**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to honor a resident's documented code status. This affected one (Resident #73) of two residents reviewed for advance directives.Findings include:Review of Resident #73 ' s medical record revealed diagnoses including late onset Alzheimer ' s disease, history of sudden cardiac arrest, hypertension, gastrostomy status, and cognitive communication deficit. Resident #73 had a signed Do Not Resuscitate Comfort Care - Arrest (DNR CC-A) order signed [DATE]. The form indicated a resident with a DNRCC-A would be treated as any other without a DNR order until the point of cardiac or respiratory arrest at which point all interventions would cease and the DNR Comfort Care protocol would be implemented. The form instructed if a resident had a DNR providers would not perform cardiopulmonary resuscitation (CPR).A nursing note dated [DATE] at 2:38 P.M. indicated the nurse found Resident #73 to be cyanotic with a respiratory rate of three breaths per minute. Staff went to retrieve oxygen supplies while Licensed Practical Nurse (LPN) #115 grabbed the crash cart and another nurse called 911. CPR was initiated and one round of chest compressions and respirations were provided before Resident #73 ' s pulse stopped and all breaths ceased as confirmed by two nurses. Emergency medical technicians (EMT) arrived and confirmed. The hospice nurse also arrived and was updated on Resident #73 ' s death.During an interview on [DATE] at 10:49 A.M., the Director of Nursing (DON) confirmed staff had initiated CPR on Resident #73 on [DATE] as they were confused about the DNRCC-A order. The DON stated she educated nurses regarding a resident with a DNRCC-A should not have had CPR initiated. During an interview on [DATE] at 2:10 P.M., LPN #115 stated she nor Registered Nurse (RN) #150 understood what the A at the end of the DNRCC-A meant. CPR was initiated with one set of chest compressions and one set of breaths delivered before they stopped and verified they could not detect a pulse or respirations. It was during this assessment that EMTs arrived and scanned Resident #73 ' s hospital bracelet and determined he had a DNR order and confirmed Resident #73 was absent of breaths and heart beat. CPR was discontinued.This deficiency represents noncompliance investigated under Complaint Number 1374412 (OH00167460)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure accuracy of medical records regarding bathing. This affected four (Residents #4, #5, #51 and #63) of six residents reviewed for provision of showers.Findings include: 1. Review of Resident #51's medical record revealed diagnoses including schizophrenia, bipolar disorder, depression, anxiety disorder, anxiety disorder, obsessive-compulsive disorder and dependent personality disorder. A nursing note dated 07/16/25 at 8:50 A.M. indicated Resident #51 was transferred out for a geriatric psych hospitalization. Review of nurse aide documentation in the electronic health record revealed Resident #51 was not available for showers/bathing on 07/23/25 and 07/27/25. However, shower sheet and body/skin inspection forms dated 07/23/25 and 07/27/25 indicated Resident #51 accepted showers and had skin assessments completed by nurses. Resident #51 was readmitted to the facility on [DATE]. During an interview on 08/21/25 at 11:00 A.M., it was addressed with the Director of Nursing that staff documented showers were given and skin assessments completed for Resident #51 while he was out at the hospital. No valid explanation was provided.2. Review of Resident #63's medical record revealed diagnoses including bipolar disorder, schizoaffective disorder, anxiety disorder, heart disease, congestive heart failure, and atrial fibrillation. Review of bathing records in the electronic health record revealed showers/bathing was not attempted due to medical condition or safety concerns on 07/23/25, 08/06/25 and 08/10/25. Review of shower sheets revealed inconsistencies with documentation in the electronic health record. Shower sheets on 07/23/25, 08/06/25 and 08/10/25 revealed Resident #63 refused showers instead of the shower not being attempted. There was a separate place in the electronic health record to indicate if showers were refused.On 08/18/25 at 2:03 P.M., Resident #63 stated he is told showers could not be offered at times due to staffing issues. Resident #63 denied showers were offered in accordance with the shower schedule.On 08/21/25 at 11:00 A.M. inconsistencies in documentation between the electronic health record and shower sheets were addressed with the DON who indicated she would need to educate nursing assistants on documentation.3. Review of Resident #4's medical record revealