and utilized a hearing aide, usually understood others, made herself understood and had no cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 13. The resident required extensive assistance from two staff for bed mobility, transfers, ambulation and toileting. The assessment indicated the resident had an indwelling urinary catheter. Review of the nurse's notes dated 12/17/19 at 1:42 P.M. and authored by the Assistant Director of Nursing (ADON) revealed a follow up appointment was made in regards to the Foley catheter and was scheduled for 01/09/20 at 10:00 A.M. On 01/09/20 at 8:52 A.M. interview with the Director of Nursing (DON) verified the original appointment for 09/10/19 was missed as the resident was in the hospital. Upon the resident's return on 09/12/19, the appointment was not rescheduled. Once it was identified, on 12/17/19 (over three months later), the facility called and made the appointment. The DON verified a delay in scheduling the appointment for the resident.