**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately code the preadmission screen and resident review (PASRR) status on the Minimum Data Set (MDS) 3.0 assessment for Residents #43 and #82. This affected two (Residents #43 and #82) of three residents identified by the facility as having a level two mental illness and/or an intellectual disability. The facility census was 80.Findings include:1. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, schizophrenia and depression. Review of the level two PASRR assessment from the Ohio Department of Mental Health and Addiction Services (ODMHAS) (the state contracted PASRR agency for level two serious mental illness PASRR evaluations), dated 03/06/24, revealed Resident #43 had a level two mental illness.Review of section A of the most recent comprehensive MDS 3.0 assessment dated [DATE] revealed the facility answered no to the question Is the resident currently considered by the state level II pre admission screen and resident review (PASRR) process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition?.2. Review of the medical record revealed Resident #82 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, epilepsy and anxiety disorder. Review of the level two PASRR assessment from the Ohio Department of Developmental Disabilities ([NAME]) (the state contracted PASRR agency for level two developmental disability PASRR assessments), dated 05/17/23, revealed Resident #82 had a level two developmental disability.Review of section A of the most recent comprehensive MDS 3.0 assessment dated [DATE] revealed the facility answered no to the question of Is the resident currently considered by the state level II pre admission screen and resident review (PASRR) process to have serious mental illness and/or intellectual disability (mental retardation in federal regulation) or a related condition?.Social Worker #461 verified the PASRR coding inaccuracies for Residents #43 and #82 in an interview on 07/23/25 at 3:00 P.M.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure personal protective equipment (PPE) was worn for Enhanced Barrier Precaution (EBP) during medication administration via percutaneous endoscopic gastrostomy (PEG) tube for Resident #83. This affected one (Resident #83) five residents reviewed for medication administration had the potential to affect all residents on Registered Nurse (RN) #509's assignment, who had EBP's to include (Residents #3, #12, #35, and #36). The facility failed to ensure infection control was maintained during perineal care for Resident #94. This affected one resident (Resident #94) of three residents observed for perineal care and had the potential to affect all residents on Certified Nursing Assistant (CNA) #377's assignment to include (Residents #1, #13, #19, #38, #42, #43, #60, #62 and #68) and CNA #508's assignment to include (Residents #5, #29, #39, 44, #45, #73, #80, and #89). The facility census was 80.Findings include: 1. Review of the medical record for Resident #83 revealed an admission date of 07/31/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, dysphagia, and encounter for attention to gastrostomy. Review of the care plan dated 05/10/25 revealed Resident #83 was at risk for dehydration related to use of tube feeding. Interventions included administer medications per physician orders, EBP due to tube feed, and head of bed at 30 degrees at all times. Review of the physician orders dated July 2025 revealed an order for Baclofen 5 milligram (mg) (muscle relaxer) via PEG-tube three times a day (TID) for muscle spasms and EBP due to tube feed every shift. Observation on 07/22/25 at 1:00 P.M. revealed RN #509 entered Resident #83's room, who was on EBP's for tube feeding, to administer medications via the PEG-tube site. RN #509 performed hand hygiene and donned gloves. RN #509 opened Resident #83's PEG-tube and flushed with 15 milliliter (ml) of water, followed by medication of Baclofen 5 mg mixed with 15 ml of water, followed by a 15 ml water flush. RN #509 closed the PEG-tube site, removed his gloves and performed hand hygiene before exiting Resident #509's room. RN #509 did not don a gown as required for EBP. Interview on 07/22/25 at 1:16 P.M. with RN #509 confirmed he did not wear the correct PPE to administer medications via PEG-tube. RN #509 reported he wasn't aware he had to wear PPE for tube feeding medication administration. RN #509 reported he did not know where the bin with PPE was located in Resident #83's room. Interview on 07/22/25 at 1:20 P.M. with the Director of Nursing (DON) confirmed EBP was to be in place and PPE worn for medications via PEG-tube feeding to include a gown. Observation on 07/22/25 at 1:20 P.M. with the DON in Resident #83's room revealed a plastic bin with PPE located in the corner of the room behind a Broda chair, with PRAFO boots (a foot and ankle orthotic) on top of it, and an oxygen tank in front of the bin drawers. Review of the facility policy, Enhanced Barrier Precautions, revised 03/29/24, revealed implement EBP's for the prevention of transmission of multidrug-resistant organisms (MRDO). The policy further stated make gowns and gloves available immediately near or outside of the resident's room. High-contact resident care activities include feeding tubes. 2. Review of the medical record for Resident #94 revealed an admission date of 05/12/25. Diagnoses included Alzheimer's Disease, dementia, and congestive heart failure. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #94 had severely impaired cognition and was dependent on staff for all needs. Observation on 07/23/25 at 8:17 A.M. of incontinence care for Resident #94 revealed CNAs #337 and #508 gathered supplies, explained the procedure, provided privacy, and donned gloves without performing hand hygiene first. CNA #508 placed two clean washcloths in the bottom of the sink and began to run water over them. CNA #508 then picked up one of the washcloths and added soap to it and then picked up the other washcloth and placed it on the counter and then placed the soap washcloth on top of it. CNA #508 then took a basin and placed water in it and then placed the two washcloths from the counter in the basin. CNA #508 began to perform perineal care. During perineal care when cleaning the buttocks, the washcloth had stool on it and CNA #508 got stool on her right gloved hand. CNA #508 continued to provide perineal care without removing the stool soiled glove, performing hand hygiene and donning new gloves. CNA #508 then grabbed a tube of barrier cream with the soiled glove and applied barrier cream to Interview on 07/23/25 at 8:39 A.M. with CNA #337 confirmed she did not perform hand hygiene before and after removing gloves. CNA #337 reported she did not know she had to wash hands before applying gloves and taking off gloves. Interview on 07/23/25 at 8:40 A.M. with CNA #508 confirmed she didn't wash hands before glove usage, placed two washcloths in bottom of sink, the placed the same two washcloths on the side of the sink, then got basin and placed the same two washcloths into the basin with water. CAN #508 didn't change her gloves when she got stool on the right one, applied barrier cream with the glove with stool on it, and didn't perform hygiene when she removed her gloves. Interview on 07/23/25 at 8:45 A.M. with the DON confirmed hand hygiene was to be performed before and after glove usage, for perineal care you were to use the basin and not place washcloths in bottom of sink, remove gloves when soiled with stool, and remove gloves when soiled with stool before applying barrier cream. Review of the facility policy, Perineal Care, revised 02/15/24, revealed it is to promote cleanliness and comfort and prevent infection to the extent possible and to prevent and assess for skin breakdown. The policy further stated, perform hand hygiene and put on gloves and remove gloves and perform hand hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of a self-reported incident (SRI), record review and review of the facility policies, the facility failed to ensure residents were free from unauthorized video recordings by staff. This affected one resident (#4) of three residents reviewed for abuse. The facility census was 88. Findings include: Review of Resident #4's medical record revealed an admission date of 11/21/16 and diagnoses including Alzheimer's disease, type II diabetes, dementia with other behavioral disturbance, depression, anxiety, and adult failure to thrive. Review of Resident #4's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had short and long term memory problems and severe cognitive impairment with continuous inattention and disorganized thinking. Resident #4 rejected care one to three days in the seven-day look-back period. Resident #4 required substantial to maximum assistance with toileting, set up to dress her upper body, supervision to dress her lower body and supervision for sitting to standing and to complete toileting transfers. Resident #4 was frequently incontinent of bowel and bladder. Review of a facility self-reported incident dated 10/23/24 revealed on the morning of 10/23/24, Housekeeper #344 reported to the Director of Nursing (DON) that a friend of hers (Community Person #350) called her to let her know he saw a live feed on a web-based application called Tagged where a facility staff member was at work in the resident ' s room with the resident in the background of the video. He reported he was not able to record the video but did take several screenshots (still photos) during the live feed. The DON reported this to the Administrator and an investigation was immediately started. Certified Nursing Assistant (CNA) #349 and Resident #4 were identified in the video. CNA #349 was suspended immediately pending outcome of the investigation. Interviews were completed with staff; CNA #349 denied the allegation and reported Licensed Practical Nurse (LPN) #244 was in the room while she got Resident #4 dressed as she tended to be combative. LPN #244 denied the allegation and denied seeing CNA #349's phone or a camera while in the room. Interview with Community Person (CP) #350 confirmed he saw the live video and reported the recording device was across the room from where Resident #4 was being provided care. He stated it appeared as though the employee was changing the residents' brief but at no time was Resident #4 observed to be naked or with private areas exposed to the viewer and the staff member did not make fun of the resident or disparage her in any way. Residents on the 300 hall (where Resident #4 resided) were interviewed by Social Service Designee (SSD) #325 with no additional concerns reported; Resident #4 was not able to provide coherent information when interviewed due to her advanced dementia. The facility determined the allegation to be unsubstantiated for abuse as Resident #4 was in the background of the video but the content of the video was not demeaning or humiliating to the resident. The facility disciplined CNA #349 for violation of resident privacy policies as a result of their investigation. Continued review of the facility investigation revealed a photo timed 10/23/24 at 6:59 A.M. with Resident #4 in a blouse and pants putting socks on. A second photo with the same time-stamp revealed a blurry photo of CNA #349 with Resident #4's blurry face noted in the background and the rest of Resident #4's body was not visible as CNA #349 was in the foreground. Review of a photo timed 10/23/24 at 7:02 A.M. with Resident #4 laying across her bed with her heels resting on the edge of the bed. Resident #4 had on blue socks and her top was covered but her legs including her thighs were bare. Resident #4's buttocks or private areas were not observable from the photo. Review of a photo timed 10/23/24 at 7:16 A.M. revealed CNA #349 in the facility hallway, with tubing in her hands and the room number 308 is visible in the background. Interview on 11/12/24 at 10:49 A.M. with the Administrator regarding the SRI on 10/23/24 revealed Housekeeper #344 said her friend, CP #350 said an employee [CNA #349] was live in the facility in a resident's room on social media between 6:30 A.M. and 7:00 A.M. The social media application, called Tagged, was used for dating and involved users taking videos of themselves. The Administrator indicated he interviewed CP #350 by phone for the facility investigation and learned CNA #349's phone was propped up in the resident's room as she completed resident care and he did not observe Resident #4 naked. The Administrator stated as far as he was aware, no one at the facility had seen the video except CP #350. Interview on 11/12/24 at 11:37 A.M. with CNA #349 revealed she worked a 16-hour shift from 10/22/24 into 10/23/24. CNA #349 stated Resident #4 was combative so did not provide care at that time and continued to care for her other residents. CNA #349 stated LPN #244 told her on her way out of the facility she needed to care for Resident #4 and they could do it together. CNA #349 stated she was on her phone watching videos on Tagged (dating application) and was unaware a user had requested to livestream. CNA #349 could not deny the livestream request and thus her phone started to record while she was in Resident #4's room. CNA #349 denied making disparaging comments to Resident #4 and indicated she was very polite. CNA #349 verified she provided personal care to Resident #4 but her breasts and perineal areas were not exposed at any time. CNA #349 explained on Tagged, a video would be live and once it was over it would not be saved anywhere as it was not posted to an account but was live content. CNA #349 was unaware if any one at the facility had seen the video and called it a lesson learned. Interview was attempted with CP #350 on 11/12/24 at 11:50 A.M. but was not successful. Interview on 11/12/24 at 11:54 A.M. with Housekeeper #344 revealed her children's father, CP #350, was on Tagged and had sent photos of Individual #4 to the DON from the livestream as he saw she was being changed, recognized the facility and was 'bothered by the situation.' Housekeeper #344 indicated she had seen the photos but not the video and indicated Resident #4's private areas were not visible in the photos. Interview was attempted with LPN #244 on 11/12/24 at 12:08 P.M. but was not successful. Interview on 11/12/24 at 12:10 P.M. with the DON revealed she helped with the SRI investigation on 10/23/23 and indicated the photos in the file were what they received from CP #350. The DON stated the only staff members aside from herself and the Administrator that had viewed the photos was Housekeeper #344 and she was unaware of anyone at the facility that had viewed the video as of the time of the interview. The DON also verified Resident #4 was not interviewable due to cognitive status. Interview was attempted with Resident #4's responsible party on 11/12/24 at 1:52 P.M. but was not successful. Follow-up interview on 11/12/24 at 2:25 P.M. with the DON verified the identified privacy concerns with Resident #4 as a result of CNA #349's phone recording the resident without her consent or knowledge. The DON confirmed CNA #349 was terminated as a result of the facility's investigation due to not meeting privacy and facility policy expectations as they could not determine abuse had occurred. Review of the policy, Personal Cell Phones, reviewed/revised 04/01/24 revealed the facility would provide quality care to its residents without interruption. The facility prohibits employees from using personal cell phones for any reason on the nursing units or in working areas of the facility. This includes calls, texts, social media or any other use of cell phones. Under no circumstances should employees take pictures, videos or any other personal representations of any resident, family member, visitor, or staff member for the purpose of personal use, social media or any other reason. Review of the policy, Resident Rights, dated 2024 revealed the resident had the right to personal privacy including medical treatment and personal care. This deficiency represents non-compliance investigated under Master Complaint Number OH00159552 and Complaint Number OH00159466.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to report a change in condition to Resident #50's responsible party and physician, when the resident was sexually abused and was agitated and crying. This affected one resident (Resident #50) of three residents reviewed for notification of change in condition. Findings include: Review of Resident #50's open medical record revealed the resident was admitted on [DATE] with diagnoses including Parkinson's disease with dyskinesia, unspecified dementia and anxiety disorder. Review of Resident #50's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #50's police report dated 06/06/24 authored by Police #359 indicated they were called to facility by Resident #50's family regarding an incident that occurred with Resident #50. Resident #50's family was told by staff members a male tried to inappropriately touch her mother under her gown during the evening of 06/05/24. Review of Resident #50's undated Police Department Witness Statement form authored by Licensed Practical Nurse (LPN) #223 indicated she was informed Resident #101 attempted to reach inside Resident #50's brief. She did not witness the activity. A full assessment was completed of Resident #50 for physical trauma or injury. Review of Resident #50's undated Police Department Witness Statement form authored by State Tested Nursing Assistant (STNA) #284 indicated on 06/05/24 she observed Resident #101 attempting to touch Resident #50 inappropriately. The residents were separated. Review of Resident #50's undated Police Department Witness Statement form authored by STNA #340 indicated on 06/05/24, the employee overheard a commotion and observed another STNA removing Resident #101 away from Resident #50 because his hands was on the wheelchair and he would not let go. Resident #101 was taken back to his room. Resident #50's incontinence brief was intact. Review of Resident #50's medical record did not reveal entries in the progress notes concerning physical or sexual abuse by Resident #101 on 06/05/24 per the police report. There was no evidence of the resident's assessment when the incident occurred or following up with the resident after the incident. There was no evidence Resident #50's physician or representative was notified of the incident. Interview on 07/01/24 at 7:50 A.M. with Resident #50's daughter indicated she called the local police department because she felt the resident had increased agitation and possible abuse concerns. She reported not being notified of the incident with Resident #101 or that her mother was upset in any way. Interview on 07/01/24 at 9:53 A.M. with Director of Nursing (DON) confirmed the nursing staff should have contacted the physician and family regarding the change in condition of Resident #50. DON reported she became aware of an incident with Resident #50 on 06/06/24, the next day, when Resident #50's daughter was at the facility and upset that her mom didn't seem right. Resident #50's daughter called the police that day. DON reported Resident #50 had a change in condition on 06/05/24 when she was upset. DON reported the family should have been notified right away of the change in her condition. Interview on 07/01/24 at 10:15 A.M. with LPN #220 revealed Resident #50's daughter asked her on 06/06/24 if something happened to her mom, daughter had tears in her eyes, and LPN #220 did not know anything happened. LPN #220 went and got their supervisor and DON. Interview on 07/01/24 at 2:58 P.M. with STNA #227 indicated she was told by STNA #340 that another resident had reached over and fondled Resident #50 in the lady parts down below. She stated staff intervened when Resident #50 screamed and the residents were separated. Interview on 07/01/24 at 4:37 P.M. with STNA #340 reported she did not witness sexual abuse and denied telling another STNA about the abuse. The resident did not have pants on at the time of the incident. STNA #340 indicated she was the staff member who got the resident out of bed from a nap prior to dinner on 06/05/24 because the husband came in to visit. STNA #340 confirmed she dressed the resident in a top and incontinence brief with no pants or bottoms. She only placed sheet over her legs. STNA #340 stated she placed Resident #50 back in bed following the incident with Resident #101 and the resident still had a top on and a incontinence brief with a sheet over her legs. Interview on 07/02/24 at 7:27 A.M. with STNA #284 revealed Resident #101 was sitting next to Resident #50 on 06/05/24 at the nursing station. Resident #101 had his hand (unknown which hand) in Resident #50's brief. Resident #50 was observed to be crying and Resident #101 was removed from the area. Another STNA (unknown who the employee was) was observed hugging Resident #50) and asked her if she was ok. Resident #50 reported she was not ok. Interview on 07/02/24 at 10:49 A.M. with LPN #223 stated she did not witness the incident between Resident #50 and #101. She confirmed she wrote a statement, and she said a State Tested Nursing Assistant (STNA) told her about the sexual abuse incident. Interview on 07/02/24 at 12:20 P.M. with LPN #290 revealed she worked on a different hall on 06/05/24 and was coming up to the nurse's station and remembers Resident #50 was upset, crying, and shaking after the incident with Resident #101. Review of facility policy, Notification of Changes, revised 12/15/23, revealed the purpose of this policy is to ensure the facility promptly inform the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. This deficiency represents non-compliance investigated under Complaint Number OH00154684.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement there abuse prohibition policy after an allegation of abuse was made to protect the residents, thoroughly investigation the allegation, and report the allegations and findings to the State agency. This finding affected two residents (Residents #6 and Resident #50) of three residents reviewed for abuse. Findings include: 1. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease with dyskinesia, unspecified dementia and anxiety disorder. Review of Resident #50's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of a police report for Resident #50 dated 06/06/24 authored by Police #359 revealed they were called to the facility by Resident #50's family regarding an incident that occurred with Resident #101. Resident #50's family member was told by staff members a male (resident) tried to inappropriately touch her mother (Resident #50) under her gown during the evening of 06/05/24. Review of an undated Police Department Witness Statement form authored by Licensed Practical Nurse (LPN) #223 indicated she was informed Resident #101 attempted to reach inside Resident #50's brief. She did not witness the activity. A full assessment was completed of Resident #50 for physical trauma or injury. Review of an undated Police Department Witness Statement form authored by State Tested Nursing Assistant (STNA) #284 indicated on 06/05/24 she observed Resident #101 attempting to touch Resident #50 inappropriately. The residents were separated. Review of an undated Police Department Witness Statement form authored by STNA #340 indicated on 06/05/24, the employee overheard a commotion and observed another STNA removing Resident #101 away from Resident #50 because his hands were on the wheelchair and he would not let go. Resident #101 was taken back to his room. Resident #50's incontinence brief was intact. Review of Resident #50's medical record did not reveal entries in the progress notes concerning physical or sexual abuse by Resident #101 on 06/05/24 per the police report. There was no evidence of the resident's assessment when the incident occurred or of any follow-up with the resident after the incident. Interview on 07/01/24 at 7:50 A.M. with Resident #50's daughter indicated she called the local police department related to this incident because she felt the resident had increased agitation (as a result of the incident) and related to possible abuse concerns. An attempt to interview Resident #50 on 07/01/24 at 10:01 A.M. was unsuccessful as the resident only knew her name and was not interviewable. Interview on 07/01/24 at 2:58 P.M. with STNA #227 revealed she was told by STNA #340 that another resident had reached over and fondled Resident #50 in the lady parts down below. She stated staff intervened when Resident #50 screamed and the residents were separated. Interview on 07/01/24 at 4:37 P.M. with STNA #340 revealed she did not witness this sexual abuse and denied telling another STNA about the abuse. The STNA further stated, the resident (#50) did not have pants on at the time of the incident. STNA #340 indicated she was the staff member who got Resident #50 out of bed from a nap prior to dinner on 06/05/24 because the resident's husband came in to visit. STNA #340 confirmed she dressed the resident in a top and incontinence brief with no pants or bottoms and only placed a sheet over her legs. STNA #340 stated she placed Resident #50 back in bed following the incident with Resident #101 and the resident still had a top on and a incontinence brief with a sheet over her legs. Interview on 07/02/24 at 7:27 A.M. with STNA #284 revealed Resident #101 was sitting next to Resident #50 on 06/05/24 at the nursing station. Resident #101 had his hand (unknown which hand) in Resident #50's brief. Resident #50 was observed to be crying and Resident #101 was removed from the area. Another STNA (unknown who the employee was) was observed hugging Resident #50 and asked her if she was ok. Resident #50 reported she was not ok. Interview on 07/02/24 at 10:49 A.M. with LPN #223 revealed she did not witness the incident between Resident #50 and #101. She confirmed she wrote a statement, and she said an STNA told her about the sexual abuse incident. Interview on 07/02/24 at 11:26 A.M. with the Director of Nursing (DON) confirmed she was informed of this incident between Resident #50 and #101 on 06/06/24 by staff members. The DON confirmed she was aware the local police department came into the facility on [DATE] to investigate a concern with Resident #50 but stated she did not feel it was abuse so she did not conduct a thorough investigation and did not report the incident to State agency. The DON confirmed the facility could not provide evidence of any type of assessment of Resident #50 after the incident on 06/05/24. Interview on 07/02/24 at 12:20 P.M. with LPN #290 revealed she worked on a different hall on 06/05/24 and was coming up to the nurse's station and remembered Resident #50 was upset, crying, and shaking after the incident with Resident #101. Review of Resident #101's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on 06/06/24 (to an assisted living) with diagnoses including hemiplegia, malignant neoplasm of the bladder and anxiety disorder. Review of Resident #101's comprehensive care plan dated 01/19/24 revealed the care plan did not include interventions to address sexual abuse or inappropriate sexual behavior. Interview on 07/02/24 at 3:09 P.M. with Licensed Social Worker (LSW) #287, who does care plans for resident behaviors, confirmed Resident #101's did not have a comprehensive and individualized plan of care in place to prevent sexual abuse/address sexually inappropriate behavior(s). 2. Review of Resident #6's medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia, anxiety disorder and anemia. Review of Resident #6's quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Interview on 07/02/24 at 11:26 A.M. with the DON revealed she had been informed of an incident involving Resident #6 and she stated she felt what was reported to her was not sexual abuse. She stated a nurse had told her Resident #101 had attempted to grab Resident #6 by his pants. She denied reporting this incident of sexual abuse to the State agency and denied doing a thorough investigation because she stated she did not feel it was abuse. An attempt to interview Resident #6 on 07/08/24 at 12:50 P.M. was unsuccessful as the resident was cognitively impaired and was only able to state his name. Review of Resident #6's medical record revealed no evidence the incident between Resident #101 and Resident #6 was documented in his record. The record did not include an assessment after the incident. Review of Resident #101's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on 06/06/24 (to an assisted living) with diagnoses including hemiplegia, malignant neoplasm of the bladder and anxiety disorder. Review of Resident #101's comprehensive care plan dated 01/19/24 revealed the care plan did not include interventions to address sexual abuse or inappropriate sexual behavior. Review of Resident #101's progress note dated 04/25/24 at 6:39 A.M. authored by Registered Nurse (RN) #299 revealed the resident was up at the nursing station sitting next to Resident #6 and attempting to grab at Resident #6's penis. The resident was pulling at his pants and trying to put his hand down the resident's pants. Resident #6 yelled and stated, you are hurting me. The resident was moved into the television room and kept coming up to the other residents to touch them inappropriately. The note indicated nursing would continue to monitor. Review of Resident #101's progress note dated 04/28/24 at 11:08 A.M. authored by LPN #290 indicated the resident was wheeling himself up to female and male residents and placing his hand under their clothes and attempting to touch them. The staff removed him away from the residents and observed him by taking him to his room. The physician was notified. The note did not identify which residents were involved. Interview on 07/02/24 at 12:20 P.M. with LPN #290 revealed on 04/28/24, Resident #101 was wheeling himself up and placing his hands under both male and female resident's clothing. She confirmed Resident #101 had behaviors of touching other residents' underneath of their clothes and stated she had witnessed him placing his hands under a female resident's clothing but she could not recall the resident's name or date of the incident. She stated of course it was sexual abuse however, she could not state who she had reported the incident too. Interview on 07/02/24 at 3:09 P.M. with Licensed Social Worker (LSW) #287, who does care plans for resident behaviors, confirmed Resident #101's did not have a comprehensive and individualized plan of care in place to prevent sexual abuse/address sexually inappropriate behavior(s). Review of the facility policy, Abuse, Neglect, and Exploitation, revised 12/04/23 revealed the facility defined sexual abuse as non-consensual sexual contact of any type with a resident. The policy revealed the facility would provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Investigation of Alleged, Neglect and Exploitation included an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigation include: identifying staff responsible for the investigation; exercising caution in handing evidence that could be used in a criminal investigation, investigating different types of alleged violations, identifying and interviewing all persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining is abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause, and provide complete and thorough documentation of the investigation. Protection of Resident included the facility will make efforts to ensure all residents are protected from physical and psychosocial harm as well as additional abuse, during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation; examining the victim for any sign of injury, including a physician examination or psychosocial assessment if needed; increased supervision of the alleged victim and residents; room or staffing changes, if necessary, to protect the resident from the alleged perpetrator; protection from retaliation; providing emotional support and counseling to the resident during and after the investigation, as needed; revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. Reporting Response included the facility will have written procedures that include but are not limited to: reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes which are immediately, but not later than two hours after the allegation is made if that even that causes the allegation involve abuse or result in seriously body injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury; assuring that reporters are free fro retaliation or reprisal; promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports suspicion of a crime; taking all necessary actions as a result if the investigation, which may include, but are not limited to the following: analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident occurred, and what changes are needed to prevent further occurrences; defining how care provision will be changed and/or improved to protect residents receiving services; training of staff on changes made and demonstration of staff competency after training is implemented; the expected date for implementation; and identification of staff responsible for monitoring the implementation of the plan. Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within five working days of the incident, as required by state agencies. This deficiency represents non-compliance investigated under Master Complaint Number OH00154836 and Complaint Number OH00154684.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to timely report allegations of sexual abuse to the Administrator and State agency. This finding affected two residents (Residents #6 and Resident #50) of three residents reviewed for abuse. Findings include: 1. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease with dyskinesia, unspecified dementia and anxiety disorder. Review of Resident #50's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of a police report for Resident #50 dated 06/06/24 authored by Police #359 revealed they were called to the facility by Resident #50's family regarding an incident that occurred with Resident #101. Resident #50's family member was told by staff members a male (resident) tried to inappropriately touch her mother (Resident #50) under her gown during the evening of 06/05/24. Review of an undated Police Department Witness Statement form authored by Licensed Practical Nurse (LPN) #223 indicated she was informed Resident #101 attempted to reach inside Resident #50's brief. She did not witness the activity. A full assessment was completed of Resident #50 for physical trauma or injury. Review of an undated Police Department Witness Statement form authored by State Tested Nursing Assistant (STNA) #284 indicated on 06/05/24 she observed Resident #101 attempting to touch Resident #50 inappropriately. The residents were separated. Review of an undated Police Department Witness Statement form authored by STNA #340 indicated on 06/05/24, the employee overheard a commotion and observed another STNA removing Resident #101 away from Resident #50 because his hands were on the wheelchair and he would not let go. Resident #101 was taken back to his room. Resident #50's incontinence brief was intact. Review of Resident #50's medical record did not reveal entries in the progress notes concerning physical or sexual abuse by Resident #101 on 06/05/24 per the police report. There was no evidence of the resident's assessment when the incident occurred or of any follow-up with the resident after the incident. Interview on 07/01/24 at 7:50 A.M. with Resident #50's daughter indicated she called the local police department related to this incident because she felt the resident had increased agitation (as a result of the incident) and related to possible abuse concerns. An attempt to interview Resident #50 on 07/01/24 at 10:01 A.M. was unsuccessful as the resident only knew her name and was not interviewable. Interview on 07/01/24 at 2:58 P.M. with STNA #227 revealed she was told by STNA #340 that another resident had reached over and fondled Resident #50 in the lady parts down below. She stated staff intervened when Resident #50 screamed and the residents were separated. Interview on 07/01/24 at 4:37 P.M. with STNA #340 revealed she did not witness this sexual abuse and denied telling another STNA about the abuse. The STNA further stated, the resident (#50) did not have pants on at the time of the incident. STNA #340 indicated she was the staff member who got Resident #50 out of bed from a nap prior to dinner on 06/05/24 because the resident's husband came in to visit. STNA #340 confirmed she dressed the resident in a top and incontinence brief with no pants or bottoms and only placed a sheet over her legs. STNA #340 stated she placed Resident #50 back in bed following the incident with Resident #101 and the resident still had a top on and a incontinence brief with a sheet over her legs. Interview on 07/02/24 at 7:27 A.M. with STNA #284 revealed Resident #101 was sitting next to Resident #50 on 06/05/24 at the nursing station. Resident #101 had his hand (unknown which hand) in Resident #50's brief. Resident #50 was observed to be crying and Resident #101 was removed from the area. Another STNA (unknown who the employee was) was observed hugging Resident #50 and asked her if she was ok. Resident #50 reported she was not ok. Interview on 07/02/24 at 10:49 A.M. with LPN #223 revealed she did not witness the incident between Resident #50 and #101. She confirmed she wrote a statement, and she said an STNA told her about the sexual abuse incident. Interview on 07/02/24 at 11:26 A.M. with the Director of Nursing (DON) confirmed she was informed of this incident between Resident #50 and #101 on 06/06/24 by staff members. The DON confirmed she was aware the local police department came into the facility on [DATE] to investigate a concern with Resident #50 but stated she did not feel it was abuse so she did not conduct a thorough investigation and did not report the incident to State agency. The DON confirmed the facility could not provide evidence of any type of assessment of Resident #50 after the incident on 06/05/24. Interview on 07/02/24 at 12:20 P.M. with LPN #290 revealed she worked on a different hall on 06/05/24 and was coming up to the nurse's station and remembered Resident #50 was upset, crying, and shaking after the incident with Resident #101. Review of Resident #101's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on 06/06/24 (to an assisted living) with diagnoses including hemiplegia, malignant neoplasm of the bladder and anxiety disorder. Review of Resident #101's comprehensive care plan dated 01/19/24 revealed the care plan did not include interventions to address sexual abuse or inappropriate sexual behavior. Interview on 07/02/24 at 3:09 P.M. with Licensed Social Worker (LSW) #287, who does care plans for resident behaviors, confirmed Resident #101's did not have a comprehensive and individualized plan of care in place to prevent sexual abuse/address sexually inappropriate behavior(s). 2. Review of Resident #6's medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia, anxiety disorder and anemia. Review of Resident #6's quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Interview on 07/02/24 at 11:26 A.M. with the DON revealed she had been informed of an incident involving Resident #6 and she stated she felt what was reported to her was not sexual abuse. She stated a nurse had told her Resident #101 had attempted to grab Resident #6 by his pants. She denied reporting this incident of sexual abuse to the State agency and denied doing a thorough investigation because she stated she did not feel it was abuse. An attempt to interview Resident #6 on 07/08/24 at 12:50 P.M. was unsuccessful as the resident was cognitively impaired and was only able to state his name. Review of Resident #6's medical record revealed no evidence the incident between Resident #101 and Resident #6 was documented in his record. The record did not include an assessment after the incident. Review of Resident #101's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on 06/06/24 (to an assisted living) with diagnoses including hemiplegia, malignant neoplasm of the bladder and anxiety disorder. Review of Resident #101's comprehensive care plan dated 01/19/24 revealed the care plan did not include interventions to address sexual abuse or inappropriate sexual behavior. Review of Resident #101's progress note dated 04/25/24 at 6:39 A.M. authored by Registered Nurse (RN) #299 revealed the resident was up at the nursing station sitting next to Resident #6 and attempting to grab at Resident #6's penis. The resident was pulling at his pants and trying to put his hand down the resident's pants. Resident #6 yelled and stated, you are hurting me. The resident was moved into the television room and kept coming up to the other residents to touch them inappropriately. The note indicated nursing would continue to monitor. Review of Resident #101's progress note dated 04/28/24 at 11:08 A.M. authored by LPN #290 indicated the resident was wheeling himself up to female and male residents and placing his hand under their clothes and attempting to touch them. The staff removed him away from the residents and observed him by taking him to his room. The physician was notified. The note did not identify which residents were involved. Interview on 07/02/24 at 12:20 P.M. with LPN #290 revealed on 04/28/24, Resident #101 was wheeling himself up and placing his hands under both male and female resident's clothing. She confirmed Resident #101 had behaviors of touching other residents' underneath of their clothes and stated she had witnessed him placing his hands under a female resident's clothing but she could not recall the resident's name or date of the incident. She stated of course it was sexual abuse however, she could not state who she had reported the incident too. Interview on 07/02/24 at 3:09 P.M. with Licensed Social Worker (LSW) #287, who does care plans for resident behaviors, confirmed Resident #101's did not have a comprehensive and individualized plan of care in place to prevent sexual abuse/address sexually inappropriate behavior(s). Review of the facility policy, Abuse, Neglect, and Exploitation, revised 12/04/23 revealed the facility defined sexual abuse as non-consensual sexual contact of any type with a resident. The policy revealed the facility would provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Reporting Response included the facility will have written procedures that include but are not limited to: reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes which are immediately, but not later than two hours after the allegation is made if that even that causes the allegation involve abuse or result in seriously body injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury; assuring that reporters are free fro retaliation or reprisal; promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports suspicion of a crime; taking all necessary actions as a result if the investigation, which may include, but are not limited to the following: analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident occurred, and what changes are needed to prevent further occurrences; defining how care provision will be changed and/or improved to protect residents receiving services; training of staff on changes made and demonstration of staff competency after training is implemented; the expected date for implementation; and identification of staff responsible for monitoring the implementation of the plan. Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within five working days of the incident, as required by state agencies. This deficiency represents non-compliance investigated under Master Complaint Number OH00154836 and Complaint Number OH00154684.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to thoroughly investigate allegations of resident to resident sexual abuse for Resident #6 and Resident #50. This affected two residents (Resident 6 and Resident #50) of three residents reviewed for abuse. Findings include: 1. Review of Resident #50's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease with dyskinesia, unspecified dementia and anxiety disorder. Review of Resident #50's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of a police report for Resident #50 dated 06/06/24 authored by Police #359 revealed they were called to the facility by Resident #50's family regarding an incident that occurred with Resident #101. Resident #50's family member was told by staff members a male (resident) tried to inappropriately touch her mother (Resident #50) under her gown during the evening of 06/05/24. Review of an undated Police Department Witness Statement form authored by Licensed Practical Nurse (LPN) #223 indicated she was informed Resident #101 attempted to reach inside Resident #50's brief. She did not witness the activity. A full assessment was completed of Resident #50 for physical trauma or injury. Review of an undated Police Department Witness Statement form authored by State Tested Nursing Assistant (STNA) #284 indicated on 06/05/24 she observed Resident #101 attempting to touch Resident #50 inappropriately. The residents were separated. Review of an undated Police Department Witness Statement form authored by STNA #340 indicated on 06/05/24, the employee overheard a commotion and observed another STNA removing Resident #101 away from Resident #50 because his hands were on the wheelchair and he would not let go. Resident #101 was taken back to his room. Resident #50's incontinence brief was intact. Review of Resident #50's medical record did not reveal entries in the progress notes concerning physical or sexual abuse by Resident #101 on 06/05/24 per the police report. There was no evidence of the resident's assessment when the incident occurred or of any follow-up with the resident after the incident. Interview on 07/01/24 at 7:50 A.M. with Resident #50's daughter indicated she called the local police department related to this incident because she felt the resident had increased agitation (as a result of the incident) and related to possible abuse concerns. An attempt to interview Resident #50 on 07/01/24 at 10:01 A.M. was unsuccessful as the resident only knew her name and was not interviewable. Interview on 07/01/24 at 2:58 P.M. with STNA #227 revealed she was told by STNA #340 that another resident had reached over and fondled Resident #50 in the lady parts down below. She stated staff intervened when Resident #50 screamed and the residents were separated. Interview on 07/01/24 at 4:37 P.M. with STNA #340 revealed she did not witness this sexual abuse and denied telling another STNA about the abuse. The STNA further stated, the resident (#50) did not have pants on at the time of the incident. STNA #340 indicated she was the staff member who got Resident #50 out of bed from a nap prior to dinner on 06/05/24 because the resident's husband came in to visit. STNA #340 confirmed she dressed the resident in a top and incontinence brief with no pants or bottoms and only placed a sheet over her legs. STNA #340 stated she placed Resident #50 back in bed following the incident with Resident #101 and the resident still had a top on and a incontinence brief with a sheet over her legs. Interview on 07/02/24 at 7:27 A.M. with STNA #284 revealed Resident #101 was sitting next to Resident #50 on 06/05/24 at the nursing station. Resident #101 had his hand (unknown which hand) in Resident #50's brief. Resident #50 was observed to be crying and Resident #101 was removed from the area. Another STNA (unknown who the employee was) was observed hugging Resident #50 and asked her if she was ok. Resident #50 reported she was not ok. Interview on 07/02/24 at 10:49 A.M. with LPN #223 revealed she did not witness the incident between Resident #50 and #101. She confirmed she wrote a statement, and she said an STNA told her about the sexual abuse incident. Interview on 07/02/24 at 11:26 A.M. with the Director of Nursing (DON) confirmed she was informed of this incident between Resident #50 and #101 on 06/06/24 by staff members. The DON confirmed she was aware the local police department came into the facility on [DATE] to investigate a concern with Resident #50 but stated she did not feel it was abuse so she did not conduct a thorough investigation and did not report the incident to State agency. The DON confirmed the facility could not provide evidence of any type of assessment of Resident #50 after the incident on 06/05/24. Interview on 07/02/24 at 12:20 P.M. with LPN #290 revealed she worked on a different hall on 06/05/24 and was coming up to the nurse's station and remembered Resident #50 was upset, crying, and shaking after the incident with Resident #101. Review of Resident #101's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on 06/06/24 (to an assisted living) with diagnoses including hemiplegia, malignant neoplasm of the bladder and anxiety disorder. Review of Resident #101's comprehensive care plan dated 01/19/24 revealed the care plan did not include interventions to address sexual abuse or inappropriate sexual behavior. Interview on 07/02/24 at 3:09 P.M. with Licensed Social Worker (LSW) #287, who does care plans for resident behaviors, confirmed Resident #101's did not have a comprehensive and individualized plan of care in place to prevent sexual abuse/address sexually inappropriate behavior(s). 2. Review of Resident #6's medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including unspecified dementia, anxiety disorder and anemia. Review of Resident #6's quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem. Interview on 07/02/24 at 11:26 A.M. with the DON revealed she had been informed of an incident involving Resident #6 and she stated she felt what was reported to her was not sexual abuse. She stated a nurse had told her Resident #101 had attempted to grab Resident #6 by his pants. She denied reporting this incident of sexual abuse to the State agency and denied doing a thorough investigation because she stated she did not feel it was abuse. An attempt to interview Resident #6 on 07/08/24 at 12:50 P.M. was unsuccessful as the resident was cognitively impaired and was only able to state his name. Review of Resident #6's medical record revealed no evidence the incident between Resident #101 and Resident #6 was documented in his record. The record did not include an assessment after the incident. Review of Resident #101's closed medical record revealed the resident was admitted to the facility on [DATE] and discharged on 06/06/24 (to an assisted living) with diagnoses including hemiplegia, malignant neoplasm of the bladder and anxiety disorder. Review of Resident #101's comprehensive care plan dated 01/19/24 revealed the care plan did not include interventions to address sexual abuse or inappropriate sexual behavior. Review of Resident #101's progress note dated 04/25/24 at 6:39 A.M. authored by Registered Nurse (RN) #299 revealed the resident was up at the nursing station sitting next to Resident #6 and attempting to grab at Resident #6's penis. The resident was pulling at his pants and trying to put his hand down the resident's pants. Resident #6 yelled and stated, you are hurting me. The resident was moved into the television room and kept coming up to the other residents to touch them inappropriately. The note indicated nursing would continue to monitor. Review of Resident #101's progress note dated 04/28/24 at 11:08 A.M. authored by LPN #290 indicated the resident was wheeling himself up to female and male residents and placing his hand under their clothes and attempting to touch them. The staff removed him away from the residents and observed him by taking him to his room. The physician was notified. The note did not identify which residents were involved. Interview on 07/02/24 at 12:20 P.M. with LPN #290 revealed on 04/28/24, Resident #101 was wheeling himself up and placing his hands under both male and female resident's clothing. She confirmed Resident #101 had behaviors of touching other residents' underneath of their clothes and stated she had witnessed him placing his hands under a female resident's clothing but she could not recall the resident's name or date of the incident. She stated of course it was sexual abuse however, she could not state who she had reported the incident too. Interview on 07/02/24 at 3:09 P.M. with Licensed Social Worker (LSW) #287, who does care plans for resident behaviors, confirmed Resident #101's did not have a comprehensive and individualized plan of care in place to prevent sexual abuse/address sexually inappropriate behavior(s). Review of the facility policy, Abuse, Neglect, and Exploitation, revised 12/04/23 revealed the facility defined sexual abuse as non-consensual sexual contact of any type with a resident. The policy revealed the facility would provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Investigation of Alleged, Neglect and Exploitation included an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigation include: identifying staff responsible for the investigation; exercising caution in handing evidence that could be used in a criminal investigation, investigating different types of alleged violations, identifying and interviewing all persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining is abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause, and provide complete and thorough documentation of the investigation. This deficiency represents non-compliance investigated under Master Complaint Number OH00154836 and Complaint Number OH00154684.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement comprehensive care plans for Resident #100's Intravenous (IV) medication. This affected one residents (Resident #100) out of three residents reviewed for care plans. Findings include: Review of the medical record for Resident #100 revealed an admission date of 03/22/24 and a discharge date of 04/26/24 with diagnosis including but not limited to displaced intertrochanteric fracture of right femur, rheumatoid arthritis, chronic obstructive pulmonary disease (COPD), paroxysmal atrial fibrillation, chronic diastolic congestive heart failure, anxiety disorder, and depression. Review of the Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #100 had intact cognition. Review of the physician order dated 04/15/24 revealed an order for Intravenous (IV) for Zosyn (antibiotic medication) reconstitute 3.375 (3-0.375) gram (gm) (piperacillin sodium-tazobactam sodium) administer every 6 hours for atelectasis (complete or parital collapse of lung). Review of the current care plan dated 03/22/24 revealed no care plan to address Resident #100's IV medication. Interview on 07/02/24 at 1:50 P.M. with LPN #285 (MDS Nurse) confirmed there was no care plan for the IV for Resident #100.

Based on observation, interview and record review, the facility failed to report a change in condition to Resident #275's responsible party and physician, who had bruising to the left side of her neck. This affected one resident (Resident #275) of two residents reviewed for notification of change in condition. Findings include: Record review for Resident #275 revealed an admission date of 12/15/22. Diagnosis included history of congestive heart failure and paroxysmal atrial fibrillation. Record review of the admission Baseline Care Plan dated 12/15/22 completed by Licensed Practical Nurse (LPN) #582 revealed Resident #275 was alert to person and confused. Resident #275 had an unsteady gait and weakness. Resident #275 was dependent for toileting, required extensive assistance for bed mobility and total dependence for transfers of two person physical assistants. Record review of the admission Skin Assessment initiated by Licensed Practical Nurse #544 dated 12/16/22 revealed Resident #275 had bruising to the chest and on both arms. Record review of the physician orders for December 2022 for Resident #275 revealed Resident #275 had orders for coumadin five milligrams (mg) by mouth at bed time for atrial fibrillation. Orders included to monitor for signs and symptoms of bleeding every shift due to anticoagulants. Record review of Resident #275's medical record revealed no documentation of the bruising to Resident #275's left side of her neck. Observation on 12/19/22 at 10:03 A.M. revealed Resident #275 was sitting up in a wheelchair in her room. The door to her room had been closed. Resident #275 was sitting in the chair with no shirt on and just a bra. Resident #275's shirt was lying on the floor next to her. Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. The bilateral arms had multiple small bruises. Resident #275 rambled and was unable to explain how the large bruise to her neck occurred. Interview on 12/19/22 at 10:08 A.M. with State Tested Nursing Assistant (STNA) #559 revealed she assisted Resident #275 with A.M. care and was unsure how the bruising occurred to Resident #275's neck. STNA #559 revealed Resident #275 often removed her own clothing. Interview on 12/19/22 at 10:15 A.M. with LPN #542 revealed she was Resident #275's charge nurse and was aware Resident #275 had bruising to her neck. LPN #542 revealed she normally did not work with Resident #275 and was unsure how the bruising occurred. Interview on 12/19/22 at 12:24 P.M. with Resident #275's daughter confirmed she was also Resident #275 Power of Attorney (POA)/Responsible Party. Resident #275's daughter revealed she last visited Resident #275 on 12/15/22 when she was admitted to the facility. Resident #275's daughter revealed she had not been contacted of any changes in condition by the facility regarding Resident #275 and was unaware of any bruising to Resident #275's left side of her neck. Interview and observation on 12/20/22 at 1:36 P.M. with Registered Nurse (RN) #524 confirmed he was Resident #275's charge nurse. Observation of Resident #275's bruising to the left side of her neck with RN #524 confirmed Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. RN #524 revealed he was unaware Resident #524 had bruising to her neck area. Interview and observation on 12/20/22 at 1:45 P.M. with Wound Care Nurse Licensed Practical Nurse (LPN) #532 revealed she completed a skin assessment for Resident #275 on 12/16/22 (date after admission) during the day shift. Wound Care Nurse LPN #532 revealed Resident #275 did not have any bruising to her neck when she assessed her on 12/16/22. Record review of the progress note for Resident #275 dated 12/20/22 at 3:26 P.M. completed by RN #524 revealed Resident #275 had a dark purple in color with light purple bruise from the mid breast to the left ear lobe which measured 26 centimeters (cm) in length by 11 cm in width. Resident #275 also had a dark purple bruise to the left upper arm that measured 13 cm by 12 cm. Interview on 12/20/22 at 3:21 P.M. with Director of Nursing confirmed the physician nor certified nurse practitioner (CNP) had been made aware of Resident #275's bruise to the left side of the neck. Interview on 12/20/22 at 3:38 P.M. with LPN #535 revealed she worked with Resident #275 on 12/16/22 during the evening shift, 3:00 P.M. to 11:00 P.M. LPN #535 confirmed Resident #275 had the large bruise to her left neck area at that time. LPN #375 confirmed she did not report the bruise to anyone and revealed she assumed the bruise to Resident #275's neck was present on admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to timely report and investigate an injury of unknown origin for Resident #275. This affected one resident (Resident #275) of two residents reviewed for injuries of unknown origin. Findings include: Record review for Resident #275 revealed an admission date of 12/15/22. Diagnosis included history of congestive heart failure and paroxysmal atrial fibrillation. Record review of the admission Baseline Care Plan dated 12/15/22 completed by Licensed Practical Nurse (LPN) #582 revealed Resident #275 was alert to person and confused. Resident #275 had an unsteady gait and weakness. Resident #275 was dependent for toileting, required extensive assistance for bed mobility and total dependence for transfers of two person physical assistants. Record review of the admission Skin assessment dated [DATE] initiated by LPN #544 revealed Resident #275 had bruising to the chest and on both arms. Record review of the physician orders for December 2022 for Resident #275 revealed Resident #275 had orders for coumadin five milligrams (mg) by mouth at bed time for atrial fibrillation. Orders included to monitor for signs and symptoms of bleeding every shift due to anticoagulants. Record review of Resident #275's medical record revealed no documentation of bruising to Resident #275's left side of her neck. Observation on 12/19/22 at 10:03 A.M. revealed Resident #275 was sitting up in a wheelchair in her room. The door to her room had been closed. Resident #275 was sitting in the chair with no shirt on and just a bra. Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. The bilateral arms had multiple small bruises. Resident #275 rambled and was unable to explain how the large bruise to her neck occurred. Interview on 12/19/22 at 10:08 A.M. with State Tested Nursing Assistant (STNA) #559 revealed she assisted Resident #275 with A.M. care and was unsure how the bruising occurred to Resident #275's neck. Interview on 12/19/22 at 10:15 A.M. with Licensed Practical Nurse (LPN) #542 revealed she was Resident #275's charge nurse and was aware Resident #275 had bruising to her neck. LPN #542 revealed she normally did not work with Resident #275 and was unsure how the bruising occurred. Interview and observation on 12/20/22 at 1:36 P.M. with Registered Nurse (RN) #524 confirmed he was Resident #275's charge nurse. Observation of Resident #275's bruising to the left side of her neck with RN #524 confirmed Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. RN #524 revealed he was unaware Resident #524 had bruising to her neck area. Interview and observation on 12/20/22 at 1:45 P.M. with Wound Care Nurse Licensed Practical Nurse (LPN) #532 revealed she completed a skin assessment for Resident #275 (initiated by LPN #544) on 12/16/22 during the day shift. Wound Care Nurse LPN #532 revealed Resident #275 did not have any bruising to her neck when she assessed her on 12/16/22. Interview on 12/20/22 at 1:53 P. M with Director of Nursing (DON) and Administrator revealed the DON was not made aware of the bruising at the time it occurred on Resident #275's neck. DON confirmed this was bruising that occurred after admission and she should have been updated when it occurred so she could investigate the cause of the injury. Record review of the progress note for Resident #275 dated 12/20/22 at 3:26 P.M. completed by RN #524 revealed Resident #275 had a dark purple in color with light purple bruise from the mid breast to the left ear lobe which measured 26 centimeters (cm) in length by 11 cm in width. Resident #275 also had a dark purple bruise to the left upper arm that measured 13 cm by 12 cm. Interview on 12/20/22 at 3:38 P.M. with LPN #535 revealed she worked with Resident #275 on 12/16/22 during the evening shift, 3:00 P.M. to 11:00 P.M. LPN #535 confirmed Resident #275 had the large bruise to her left neck area at that time. LPN #375 confirmed she did not report the bruise to anyone and revealed she assumed the bruise to Resident #275's neck was present on admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain accurate Minimum Data Set (MDS) assessments for Resident #30 and Resident #66. This affected two residents (Resident #30 and Resident #60) of seven residents reviewed for accuracy of assessments. Findings include: 1. Review of the medical record for Resident #66 revealed an admission date of 08/18/22. Diagnoses included dementia without behavioral disturbance, fibromyalgia, muscle weakness, difficulty walking, and depression. Review of physician order dated 08/18/22 revealed Resident #66 had order for 325 milligram (mg) tablet of Tramadol twice daily for pain. Review of the discharge Minimum Data Set (MDS) assessment, dated 10/21/22, revealed Resident #66 had impaired cognition. The assessment indicated Resident #66 had no falls with injury. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/24/22, revealed Resident #66 had impaired cognition. The assessment indicated Resident #66 had one fall with no injuries and Resident #66 received as needed pain medications. Review of progress Notes from August 2022 to December 2022 revealed Resident #66 had falls on 09/22/22, 09/23/22, and 11/24/22. Resident #66 was reported to sustain skin tear to right elbow from the 09/22/22 fall, skin tear on bilateral arms and left thigh on 09/23/22, and skin tears to right elbow, right wrist, and right forearm at 11/24/22 fall. Interview on 12/21/22 at 3:00 P.M. with Licensed Practical Nurse (LPN) #534 confirmed she miscoded falls with injury on 09/22/22 and 09/23/22 for 10/21/22 MDS assessment and fall with injury on 11/24/22 for the 11/24/22 MDS assessment. LPN #534 confirmed she miscoded the regimented pain medication. 2. Review of medical record for Resident #30 revealed an admission date of 05/27/22. Diagnoses included major depressive disorder, anxiety disorder, acute kidney failure and Barrette's esophagus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/02/22, revealed the resident had intact cognition. The MDS dated [DATE], 12/03/22 and current MDS assessment dated for 03/05/23 indicated Resident #30 was ordered a mechanical soft diet and a prescribed weight loss regimen. Interview on 12/20/22 at 315 P.M. with Diet Manager (DM) #501 stated Resident #30 was not on a weight loss program, the manager stated resident received a boost nutritional supplement daily. The manager stated she personally takes the menus down to resident for the resident to choose her meals because she was so picky with meals. Interview on 12/20/22 at 3:20 P.M. with Dietitian #619 stated Resident #30 was not on a weight loss program and the dietitian verified the error in documentation on the MDS. Interview on 12/20/22 at 3:38 P.M. with LPN #534 stated Resident #30 was not on a weight loss program, and verified the error in documentation on the MDS.

Based on observation, interview and record review, the facility failed to complete a comprehensive baseline care plan for Resident #275 to include care for bruising and anticoagulant therapy. This affected one resident (Resident #275) of three residents reviewed for baseline care plans. Findings include: Record review for Resident #275 revealed an admission date of 12/15/22. Diagnosis included history of congestive heart failure and paroxysmal atrial fibrillation. Record review of the admission Baseline Care Plan dated 12/15/22 completed by Licensed Practical Nurse (LPN) #582 revealed Resident #275 was alert to person and confused. Resident #275 had an unsteady gait and weakness. Resident #275 was dependent for toileting, required extensive assistance for bed mobility and total dependence for transfers of two person physical assistants. Record review of the admission Skin Assessment initiated by Licensed Practical Nurse #544 dated 12/16/22 revealed Resident #275 had bruising to the chest and on both arms. Record review of the physician orders for December 2022 for Resident #275 revealed Resident #275 had orders for Coumadin (anticoagulant medication) five milligrams (mg) by mouth at bed time for atrial fibrillation. Orders included to monitor for signs and symptoms of bleeding every shift due to anticoagulants. Review of the admission Baseline Care Plan revealed it was silent of a plan to manage the resident's anticoagulant therapy, bruising or skin impairments. Observation on 12/19/22 at 10:03 A.M. revealed Resident #275 was sitting up in a wheelchair in her room. The door to her room had been closed. Resident #275 was sitting in the chair with no shirt on and just a bra. Resident #275's shirt was lying on the floor next to her. Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. The bilateral arms had multiple small bruises. Resident #275 rambled and was unable to explain how the large bruise to her neck occurred. Record review of Resident #275's medical record revealed no documentation of the bruising to Resident #275's left side of her neck. Interview and observation on 12/20/22 at 1:36 P.M. with Registered Nurse (RN) #524 confirmed he was Resident #275's charge nurse. Observation of Resident #275's bruising to the left side of her neck with RN #524 confirmed Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. RN #524 revealed he was unaware Resident #524 had bruising to her neck area. Interview and observation on 12/20/22 at 1:45 P.M. with Wound Care Nurse Licensed Practical Nurse (LPN) #532 revealed she completed a skin assessment for Resident #275 on 12/16/22 (date after admission) during the day shift. Wound Care Nurse LPN #532 revealed Resident #275 did not have any bruising to her neck when she assessed her on 12/16/22. Interview on 12/20/22 at 3:21 P.M. with Director of Nursing (DON) confirmed the baseline care plan did not include the location of Resident #275's bruising on admission, the use of Coumadin and need for continued monitoring for additional bruising. DON confirmed these items should have been added to the baseline care plan. Interview on 12/20/22 at 3:59 P.M. with Certified Nurse Practitioner (CNP) #618 confirmed he was not made aware of the additional bruising which included the bruising to Resident #275's left side of her neck and the new bruise located on Resident #275's left upper arm. CNP #618 revealed due to the additional bruising, his concern for Resident #275 was bleeding. CNP #618 revealed he would hold Resident #275's coumadin and obtain additional lab values.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement comprehensive care plans for Resident #67's pain and Resident #66's pain and infection. This affected one resident (Resident #66) of three residents reviewed for infections and two residents (Resident #66 and #67) of five reviewed for pain. Findings include: 1. Review of the medical record for Resident #66 revealed an admission date of 08/18/22. Diagnoses included dementia without behavioral disturbance, fibromyalgia, muscle weakness, difficulty walking, and depression. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/24/22, revealed Resident #66 had impaired cognition. The assessment indicated Resident #66 had one fall with no injuries and Resident #66 received as needed pain medications. Review of physician order dated 08/18/22 revealed Resident #66 had order for 325 milligram (mg) tablet of Tramadol twice daily for pain, 1 drop of Gentamicin Sulfate in left eye four times per day for infection, and 250 mg Keflex once daily for infection prophylactic. Review of current care plan for 12/22/22 revealed no care plan to address Resident #66's pain or infections. Interview on 12/22/22 at 10:14 A.M. with Licensed Practical Nurse (LPN) #534 confirmed there was no care plans for pain or infection control in the current care plan for Resident #66. 2. Record review for Resident #67 revealed an admission date of 10/08/22. Diagnosis included hypertensive heart and chronic kidney disease with heart failure. Record review of the admission Medicare five day Minimum Data Set, dated [DATE] revealed Resident #67 was cognitively intact. Resident #67 received routine pain medication rated a five on the pain scale of one to 10. Record review of the physician orders dated 10/09/22 revealed Resident #67 had an order Chlorhexidine Gluconate solution 0.12% 30 milliliters (ml) mucous membrane two times a day for mouth pain. Record review of the current care plan for 12/22/22 revealed Resident #67 had no care plan to address pain. Interview on 12/22/22 at 10:34 A.M. with LPN #531 confirmed there was pain care plan in the current comprehensive care plan for Resident #67.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to update the care plan for Resident #274 to include her missing eye glasses. This affected one resident (Resident #274) of five residents reviewed for comprehensive care plans. Findings include: Record review for Resident #274 revealed an admission date of 01/12/15. Diagnosis included Parkinson's disease and combined forms of age related cataract, bilateral. Record review of the activity assessment dated [DATE] revealed Resident #274 enjoyed spending most of her time reading the bible, sitting in silence, and visiting with friends. Record review of the quarterly Minimum Data Set, dated [DATE] revealed resident was able to make herself understood, usually understands others, vision was impaired and wore corrective lenses. Resident #274 required supervision with activities of daily living. Record review of the care plan dated 09/29/22 revealed Resident #274 had a potential for communication problem related to severely impaired cognition, unclear speech and impaired hearing. Resident #274 spoke German so she required a longer period to understand and be understood. Interventions included to face Resident #274 and make eye contact, use alternative communication tools as needed such as the communication book/board. Resident #274 had impaired vision related to cataracts. Interventions included to arrange consultation with eye care practitioner as required and Resident #274 required the following visual aids, glasses. Record review of the progress note for Resident #274 dated 11/21/22 (untimed) completed by Optometrist #619 revealed the examination was completed for a follow up six months for cataracts and dry eyes. Spectacle exam included flat top bifocal which resident was noted to have. Observation on 12/19/22 at 11:00 A.M. of Resident #274 revealed Resident #274 was sitting up in her wheelchair in her room. Resident #274 was not wearing eye glasses. Resident #274 spoke a different language and the surveyor was unable to communicate with Resident #274. On the nightstand near Resident #274 was a a bible (German) and watch magazines. Interview on 12/19/22 at 11:54 A.M. with Resident #274's daughter revealed Resident #274's eye glasses were missing at facility for over six months. Resident #274 wore her glasses daily due to poor vision. Resident #274 enjoyed reading which was difficult for her without the glasses. Resident #274's daughter revealed the staff told her the eye doctor was coming months ago to replace the glasses. Resident #274's daughter revealed she requested the facility let her know when the eye doctor was coming so she could be there due to Resident #274 spoke German and the doctor would not be able to understand her during the assessment. Resident #274's daughter revealed the facility did not let her know when the appointment was so when the eye doctor visited, he was unable to understand her and Resident #274 still had not received her new glasses. Interview on 12/21/22 at 10:16 A.M. with Licensed Social Worker (LSW) #594 revealed Resident #274 and her daughter had a care conference on 08/05/22 at 11:41 A.M. LSW #594 revealed this was the first time she became aware Resident #274 was missing her eye glasses. LSW #594 confirmed she forgot to communicate with Optometrist #619 prior to his visit and also when he visited Resident #274 in November 2022 that Resident #274 needed her eye glasses replaced. LSW #594 confirmed Optometrist #274 was unaware Resident #274's eye glasses were missing at the time of the visit and the eyeglasses have not been reordered. LSW revealed the optometrist visited the facility quarterly to see residents and would also make emergency visits if needed. Interview on 12/21/22 at 2:08 P.M. with State Tested Nursing Assistant (STNA) #559 revealed Resident #274's glasses had been missing for a while. STNA #559 revealed prior to Resident #274's glasses missing, Resident #274 would put her glasses on and take them off herself. STNA #559 revealed Resident #274 enjoyed watching television (German channels when available) and reading the bible with her daughter. Interview on 12/21/22 at 2:44 P.M. with Licensed Practical Nurse (LPN)/Care Plan Nurse #531 confirmed Resident #274's care plan was not updated for vision and not having her glasses available. LPN/Care Plan Nurse #531 revealed the care plan should have been updated with the quarterly MDS.

Based on observation, interview and record review, the facility failed to monitor Resident #275's change in condition related to bruising. This affected one resident (Resident #275) of three residents reviewed for quality of care. Findings include: Record review for Resident #275 revealed an admission date of 12/15/22. Diagnosis included history of congestive heart failure and paroxysmal atrial fibrillation. Record review of the admission Baseline Care Plan dated 12/15/22 completed by Licensed Practical Nurse (LPN) #582 revealed Resident #275 was alert to person and confused. Resident #275 had an unsteady gait and weakness. Resident #275 was dependent for toileting, required extensive assistance for bed mobility and total dependence for transfers of two person physical assistants. Record review of the admission Skin Assessment initiated by Licensed Practical Nurse #544 dated 12/16/22 revealed Resident #275 had bruising to the chest and on both arms. Record review of the physician orders for December 2022 for Resident #275 revealed Resident #275 had orders for Coumadin five milligrams (mg) by mouth at bed time for atrial fibrillation. Orders included to monitor for signs and symptoms of bleeding every shift due to anticoagulants. Record review of Resident #275's medical record revealed no documentation of bruising to Resident #275's left side of her neck. Observation on 12/19/22 at 10:03 A.M. revealed Resident #275 was sitting up in a wheelchair in her room. The door to her room had been closed. Resident #275 was sitting in the chair with no shirt on and just a bra. Resident #275's shirt was lying on the floor next to her. Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. The bilateral arms had multiple small bruises. Resident #275 rambled and was unable to explain how the large bruise to her neck occurred. Interview on 12/19/22 at 10:08 A.M. with State Tested Nursing Assistant (STNA) #559 revealed she assisted Resident #275 with A.M. care and was unsure how the bruising occurred to Resident #275's neck. STNA #559 revealed Resident #275 often removed her own clothing. Interview on 12/19/22 at 10:15 A.M. with Licensed Practical Nurse (LPN) #542 revealed she was Resident #275's charge nurse and was aware Resident #275 had bruising to her neck. LPN #542 revealed she normally did not work with Resident #275 and was unsure how the bruising occurred. Interview and observation on 12/20/22 at 1:36 P.M. with Registered Nurse (RN) #524 confirmed he was Resident #275's charge nurse. Observation of Resident #275's bruising to the left side of her neck with RN #524 confirmed Resident #275 had a large dark blue/ purple bruise covering the entire left side of her neck including a portion of the upper left chest. RN #524 revealed he was unaware Resident #524 had bruising to her neck area. Interview and observation on 12/20/22 at 1:45 P.M. with Wound Care Nurse LPN #532 revealed she completed a skin assessment for Resident #275 on 12/16/22 (date after admission) during the day shift. Wound Care Nurse LPN #532 revealed Resident #275 did not have any bruising to her neck when she assessed her on 12/16/22. Record review of the progress note for Resident #275 dated 12/20/22 at 3:26 P.M. completed by RN #524 revealed Resident #275 had a dark purple in color with light purple bruise from the mid breast to the left ear lobe which measured 26 centimeters (cm) in length by 11 cm in width. Resident #275 also had a dark purple bruise to the left upper arm that measured 13 cm by 12 cm. Interview on 12/20/22 at 3:21 P.M. with Director of Nursing confirmed the physician nor Certified Nurse Practitioner (CNP) #618 had been made aware of Resident #275's bruise to the left side of the neck. Interview on 12/20/22 at 3:38 P.M. with LPN #535 revealed she worked with Resident #275 on 12/16/22 during the evening shift, 3:00 P.M. to 11:00 P.M. LPN #535 confirmed Resident #275 had the large bruise to her left neck area at that time. LPN #375 confirmed she did not report the bruise to anyone and revealed she assumed the bruise to Resident #275's neck was present on admission. Interview on 12/20/22 at 3:59 P.M. with CNP #618 confirmed he was not made aware of the additional bruising which included the bruising to Resident #275's left side of her neck and the new bruise located on Resident #275's left upper arm. CNP #618 revealed due to the additional bruising, his concern for Resident #275 was bleeding. CNP #618 revealed he would hold Resident #275's coumadin and obtain additional lab values.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assist Resident #274 in replacing lost eye glasses to help maintain vision. This affected one resident (Resident #274) of one resident reviewed for vision. Findings include: Record review for Resident #274 revealed an admission date of 01/12/15. Diagnosis included Parkinson's disease and combined forms of age related cataract, bilateral. Record review of the activity assessment dated [DATE] revealed Resident #274 enjoyed spending most of her time reading the bible, sitting in silence, and visiting with friends. Record review of the quarterly Minimum Data Set, dated [DATE] revealed resident was able to make herself understood, usually understands others, vision was impaired and wore corrective lenses. Resident required supervision with activities of daily living. Record review of the care plan dated 09/29/22 revealed Resident #274 had a potential for communication problem related to severely impaired cognition, unclear speech and impaired hearing. Resident #274 spoke German so she required a longer period to understand and be understood. Interventions included to face Resident #274 and make eye contact, use alternative communication tools as needed such as the communication book/board. Resident #274 had impaired vision related to cataracts. Interventions included to arrange consultation with eye care practitioner as required and Resident #274 required the following visual aids, glasses. Record review of the progress note for Resident #274 dated 11/21/22 (untimed) completed by Optometrist #619 revealed the examination was completed for a follow up six months for cataracts and dry eyes. Spectacle exam included flat top bifocal which resident was noted to have. Observation on 12/19/22 at 11:00 A.M. of Resident #274 revealed Resident #274 was sitting up in her wheelchair in her room. Resident #274 was not wearing eye glasses. Resident #274 spoke a different language and the surveyor was unable to communicate with Resident #274. On the nightstand near Resident #274 was a a bible (German) and watch magazines. Interview on 12/19/22 at 11:54 A.M. with Resident #274's daughter revealed Resident #274's eye glasses were missing at facility for over six months. Resident #274 wore her glasses daily due to poor vision. Resident #274 enjoyed reading which was difficult for her without the glasses. Resident #274's daughter revealed the staff told her the eye doctor was coming months ago to replace the glasses. Resident #274's daughter revealed she requested the facility let her know when the eye doctor was coming so she could be there due to Resident #274 spoke German and the doctor would not be able to understand her during the assessment. Resident #274's daughter revealed the facility did not let her know when the appointment was so when the eye doctor visited, he was unable to understand her and Resident #274 still had not received her new glasses. Interview on 12/21/22 at 10:16 A.M. with Licensed Social Worker (LSW) #594 revealed Resident #274 and her daughter had a care conference on 08/05/22 at 11:41 A.M. LSW #594 revealed this was the first time she became aware Resident #274 was missing her eye glasses. LSW #594 confirmed she forgot to communicate with Optometrist #619 prior to his visit and also when he visited Resident #274 in November 2022 that Resident #274 needed her eye glasses replaced. LSW #594 confirmed Optometrist #274 was unaware Resident #274's eye glasses were missing at the time of the visit and the eyeglasses have not been reordered. LSW #594 revealed the optometrist visited the facility quarterly to see residents and would also make emergency visits if needed. Interview on 12/21/22 at 2:08 P.M. with State Tested Nursing Assistant (STNA) #559 revealed Resident #274's glasses had been missing for a while. STNA #559 revealed prior to Resident #274's glasses missing, Resident #274 would put her glasses on and take them off herself. STNA #559 revealed Resident #274 enjoyed watching television (German channels when available) and reading the bible with her daughter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident #42's chronic pain was addressed in a timely manner. This affected one resident (Resident #42) of five residents reviewed for medications. Findings include: Review of the medical record for Resident #42 revealed admission date of 03/17/22. Diagnoses included generalized osteoarthritis, fibromyalgia, age related osteoporosis, anxiety disorder, spinal stenosis, history of clavicle and thoracic spinal vertebra #7 fracture, presence of left artificial hip joint, and pain of unspecified joint. Review of Care Plan dated 07/21/22 revealed Resident #42 had alteration in comfort related to fibromyalgia, osteoporosis, spinal stenosis, and history of fractures. Interventions included administer medications as ordered, monitor for side effects and effectiveness, report abnormal findings to physician, monitor and report signs and symptoms of non-verbal pain, report requests of pain treatment, and notify physician of breakthrough pain. Review of Psych Solutions progress note dated 09/27/22 revealed staff reported Resident #42 was seeking medications at times and was noted to watch clock for pain medications. Resident #42 had worsening anxiety and chronic somatic complaints. Psych Nurse Practitioner recommended pain management consult. Review of nursing progress note dated 09/29/22 revealed physician rounded and new order to increase Gabapentin to 200 milligrams (mg) three times per day. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 received scheduled and as needed (PRN) pain medication. Resident #42 reported frequent pain in last five days. Resident #42 reported seven out of 10 pain which made it hard to sleep and limited day to day activities. Review of the current physician's orders for December 2022 revealed Resident #42 had standing orders for 200 mg Gabapentin three times per day for pain, 1 percent (%) Voltaren gel applied to right hip twice daily for pain, and 4% Lidocaine patch applied to right knee once daily for pain. Resident #42 had as needed orders for 650 mg Acetaminophen every eight hours for pain and 325 mg Percocet every four hours as needed for moderate pain. Resident #42 had order to monitor pain level every shift. Review of medication administration record (MAR) for November 2022 revealed Resident #42 used as needed (PRN) Acetaminophen on 11/27/22 for pain with effective results. Resident #42 received PRN Percocet, six doses on 11/29/22, five doses on 11/04/22, 11/06/22, 11/11/22, 11/15/22, 11/17/22, 11/19/22, 11/23/22, 11/25/22, and 11/27/22, and three doses on 11/05/22, 11/07/22, 11/08/22, 11/10/22, 11/13/22, 11/16/22, 11/20/22, 11/24/22, 11/28/22, and 11/30/22 with complaints of four to 10 out of 10 pains. Resident #42 also received scheduled medications as ordered for pain including Gabapentin, Voltaren gel, and Lidocaine patch. Review of Physician's Progress Note dated 11/14/22 revealed Resident #42 was reviewed for general medical care follow up and had medications reviewed. There was no indication of review of frequent reports of moderate to severe pain. Review of MAR for December 2022 revealed Resident #42 used PRN Acetaminophen on 12/11/22 for pain with effective results. Resident #42 received PRN Percocet, six doses on 12/01/22, five doses on 12/02/22, 12/04/22, 12/09/22, and 12/15/22, and four doses on 12/05/22, 12/06/22, 12/07/22, 12/08/22, 12/10/22, 12/11/22/, 12/12/22, 12/13/22, 12/16/22, 12/17/22, 12/18/22. Resident #42 used two doses of PRN Percocet on 12/03/22. Resident #42 was complaining of pain ranging from two to eight out of 10. Resident #42 also received scheduled medications as ordered for pain including Gabapentin, Voltaren gel, and Lidocaine patch. Interview on 12/19/22 at 11:18 A.M. with Resident #42 revealed she had been having a lot more pain in legs, hands, and feet. Resident #42 described the pain was throbbing. Resident #42 indicated she had reported pain to facility staff. During interview Resident #42 was observed to be laying back in bed with legs pulled up. Resident #42 was noted to be restless and squirming in bed with eyes closed throughout most of the interview. Resident #42's legs appeared to be tensed. Resident #42 indicated the facility provided her with a gel for pain however it did not help. Review of phone physician's order form dated 12/21/22 revealed physician placed order for pain management consult for fibromyalgia. Interview on 12/21/22 at 2:01 P.M. with Licensed Practical Nurse (LPN) #542 revealed Resident #42 had been declining. Resident #42 was noted to ask for her PRN Percocet every four hours. LPN #542 noted Resident #42 would count pills in cup and ask for Percocet even if not due. LPN #542 indicated she won't report the pain but watches the clock. Interview on 12/21/22 at 2:06 P.M. with State Tested Nursing Assistant (STNA) #562 revealed Resident #42 does most of her care on her own. STNA #562 noted Resident #42 always just wants her pain medications. Interview on 12/21/22 at 3:07 P.M. with Director of Nursing (DON) and Registered Nurse (RN) Supervisor #522 revealed the social worker usually gets the psych notes and files them right away. The psych team usually does not make many recommendations so we must have missed the recommendation for pain management consult. DON indicated Resident #42 was declining in October 2022 and we recommended hospice services however the family was not agreeable. RN Supervisor #522 indicated Resident #42 has good and bad days with pain. DON reported when she works the floor and passes medications Resident #42 knows to the minute when she can get PRN Percocet. DON and RN Supervisor #522 confirmed pain management recommendation was not addressed until 12/21/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to properly store and secure medications for Resident #30 and Resident #67. This affected two residents (Resident #30 and #67) of two residents reviewed for medication storage. Findings include: 1. Record review for Resident #30 revealed an admission date of 11/08/21. Diagnosis included hypertensive heart disease, paroxysmal atrial fibrillation, Barrette's esophagus without dysplasia, gastro-esophageal reflux disease (GERD), gout, and need for assistance with personal care. Record review of the Modification of Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was cognitively intact. Resident #30 required supervision with activities of daily living. Record review of the care plan dated 12/04/22 revealed Resident #30 had an alteration in the digestive system related to hiatal hernia, Barret's esophagus, and GERD. Interventions included to administer medication per the physician orders. Record review of the physician orders for 12/19/22 for Resident #30 revealed orders for Metoprolol Succinate extended release (ER) tablet 25 milligrams (mg) by mouth two times a day for hypertension, hold for heart rate below 60 or systolic blood pressure below 110, Omeprazole tablet delayed release 20 mg two times a day for GERD, and Zyloprim tablet 300 mg (Allopurinol) give one tablet by mouth one time a day for gout. Observation on 12/19/22 at 9:38 A.M. revealed Resident #30 was resting quietly in bed with her eyes closed. A medication cup was sitting on the bedside table with three pills in the cup, one white, one brown and one orange. Interview on 12/19/22 at 9:40 A.M. with Licensed Practical Nurse (LPN) #542 verified the medications Allopurinol, Omeprazole, and Metoprolol were left at Resident #30's bedside. Interview on 12/19/22 at 1:23 P.M. with Resident #30 revealed staff always left her medications for her to take when she got up. Interview on 12/22/22 at 10:38 A.M. with Director of Nursing (DON) confirmed Resident #30 did not have orders to self administer medications. DON revealed she would expect the nurse to stay with the residents until the resident either took the medication or refused the medication. 2. Record review for Resident #67 revealed an admission date of 10/08/22. Diagnosis included hypertensive heart and chronic kidney disease with heart failure. Record review of the admission Medicare five day Minimum Data Set, dated [DATE] revealed Resident #67 was cognitively intact. Resident #67 required extensive assistance of two for bed mobility, transfers, dressing and one person physical assist and supervision with eating. Resident #67 received routine pain medication rated a five on the pain scale of one to 10. Record review of the physician orders dated 10/09/22 revealed Resident #67 had an order Chlorhexidine Gluconate solution 0.12% 30 milliliters (ml) mucous membrane two times a day for mouth pain. Medication scheduled to be administered at 9:00 A.M. and 5:00 P.M. Record review of the care plan dated 10/10/22 revealed Resident #67 had an activity of daily living self care performance deficit due to musculoskeletal impairment, decreased mobility. Interventions included to allow time for completion of any task, do not rush, praise/encourage all efforts. Observation on 12/19/22 at 10:14 A.M. revealed Resident #67 was up in his wheelchair and exiting his room. Observation revealed Resident #67 had a liquid medication in a medication cup sitting on his bedside table. Resident #67 revealed he had forgotten to take his medication. Interview on 12/19/22 at 10:15 A.M. with LPN #542 revealed the medication left on Resident #67's bedside table was Chlorhexidine Gluconate solution. LPN #542 revealed if residents were alert and oriented, she would tell them what medications they had then leave it for them and come back later to check on them. Interview on 12/22/22 at 10:38 A.M. with Director of Nursing (DON) confirmed Resident #67 did not have orders to self administer medications. DON revealed she would expect the nurse to stay with the residents until the resident either took the medication or refused the medication.

Based on observation, interview and record review, the facility failed to ensure privacy was provided for during medication administration. This affected one (Resident #80) of four residents (Resident #34, #36, #80 and #86) observed for medication administration. The facility census was 86. Findings include: Medication administration for Resident #80 was observed on 10/02/19 at 3:55 P.M. with Licensed Practical Nurse (LPN) #824. LPN #824 stated Resident #80 had an NG (naso-gastric) tube (feeding tube through his nose into his stomach) and received his medications through the tube. She stated he also received two different eye drops which required a waiting period between the drops. She obtained the first bottle of eye drops and entered the resident's room. Her medication cart was parked outside the resident's room, but did not block the view of the resident from the hallway, as the cart was to the side of the door. The resident was sitting in a recliner, on the side of the bed near the door. He was completely visible from the doorway as he was positioned close to the middle of the room in his recliner. He also had a female visitor in the room. LPN #824 greeted the resident and stated she was going to instill the eye drop. She did not shut the door or ask the resident if it was acceptable to administer the eye drop and other medication with the visitor present. She administered the eye drop. LPN #824 returned to her medication cart, prepared the medication for administration into the resident's NG tube. She went back in the room and did not shut the door. LPN #824 administered the medications by NG tube by disconnecting the tube feeding, holding the tube up and instilling multiple flushes and medications. This procedure would have been visible to any staff, resident or visitor walking through the hall past his room. LPN #824 completed the NG medication procedure and returned to her cart, retrieving the second bottle of eye drops. She again entered the room and without shutting the door, administered the eye drops to the resident. After the medication pass was complete, LPN #824 was interviewed and verified she had not shut the resident's door for privacy or asked him about whether he would like the visitor to remain in the room during the process. She verified she should have provided privacy and choice for the resident. She further verified staff, residents or visitors could have observed the procedures as they passed by the room of Resident #80, because of where his recliner was positioned in his room. An interview with the Director of Nursing (DON) on 10/02/19 at 4:50 P.M. confirmed resident privacy should be respected, and LPN #824 should have shut the door while administering medications to Resident #80. An interview with Resident #80 on 10/03/19 at 2:30 P.M. confirmed the door had not been shut during the medication pass. He stated the visitor was a friend of his, and indicated he wasn't sure if he cared that she observed the procedure. The facility did not provide a specific policy regarding resident privacy but did provide a copy of the rights of residents, undated, which indicated residents should have the right to privacy during medical examination or treatment and in the care of personal or bodily needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an accurate assessment in the record of Resident #66 regarding a transfer to the hospital. This affected one of three residents (Residents #27, #66 and #84) reviewed for hospitalization. The facility census was 86. Findings include: Review of the record of Resident #66 revealed he was admitted to the facility on [DATE] with diagnoses including aphasia (loss of ability to understand or express language), seizure disorder and hypertension (high blood pressure). Review of his quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was severely cognitively impaired. Review of the record revealed a nursing note dated 06/22/19 at 11:54 P.M. which indicted the resident was stable with no concerns. The next note dated 06/24/19 at 12:57 P.M. revealed the resident had been discharged to the hospital on [DATE]. The next note in the record dated 06/25/19 at 3:22 P.M. revealed the resident returned from the hospital after a stay for a kidney stone and urinary retention. Review of the record did not reveal any assessment or further information on the resident's medical status, change in condition or symptoms that led to his transfer to the hospital. Review of the hospital discharge paperwork dated 06/25/19 revealed the resident was admitted with abdominal pain and found to have a kidney stone that passed. An interview with the Director of Nursing on 10/02/19 at 3:30 P.M. confirmed the record did not contain an assessment of the resident's condition prior to transfer to the hospital on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Resident #54 was monitored for a reddened rash under the resident's bilateral breasts and failed to ensure coordination of Resident #76's code status. This finding affected one (Resident #54) of two residents reviewed for general skin conditions and one (Resident #76) of three residents reviewed for hospice. The facility census was 86. Findings include: Review of Resident #54's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes, muscle weakness and difficulty in walking. Review of Resident #54's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #54's physician orders revealed an order dated 06/12/19 for Nystatin cream (antifungal cream) apply to under both breasts topically two times a day for a rash and may discontinue when healed. Review of Resident #54's progress notes from 08/17/19 to 10/03/19 revealed no evidence the resident had a rash under her bilateral breasts. Review of Resident #54's medication administration records (MAR) and treatment administration records (TAR) from 09/01/19 to 10/02/19 revealed the anti-fungal cream was applied at 9:00 A.M. and 5:00 P.M. every day. Interview on 09/30/19 at 9:41 A.M. with Resident #54 revealed the staff did not put the cream underneath her breasts during the previous nightshift. Observation on 09/30/19 at 10:55 A.M. revealed Resident #54's bilateral breasts had a large reddened rash underneath both breasts which was bright red and shiny. There was no evidence any type of antifungal cream was applied underneath the bilateral breasts as documented in the medical record. Interview on 10/03/19 at 9:33 A.M. with Registered Nurse (RN) #873 indicated she was made aware at some point last week of the rash underneath Resident #54's bilateral breasts. Interview on 10/03/19 at 11:00 A.M. with Licensed Practical Nurse (LPN) #819 indicated the staff did not inform her of Resident #54's bilateral breasts rash, did not assess or monitor the resident's rash underneath her breasts and did not ensure documentation was in the resident's medical record related to the resident's bilateral breasts rash. 2. Review of Resident #76's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including lack of coordination, malaise and dementia without behavioral disturbance. Review of Resident #76's MDS 3.0 assessment dated [DATE] indicated the resident exhibited severe cognitive impairment and was on hospice services. Review of Resident #76's Ohio DNR (do not resuscitate) form dated 11/2/12 indicated the resident's code status was DNRCC-Arrest. Review of Resident #76's physician order dated 01/16/18 indicated the resident was admitted to hospice with a diagnosis of congestive heart failure (CHF). Review of Resident #76's hospice declaration page dated 01/16/18 indicated the resident's code status was DNR. Review of Resident #76's hospice code status paperwork dated 01/19/18 revealed the resident's code status was DNRCC. Interview on 10/02/19 at 5:49 P.M. with Hospice RN #900 confirmed Resident #76's code status was supposed to be DNRCC, and the code status at the facility in the resident's medical record was DNRCCA. Hospice RN #900 confirmed she missed identifying the facility did not have an accurate code status for Resident #76 and coordination of care was not completed to ensure the resident's code status was updated and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure impaired skin areas were identified, assessed and treatments were put in place as ordered for Residents #29 and 30. This affected two of three residents (Resident #29, #30 and #34) reviewed for pressure ulcers. The facility census was 86. Findings include: 1. Review of the medical record of Resident #30 revealed she was admitted to the facility on [DATE] with diagnosis including a fracture of the left ankle. She also had an immobilizer brace to her left leg. Her admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was cognitively impaired and required the extensive assistance of one to two staff members for her activities of daily living. Review of her nursing note dated 09/13/19 at 2:56 P.M. revealed the resident was observed with an open area to left outer ankle, from the brace the resident wears daily. The note indicated a treatment was put in place to cleanse the area with normal saline, cover with an antibiotic ointment and cover with Coversite (a dressing). The note also indicated a note was left with the wound nurse so the resident could be seen by the wound NP (Nurse Practioner). There was no assessment of the area noted in the record, including appearance or size of the open area. Review of the record did not reveal further narrative documentation regarding the impaired skin area. Review of a note written by the consulting wound nurse practioner, Registered Nurse (RN) #700 dated 09/17/19 revealed she assessed the wound as a pressure area and applied a new dressing of Santyl (debriding agent), calcium alginate (absorbent dressing) covered with adherent foam to be applied daily and as needed. The next note by RN #700 on 09/24/19 indicated the dressing order should be continued as previously. The note indicated the only change to the assessment was the periwound was macerated. Review of skin grids provided by the facility revealed the areas was measured on 09/17/19 as 2.0 centimeters (cm) by 1.0 cm by 0.1 cm deep. It was a stage three (an area that extends into the tissue, forming a small crater) and had a moderate amount of sero-sanguineous drainage. The skin grid indicated the skin area measured 1.4 cm by 1.0 cm by 0.1 cm with edges macerated. The skin grid entry for 09/24/19 indicated the order for the Santyl and Calcium Alginate. Review of the treatment administration record (TAR) for September 2019 did not reveal any evidence of the dressing application of the antibiotic ointment. The TAR did not show the dressing of the Santyl and Calcium Alginate ordered by the wound nurse practioner on 09/17/19 until 09/25/19. The pressure area was not measured again until 10/01/19 when an entry indicated it measured 1.1 cm by 1.0 cm by 0.1 cm. No changes were made to the treatment. An interview with the facility wound nurse, Licensed Practical Nurse (LPN) #819 on 10/02/19 at 11:54 A.M. revealed she was made aware of the open area on 09/16/19. She stated a nurse found the area on 09/13/19 and received and order for the antibiotic ointment. She stated she looked at the area on 09/16/19 because the wound nurse practioner came to the facility on Tuesday's (09/17/19), and she wanted to see if the wound should be followed by the nurse practioner. She stated she looked at the wound but did not measure it or complete an assessment. She said a dressing was in place when she looked at the area and she completed a dressing change, but did not mark the dressing change off as completed on the TAR. She stated she did not notice there was not an order in the record or TAR for staff to sign off the treatment. LPN #819 stated when the wound nurse visited on 09/17/19, she recorded the measurements obtained by the wound nurse on the skin grid. She stated she noted the wound nurse had applied the new dressing but somehow the new order for the dressing change did not get ordered or transposed to the TAR on 09/17/19. She stated she made sure the order was put on the treatment record after the wound nurse visit on 09/24/19 and it was started on 09/25/19, since the wound nurse had completed the dressing change on 09/24/19. An observation of the area and dressing change observation was made on 10/02/19 at 2:30 P.M. with LPN #821. LPN #821 completed the dressing change to the impaired skin area, which was toward the back of the resident's left leg, slightly above and lateral to the ankle. Another scabbed area measuring approximately 1.0 cm round was noted on the front of the resident's left leg, open to air. LPN #821 indicated there was no dressing to that area. She stated she had seen it before but did not know where it had come from or if the facility wound nurse was aware of its existence. An interview with LPN #821 on 10/02/19 at 3:30 P.M. revealed she was unaware of any other impaired skin area for Resident #30. She was informed of the observation of the scabbed area to the left leg and stated she would go look at it. An interview with the consulting wound nurse practioner, RN # 700, on 10/03/19 at 12:15 P.M. by phone revealed she remembered the resident. She stated she had ordered the Santyl to debride the area and the Calcium Alginate helped to absorb the moisture. She verified the wound had gotten smaller but that her note indicated the edges of the wound were macerated. She stated the description just meant the area was moist. She denied the area had declined, based off the measurements, but did not remember if she noted the correct dressing in place when she visited the resident on 09/24/19 or if she discussed with staff any concerns related to the order not carried out as ordered on 09/17/19. An interview with LPN #821 on 10/03/19 at 12:30 P.M. revealed she had not yet checked the scabbed skin area observed during the dressing change on 10/02/19. On 10/03/19 at 12:57 P.M., LPN #821 verified a scab was present on the front shin area of Resident #30's left leg, which measured 1.5 cm by 1.0 cm. She stated she was unaware of the skin area and had not seen the area when she checked the pressure area on 10/01/19. She verified impaired skin areas should be reported and investigated to determine the cause and any possible treatments that should be put in place. LPN #821 further verified the record did not contain an assessment of the pressure area discovered on 09/13/19 until 09/17/19 and that the record did not show evidence of the ordered treatment in place or the change in treatment as ordered until 09/25/19. Review of the facility policy for skin assessment documentation and prevention of pressure ulcers, dated March 2014, revealed changes in skin condition would be reported to the charge nurse and wound nurse. 2. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including dementia with Lewy bodies, severe protein-calorie malnutrition, generalized osteoarthritis, Alzheimer's disease, contracture of left hip, left knee and right lower leg, dementia with behavioral disturbance, disorder of bone density and structure, cerebrospinal fluid drainage device, hypertension, normal pressure hydrocephalus, insomnia, anxiety disorder, major depressive disorder and macular degeneration with blindness. Review of the physician orders indicated an initial treatment to the left hip was ordered on 06/19/19. Subsequently, the treatment for the left hip had been altered to aid in the healing process. The latest treatment order was 09/06/19. Review of the admission comprehensive MDS 3.0 assessment dated [DATE] indicated she was severely cognitively impaired and displayed verbal behavioral symptoms directed towards others on one to three days of the assessment period. She required the extensive assistance of one person for bed mobility, eating, toileting and personal hygiene and the extensive assistance of two plus persons for transfer. She was identified as being always incontinent of bowel and bladder. She weighed 67 pounds. She was identified at risk for the development of pressure ulcers but did not have pressure sores at the time of the assessment. Review of the pressure ulcer plan of care indicated to assess/record/monitor wound healing per facility protocol/physicians orders. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician. Review of the Braden scale for predicting pressure ulcer risk dated 06/05/19 indicated she was high risk for the development of pressure ulcers. Review of the admission assessment dated [DATE] indicated she was bed bound, her skin was intact and she needed to be fed because she was blind. There was no documented evidence of the left hip ulcer description, characteristics, measurements or location at the onset nor was there documented evidence of monitoring of the left hip ulcer until 09/20/19. The first facility documentation of the left hip ulcer other than the physician's order was by the dietary staff on 06/30/19 at 12:49 P.M. who noted the resident had a deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) of the left hip. Review of the weekly nurse note authored by LPN #871 dated 09/02/19 by at 10:07 P.M. noted a pressure ulcer was present and a pressure reducing mattress was in place. There no descriptors of this pressure ulcer. Review of the wound/skin care management documentation: The left hip ulcer was noted on 08/13/19. It was not present on admission. There was no documented evidence of the description or measurement of the area until 09/10/19 where it was identified as unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar) measuring 5.5 cm x 2.5 cm with 100% slough. Review of the bi-monthly nursing comprehensive assessment dated [DATE] indicated movement caused severe pain. She had Stage I (intact skin with non-blanchable redness) pressure ulcers on the side of her feet and a left hip protuberance. The note indicated her left heel touched her buttocks. Review of the conference meeting summary, care plan and comprehensive assessment updated dated 06/26/19 indicated on 06/14/19 she had a Stage I to II (a stage II pressure ulcer is described as partial thickness skin loss of dermis presently as a shallow open ulcer with a red pink wound bed, without slough) on the left hip, two Stage I's and a Stage II on the right foot, red knees, a Stage I on the sacrum 06/25/19 and a Stage II on the left great toe. On 07/24/19 it was noted her contractures were worsening causing her briefs to fit incorrectly. She had redness on the bony prominence's and had breakdown on her feet and left hip. On 08/21/19 she was noted to have a worsening left hip wound with necrosis (death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply). Interview with the resident representative on 09/30/19 at 10:55 A.M. indicated there was an issue because Resident #29 developed a pressure ulcer in the facility. Interview with the family member on 09/30/19 at 12:03 P.M. indicated Resident #29 developed a pressure ulcer in the facility and it was huge, covering the entire hip and buttock area. Interview with the wound nurse, LPN #819, on 10/02/19 at 11:37 A.M. verified that Hospice identified the wound on 09/06/19 and ordered a treatment for the area. She said she was not aware of the pressure ulcer until 09/10/19 and said it was 100% slough. She admitted she did not document about pressure ulcer until 09/23/19. She said the wound nurse practitioner was involved and did a partial debridement one week and last week did the rest of the debridement. LPN #819 said last week there were three more pressure ulcers identified. LPN #819 verified the facility had awareness of the pressure ulcers since 06/14/19 and failed to document the assessments to monitor the progression/regression of the area. Review of the pressure sore policy and procedure, dated March 2014, indicated the purpose was to assess all residents at risk for developing pressure areas and to assess/maintain the healing process of pressure areas. All residents would be assessed for the risk of developing pressure areas on admission, quarterly and daily during care by the charge nurse and nursing assistant. The charge nurse would assess and monitor each pressure area daily during treatment administration and document any changes in the condition in the nurse's notes. The treatment nurse would assess, monitor and document on the pressure areas every week. The charge nurse/treatment nurse to report any changes in condition of pressure areas and any lack of progress with the current treatment plan. The supervisor would notify the physician and responsible party of changes in condition and implement interventions as ordered by physician. Documentation/assessment of the ulcer should include the date, location, type and stage of the ulcer, measurements, characteristics, monitor dressings and treatments, monitor the healing progress and/or potential complications and assess, treat and monitor for pain. Review of the concern log indicated on 09/13/19 the family wanted a second opinion on her wound. The action was the resident was sent to the emergency room per the family request and returned with no new orders. This deficiency was an incidental finding to Complaint Number OH001007050.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure medications were administered properly through a naso-gastric tube. This affected Resident #80, one of four residents (Residents #34, #36, #80 and #86) observed for medication administration, with a facility census of 86. Findings include: Medication administration for Resident #80 was observed on 10/02/19 at 3:55 P.M. with Licensed Practical Nurse (LPN) #824. LPN #824 stated Resident #80 had an NG (naso-gastric) tube (feeding tube through his nose into his stomach) and received his medications through the tube. She stated she did not check for placement of the NG tube because it has a weight at the bottom in his stomach, which keeps it in place. LPN #824 prepared the medication for administration into the resident's NG tube which included four tablets. She crushed the tablets and added some warm water, stirring each with a spoon in their separate medication cups to dissolve the medications. She entered the room and disconnected the resident's tube feed solution, which was running through a pump. She used a large syringe to pull up 30 cubic centimeters (cc) of water using the plunger in the syringe. She attached the syringe with plunger to the tube and slowly pushed the water through the tube. She disconnected the syringe, removed the plunger and reconnected the syringe. Holding the syringe up with the tube connected, she poured the contents of each of the four medication cups into the syringe, flushing with water after each by pour a small amount of water into the syringe. The medications and water flowed freely through the syringe without any noted impairment. After completing the four medications, she removed the syringe, reattached the plunger and pulled up another 30 cc of water, which she pushed slowly through the tube after reconnecting it to the tube. LPN #824 then reconnected the tube feeding solution, started the tube feeding pump and indicated she was finished at 4:10 P.M. An observation of the cups that had contained the medications revealed two of the four cups had a significant amount of medication still in the cup. LPN #824 verified she had not rinsed the cups and full doses of the medications had not been delivered. She indicated the medications did not dissolve well in water and said she should have added more water to the cups to ensure the full doses could be administered. LPN #824 added a small amount of water to one of the cups, and, using the tip of the syringe with the plunger in it, stirred the medication around until it was dissolved and then pulled the medication/water mixture into the syringe. She disconnected the feeding tube and, without flushing with more water, pushed the medication with the plunger through the tube. She repeated the process with the second cup that contained residual medication, pulling the medication water mixture into the syringe after stirring it and pushing the medication through the tube with the plunger. She then pulled up 30 cc of water into the syringe and flushed the tube again. When she had finished, she again reconnected the feeding tube to the pump with the tube feed fluid and started the machine. After the medication pass, LPN #824 again verified she did not check the placement of the NG because of the weight at the bottom of the tube. She verified she had used the plunger to push water and medications through the tube. She stated she did that sometimes because it ran slowly. She verified she had not attempted to flush the tube by using gravity and that the medication/water mixtures had gone through the tube using just gravity with no problems. Review of the record revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including malnutrition, ulcerative colitis and dysphasia. An interview with the Director of Nursing on 10/02/19 at 4:50 P.M. confirmed the placement of an NG tube should be confirmed prior to medication administration and that medications and flushes should run by gravity if possible during medication administration by NG tube. Review of the facility policy on Medication Administration through Enteral Tubes, dated October 2007, revealed tube placement should be verified by inserting a small amount of air into the tube with the syringe and listen to the stomach with a stethoscope for gurgling sounds and by aspirating stomach contents with a syringe to check for residual. The policy also indicated the plunger should be removed from the syringe before inserting into the tubing to flush the tube initially, and that medication should be allowed to flow down the tube via gravity, using gentle boost with the plunger only if the medication would not flow by gravity. The policy indicated medications should not be pushed down the tube.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure the physician acted upon pharmacist recommendation timely for Residents #29 and #80. This affected two of six Residents (#17, #29, #49, #56, #66 and #80) reviewed for unnecessary medications. The facility census was 86. Findings include: 1. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including dementia with Lewy bodies, severe protein-calorie malnutrition, generalized osteoarthritis, Alzheimer's disease, contracture of left hip, left knee and right lower leg, dementia with behavioral disturbance, disorder of bone density and structure, cerebrospinal fluid drainage device, hypertension, normal pressure hydrocephalus, insomnia, anxiety disorder, major depressive disorder and macular degeneration with blindness. Review of the admission comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she was severely cognitively impaired and displayed verbal behavioral symptoms directed towards others on one to three days of the assessment period. Review of the physician order dated 06/05/19 indicated she was ordered Ativan, an antianxiety medication, 0.5 milligrams (mg) every four hours for anxiety and restlessness. Review of the pharmacy recommendation made on 06/30/19 indicated anxiolytics (Ativan) could only be used for 14 days and would need to be re-evaluated. Review of the medical record revealed the physician responded on 08/21/19 to the pharmacy recommendation dated 06/30/19 that he disagreed because she was on Hospice. There was a physician note dated 07/03/19 but did not address the Ativan. Interview with the pharmacist on 10/03/19 at 09:23 AM said he made a recommendation to review the as needed Ativan for Resident #29 on 06/30/19. He did not know what happened to the recommendation after that. 2. Review of the medical record revealed Resident #80 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including congestive heart failure, unspecified psychosis, chronic respiratory failure, anxiety, dementia with behavioral disturbance, dependence on supplemental oxygen and major depressive disorder. The physician ordered Ativan 0.5 mg every 12 hours as needed on 01/17/19 for anxiety. Review of the MDS 3.0 dated 08/13/19 indicated she had no behaviors and had used an antianxiety medication twice during the assessment period. Review of the pharmacy recommendation dated 06/30/19 indicated anxiolytics (Ativan) could only be used for 14 days and would need to be re-evaluated. The physician did not respond until 08/13/19 to extend the medication for 180 days then he would re-evaluate. The nurse practitioner then discontinued the medication on 08/13/19. Interview with the Director of Nursing on 10/02/19 at 4:00 P.M. said the physician was to respond to pharmacy recommendations within 30 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications were held as ordered based vital sign parameters for Resident #66. This affected one of six residents (Resident #17, #29, #49, #56, #66 and #80) reviewed for unnecessary medications. The facility census was 86. Findings include: Review of the medical record of Resident #66 revealed he was admitted to the facility on [DATE] with diagnoses including aphasia, seizure disorder and hypertension. Review of his quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was severely cognitively impaired. Review of the September 2019 Medication Administration Record (MAR) revealed the resident was ordered Lisinopril, a blood pressure medication, 10 milligrams once a day at 9:00 A.M., after a visit to his internal medication physician on 09/17/19. The order indicated the resident's blood pressure and pulse should be checked prior to the administration of the medication and if the resident's BP (blood pressure) was less than 110 (milligrams of mercury) or the HR (heart rate) was less than 70, the medication should be held. Review of the MAR revealed the resident's pulse was less than 70 on 09/25/19 (68 beats a minute) and on 10/01/19 (60 beats a minute), however the resident received the medication. An interview with Licensed Practical Nurse (LPN) #830 on 10/02/19 at 10:00 A.M. confirmed she was the nurse who had given the medication on 10/01/19. She stated she was aware of the parameters, but just had forgotten to hold the medication. The nurse who administered the dose on 09/25/19 was not identified. An interview with the Director of Nursing on 10/02/19 at 3:00 P.M. confirmed the medication was administered when it should have been held related to the pulse reading.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the medication error rate was less than 5%. The error rate was 10.7% with three errors in 28 opportunities, affecting Residents #34 and #80. This affected two of four residents (Residents #34, #36, #80 and #86) observed for medication administration, with a facility census of 86. Findings include: 1. Medication administration for Resident #34 was observed on 10/02/19 at 9:07 A.M. with Licensed Practical Nurse (LPN) #817. LPN #817 prepared all medications for the resident, which initially included an inhaler, an insulin injection and nine tablets or capsules. She confirmed the number of medications, including the nine pills, which were in two separate cups, one containing six pills and the other with three pills. LPN #817 administered the medications to the resident, who requested a pain pill, which she obtained and administered, completing the medication pass at 9:35 A.M. The surveyor also observed as she administered another medication to the resident on 10/02/19 at 10:16 A.M. as it was originally unavailable. Review of the residents record revealed he was admitted to the facility on [DATE] and had pressure ulcer. The resident was ordered a multivitamin on 01/25/19 to be given daily at 9:00 A.M. as a supplement, but LPN #817 had not administered the multivitamin during the medication administration. An interview with LPN #817 on 10/02/19 at 11:30 A.M. confirmed the count of the medications observed by the surveyor and that she had not administered the multivitamin. 2. Medication administration for Resident #80 was observed on 10/02/19 at 3:55 P.M. with LPN #824. LPN #824 stated Resident #80 had an NG (naso-gastric) tube (feeding tube through his nose into his stomach) and received his medications through the tube. LPN #824 administered an eye drop to Resident #80, then returned to her medication cart, prepared the medication for administration into the resident's NG tube which included four tablets. She crushed the tablets and added some warm water, stirring each with a spoon in their separate medication cups to dissolve the medications. She entered the room and disconnected the resident's tube feed solution, which was running through a pump. She administered all four medications into the NG tube individually, flushing after each. After a final flush, LPN #824 reconnected the tube feeding solution and indicated she was finished at 4:10 P.M. An observation of the cups that had contained the medications revealed two of the four cups had a significant amount of medication still in the cup. LPN #824 identified the first cup, which had a white tablet residue left in the cup, as the residents Magnesium Oxide, a supplement. A second cup contained an orange colored tablet, which LPN #824 identified as the resident's dose of Sulfasalazine, a medication to treat ulcerative colitis. There was a large amount of medication residue left in the cup. She verified she had not rinsed the cups and full doses of the medications had not been delivered. She indicated the medications did not dissolve well in water and verified she should have added more water to the cups to ensure the full doses could be administered. Review of the record revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including malnutrition, ulcerative colitis and dysphasia. The Magnesium Oxide was ordered on 08/27/19, and the Sulfasalazine was ordered on 09/09/19. An interview with the Director of Nursing on 10/02/19 at 4:50 P.M. confirmed the full amount of a medication should be administered. Review of the facility policy on Medication Administration through Enteral Tubes, dated October 2007, revealed the medication cup was to be rinsed with water to ensure the entire dose of medication had been administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an accurate assessment in the record of Resident #66 regarding a transfer to the hospital. This affected one of three residents (Residents #27, #66 and #84) reviewed for hospitalization. The facility census was 86. Findings include: Review of the record of Resident #66 revealed he was admitted to the facility on [DATE] with diagnoses including aphasia (loss of ability to understand or express language), seizure disorder and hypertension (high blood pressure). Review of his quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was severely cognitively impaired. Review of the record revealed a nursing note dated 06/22/19 at 11:54 P.M. which indicted the resident was stable with no concerns. The next note dated 06/24/19 at 12:57 P.M. revealed the resident had been discharged to the hospital on [DATE]. The next note in the record dated 06/25/19 at 3:22 P.M. revealed the resident returned from the hospital after a stay for a kidney stone and urinary retention. Review of the record did not reveal any assessment or further information on the resident's medical status, change in condition or symptoms that led to his transfer to the hospital. Review of the hospital discharge paperwork dated 06/25/19 revealed the resident was admitted with abdominal pain and found to have a kidney stone that passed. An interview with the Director of Nursing on 10/02/19 at 3:30 P.M. confirmed the record did not contain an assessment of the resident's condition prior to transfer to the hospital on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Residents #65 and #79's room and bedding was clean and sanitary. This finding affected two (Residents #65 and #79) of twenty-seven residents residing on the 100 hall. Findings include: Review of Resident #65's medical record revealed the resident was re-admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety disorder and major depressive disorder. Review of Resident #65's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment and required extensive two person assist for bed mobility, dressing and personal hygiene. Review of Resident #79's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset, alcohol-induced persisting dementia and dysphasia. Review of Resident #79's MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment and required extensive one person assist for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Observation on 09/30/19 at 9:54 A.M. revealed Residents #65 and #79's room smelled like urine, and the floor was sticky and tacky. Observation on 10/01/19 at 10:30 A.M. revealed Resident #79's bed was made up with brown soiling on the top cover. Resident #65 was in bed at the time of the observation, and Resident #79 was in the common lounge in a wheelchair. The resident room smelled like urine, and the floor was sticky and tacky. Interview on 10/01/19 at 1:08 P.M. with Housekeeping #810 indicated she mops the rooms on the 100 hall every day, and had just cleaned and mopped Residents #65 and #79's room. Housekeeping #810 indicated Resident #79 urinates on the floor. Interview on 10/01/19 at 1:53 PM. with Registered Nurse (RN) Supervisor #874 confirmed Residents #65 and #79's room smelled like urine, and Resident #79's bedsheets were soiled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility did not ensure three residents were free from flying pests. This finding affected three (Residents #33, #65 and #79) of twenty-seven residents residing on the 100 hall. Findings include: Review of Resident #65's medical record revealed the resident was re-admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety disorder and major depressive disorder. Review of Resident #65's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment and required extensive two person assist for bed mobility, dressing and personal hygiene. Review of Resident #79's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset, alcohol-induced persisting dementia and dysphasia. Review of Resident #79's MDS 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment and required extensive one person assist for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Review of Resident #33's medical record revealed the resident was readmitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis, major depressive disorder and muscle weakness. Review of Resident #33's MDS 3.0 assessment dated [DATE] indicated the resident exhibited moderate cognitive impairment and required extensive two person assist for transfers as well as extensive one person assist for bed mobility, dressing, toilet use and personal hygiene. Observation on 09/30/19 at 9:56 A.M. revealed Residents #65 and #79 were both in bed. Three flies were observed on Resident #79's bed cover, overbed table and the resident's leg, and two flies were observed on Resident #65's bed covers. Observation and subsequent interview on 09/30/19 at 10:17 A.M. with Resident #33 revealed three flies were observed on the resident's overbed table, covers and on the resident. Interview on 09/30/19 at 10:20 A.M. with Housekeeping #804 confirmed three flies were observed flying around Residents #65 and #79's room. Interview on 09/30/19 at 10:29 A.M. with Housekeeping Supervisor #814 confirmed Resident #33's room had several flies, and the facility staff swatted the flies with a fly swatter. Interview on 09/30/19 at 10:55 A.M. Resident #29's representative informed State Tested Nursing Assistant (STNA) #932 that a fly landed on the resident's eye and it was bothering her, and the representative requested a fly swatter. STNA #932 indicated she had killed a fly several days prior with the fly swatter and did not know where the fly swatter went. Observation on 10/01/19 at 1:29 P.M. revealed several flies were on Resident #33's over bed table. Interview on 10/01/19 at 1:53 P.M. with Registered Nurse (RN) Supervisor #874 confirmed flies were observed flying around in Residents #65 and #79's room and the 100 hall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #34's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, secondary malignant neoplasm of the bone and malignant neoplasm of the prostate. Review of Resident #34's MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #34's wound grids confirmed on 09/23/19 the resident had a stage two (superficial with a pale pink wound bed and serous drainage and may present itself as an abrasion, blister or shallow crater) on the right buttock and the coccyx. The right buttock was first identified 08/06/19 and the coccyx was first identified on 09/23/19 and both pressure wounds were facility acquired. Review of Resident #34's physician orders dated 09/25/19 revealed an order for a foam dressing to the right buttock and change the dressing every Monday, Wednesday and Friday and as needed and an order for Mepilex dressing (absorbent wound dressing) to the coccyx to be changed every three days and as needed. Review of Resident #34's medical record did not reveal evidence a care plan for pressure wounds was developed with measurable goals and interventions. Interview on 10/02/19 at 4:15 P.M. with LPN #818 confirmed Resident #34's medical record did not have a care plan with goals and interventions individualized for Resident #34's pressure wounds. 4. Review of Resident #76's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including lack of coordination, malaise and dementia without behavioral disturbance. Review of Resident #76's MDS 3.0 assessment dated [DATE] indicated the resident exhibited severe cognitive impairment and was on hospice services. Review of Resident #76's physician order dated 01/16/18 indicated the resident was admitted to hospice with a diagnosis of congestive heart failure (CHF). Review of Resident #76's medical record did not reveal evidence the resident had a care plan for hospice which included measurable goals and interventions to meet the resident's needs. Interview on 10/02/19 at 4:15 P.M. with LPN #818 confirmed Resident #76's medical record did not include a care plan for hospice care with measurable goals and interventions to meet the resident's needs and provide coordination of care for hospice services. 5. Review of the medical record of Resident #66 revealed he was admitted to the facility on [DATE] with diagnoses including aphasia, seizure disorder and hypertension. The record also indicated a diagnoses of calculus of the kidney (kidney stones). Review of his quarterly MDS 3.0 assessment dated [DATE] revealed he was severely cognitively impaired. Review of a nursing note dated 06/04/19 at 12:41 P.M. revealed the resident was transferred to the hospital at the request of the family for increased confusion and a note on 06/04/19 at 10:15 P.M. revealed he was admitted for kidney stones. He returned to the facility on [DATE]. Review of the record revealed a nursing note dated 06/22/19 at 11:54 P.M. which indicted the resident was stable with no concerns. The next note dated 06/24/19 at 12:57 P.M. revealed the resident had been discharged to the hospital on [DATE]. The next note in the record dated 06/25/19 at 3:22 P.M. revealed the resident returned from the hospital after a stay for a kidney stone and urinary retention. Review of the record did not reveal any assessment or further information on the resident's medical status, change in condition or symptoms that led to his transfer to the hospital. Further review of the record revealed the care plans did not contain any plans or interventions related to kidney stones or interventions to prevent or treat symptoms of pain related to the condition. An interview with LPN #818 on 10/03/19 at 2:00 P.M. confirmed she was the nurse who completed care plans for residents. She verified the resident had at least two hospitalizations for kidney stones, and the record did not contain care plans related to nursing interventions to prevent, identify or treat symptoms of the condition. 6. Review of the medical record of Resident #30 revealed she was admitted to the facility on [DATE] with diagnosis including a fracture of the left ankle. She also had an immobilizer brace to her left leg. Her admission MDS 3.0 assessment dated [DATE] revealed she was cognitively impaired and required the extensive assistance of one to two staff members for her activities of daily living. Review of her care plans dated 07/15/19 revealed she had the potential for pressure ulcer development related to decreased mobility and need for extensive assistance with mobility. Review of the nursing note dated 09/13/19 at 2:56 P.M. revealed the resident was observed with an open area to left outer ankle, from the brace the resident wears daily. The note indicated a treatment was put in place to cleanse the area with normal saline, cover with an antibiotic ointment and cover with coversite (a dressing). The note also indicated a note was left with the wound nurse so the resident could be seen by the wound NP (Nurse Practioner). There was no assessment of the area noted in the record, including appearance or size of the open area. Review of the record did not reveal further narrative documentation regarding the impaired skin area. Review of a note written by the consulting wound nurse practioner, Registered Nurse (RN) #700 dated 09/17/19 revealed she assessed the wound as a pressure area and applied a new dressing of Santyl (debriding agent), Calcium Alginate (absorbent dressing) covered with adherent foam to be applied daily and as needed. The next note by RN #700 on 09/24/19 indicated the dressing order should be continued as previously. The note indicated the only change to the assessment was the periwound was macerated. Review of skin grids provided by the facility revealed the areas was measured on 09/17/19 as 2.0 centimeters (cm) by 1.0 cm by 0.1 cm deep. It was a stage three (an area that extends into the tissue, forming a small crater) and had a moderate amount of sero-sanguineous drainage. The skin grid indicated the skin area measured 1.4 cm by 1.0 cm by 0.1 cm with edges macerated. The skin grid entry for 09/24/19 indicated the order for the Santyl and Calcium Alginate. Review of the treatment administration record (TAR) for September 2019 did not reveal any evidence of the dressing application of the antibiotic ointment. The TAR did not show the dressing of the Santyl and Calcium Alginate ordered by the wound nurse practioner on 09/17/19 until 09/25/19. The pressure area was not measured again until 10/01/19 when an entry indicated it measured 1.1 cm by 1.0 cm by 0.1 cm. No changes were made to the treatment. LPN #821 verified on 10/03/19 at 12:57 P.M. the record did not contain an assessment of the pressure area discovered on 09/13/19 until 09/17/19 and that the record did not show evidence of the ordered treatment in place or the change in treatment as ordered until 09/25/19. An interview with LPN #818 on 10/03/19 at 2:00 P.M. confirmed she was the nurse who completed care plans for residents. She verified Resident #30 had developed a pressure area from her immobilizer brace and the record did not contain a care plan related to the actual skin impairment and interventions to treat the impairment. Based on observation, interview and record review, the facility failed to develop individualized care plans for Resident's #30, #34, #59, #66, #76 and #80. This affected six residents of 41 Residents (#3, #5, #6, #7, #8, #9, #10, #12, #13, #15, #17, #19, #23, #24, #26, #27, #29, #30, #34, #38, #49, #51, #54, #55, #56, #57, #59, #63, #64, #65, #66, #75, #76, #78, #79, #80, #82, #83, #84, #282 and #283) records reviewed for individualized plans of care. The facility census was 86. Findings include: 1. Review of the medical record revealed Resident #80 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including congestive heart failure, acute kidney failure, psychosis, chronic respiratory failure, chronic kidney disease Stage 4, diabetes with diabetic polyneuropathy, hypertensive heart and chronic kidney disease with heart failure, cardiomegaly, anemia, anxiety, dementia with behavioral disturbance, automatic cardiac defibrillator, aortocoronary bypass graft, chronic ischemic heart disease, chronic gout, edema, hypertension, low back pain, chronic obstructive pulmonary disease, dependence on supplemental oxygen, reflux and major depressive disorder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she was cognitively impaired, displayed no behaviors and had the conditions as listed above. Review of the annual MDS 3.0 care area assessment (CAA) dated 11/10/18 indicated to proceed to care planning in the areas of cognition, activities of daily living, incontinence, falls, nutrition, pressure ulcers, psychotropic medication and pain. Review of the electronic plan of care revealed it was not complete. The following areas were identified but had no interventions developed: diabetes, shortness of breath, pain, cognition, anemia and activities of daily living. There was no care plan developed for psychotropic medication, incontinence or pressure ulcers. Interview and observation of Resident #80 on 09/30/19 at 10:19 A.M. said she was supposed to use her oxygen at all times. She verified her oxygen tubing was observed on the floor by her. Interview with the care plan nurse, Licensed Practical Nurse (LPN) #818, on 10/02/19 at 3:50 P.M. verified the care plans were not developed. 2. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, osteoarthritis, low back pain, osteoporosis and anxiety disorder. Review of the physician order dated 12/27/18 indicated there was a hand treatment: soak right hand in warm water, apply hydrogen peroxide with a Q-tip to each digit and palm of hand twice daily. Please medicate for pain before treatment. She was also ordered a right palm protector on 10/31/18 to be applied during waking hours and removed at night and/or at resident tolerance for positioning and hygiene. Review of the MDS 3.0 dated 07/16/19 indicated she had short and long-term memory impairment and moderate cognitive impairment. No behaviors were identified. She required the extensive assistance of one staff for personal hygiene. Her functional limitation in range of motion identified that she was impaired on one side of upper and lower extremities. Review of the annual MDS 3.0 CAA dated 04/13/19 indicated to proceed to care planning for pain, activities of daily living and behaviors. Review of the plan of care identified right side hemiplegia with interventions including use of the right hand protector and general pain interventions but was not individualized to include her resistance to all care to the right hand and the need for the family to be present to provide care to the contracted right hand. There was no evidence alternative interventions had been explored. Review of the specialist note dated 02/19/19 indicated he provided Botox therapy with some improvement in range of motion at the elbow but no improvement in the fingers. He noted she continued to have pain in the right hand, and the family was hoping something could be done to open her hand so that it could be cleaned. He indicated the diagnoses was focal dystonia, and the plan was for daily stretching of the right upper and lower extremities. Resident #59 was observed on 09/30/19 at 10:54 A.M., 10/01/19 and 10/02/19 at various times to hold her right hand tight. There was no roll or splint in place. Interview with Registered Nurse (RN) #876 on 10/03/19 at 7:47 A.M. verified no device had been placed in her right hand. He said anytime you went near the hand she screamed bloody murder. She refused treatment to the hand. He said they tried a carrot, wash cloth, gauze and she pulled them out. She was also followed by therapy but resisted any treatment. He said she had Botox treatments, and they were not effective. He said a surgical procedure had been recommended to the family to release the tendons, but the family refused for her to have surgery. He said she received Hospice services and had an as needed order for Morphine (opioid pain medication) and used to have an order for Tramadol (opioid pain medication), but it was discontinued by the nurse practitioner. He said the only time the hand got clean was when they cut her nails. He said the daughter had to be present and assist because it was a real struggle. Interview with RN Supervisor #874 and State Tested Nurse Aide (STNA) #839 on 10/03/19 at 8:33 A.M. said the family discontinued the Botox therapy because it was not helping. They verified it was a struggle to provide care to the hand because she screamed. They indicated the family had to be present for the cutting of her nails because it was so bad. The idea was to let therapy loosen her up but she refused. Interview with LPN #818 on 10/03/19 at 1:33 P.M. verified the current care plan was not individualized to include interventions for the contracted right hand, pain and refusal of care.

Based on record review or interview, the facility failed to ensure the Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property policy reflected all staff were to be checked against the Ohio Nurse Aide Registry as required in the current regulatory language. This finding had the potential to affect all residents residing in the facility. The facility census was 86. Findings include: Review of personnel files revealed from 08/31/18 to 10/03/19 revealed nine nurses including Registered Nurse (RN) #870, hired 09/16/19; Licensed Practical Nurse (LPN) #827, hired 09/13/19; LPN #834, hired 08/14/19; LPN #822, hired 07/15/19; LPN #817, hired 09/16/19; LPN #830, hired 08/14/19; RN #872, hired 06/19/19; LPN #821, hired 06/22/19; and LPN #816, hired 09/24/19 were not screened using the State of Ohio Nurse Aide Registry to identify any negative findings. Interview on 09/30/19 at 4:47 P.M. with Business Office Manager (BOM) #889 verified the facility did not check all new hires, including nurses, against the State of Ohio Nurse Aide Registry. BOM #889 confirmed she checked the unlicensed staff and the nurse aides but not the nurses against the State of Ohio Nurse Aide Registry. Review of the Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, revised 2017, indicated the facility would check with the Ohio Nurse Assistant Registry and any other registries for unlicensed persons that the facility had reason to believe contain information on an individual, prior to the use of that individual. The facility would check with all applicable licensing and certification authorities to ensure that employees hold the requisite license and/or certification status to perform their job functions and do not have a disciplinary action in effect against his or her professional license by a state licensure agency as a result of a finding of abuse, neglect, exploitation or misappropriation of resident property. Interview on 10/03/19 at 2:45 P.M. with the Administrator confirmed the abuse policy and procedure did not reflect the current regulatory language to check all new hires against the Ohio Nurse Aide Registry as required by the current regulatory language.

Based on observation, interview and policy review, the facility failed to maintain a clean and sanitary kitchen. This affected all residents who take food by mouth. The facility identified two residents (Resident's #52 and #80) that did not receive food by mouth. The facility census was 86. Findings include: The initial tour of the kitchen was conducted by the Executive Chef (EC) #930 on 09/30/19 beginning at 8:51 A.M. and the follow was observed: • The ice machine was observed to have a black substance scattered across the bottom of the white plastic chute where the ice passes into the storage bin below. Interview with EC #930 at that time verified the black substance on the white plastic chute, and reported the ice machine was cleaned weekly by maintenance. • The reach in cooler had a clear plastic container with three shelled hard-boiled eggs inside. There was debris on the inside of the container and directly on the eggs. The EC #930 verified there was debris inside the container and on the eggs and removed them from the cooler to be disposed. • The perimeter of the kitchen floor around and under appliances was heavily soiled with dirt, grease and food debris. The appliances also had a moderate amount of dried drips, food debris and grease on the sides and front of the appliances. • Two male Dietary Staff #900 and #912 wore hair nets over the tops of their head but did not contain the long braids and/or dread locks with a hair restraint. The following was observed on 10/01/19 beginning at 11:15 A.M.: • During tray line, the cook was observed to use china plates that were chipped. Interview with EC #930 at 11:23 A.M. indicated china plates with chips should have been pulled out of service. He went through the stacks of china and pulled 15 plates out of service that were chipped. • During tray line Dietary Staff #900 and #912 were observed again to wear hair nets over the tops of their head but did not contain the long braids and/or dread locks with a hair restraint. State Tested Nurse Aides (STNA) #841 came in and out of the kitchen a few times without wearing a hair net. STNA #847 was observed to wear a hair net over the top of her head but had multiple long braids that were draped over her left shoulder and hung down her chest. Interview with the EC #930 at 11:30 A.M. confirmed all of the hair needed to be covered. Review of the weekly cleaning tasks policy and procedure, dated April 2019, indicated the staff would maintain the sanitation of the kitchen through compliance with a written weekly cleaning schedule. Review of the weekly cleaning schedule from July through September 2019 indicated every Monday detail the soup kettle and scrub down all shelving, every Tuesday stove top to the dish tank and change the foil on stove drip pan, every Wednesday scrub down stainless steel walls behind equipment and detail the steamer, every Thursday clean the ice machine and deep clean coolers on line and every Friday detail tilt skillet an detail the mixer. There was no indication of when the floor was to be cleaned. There were markings to indicate the above items were completed, but there was no indication who completed the cleanings.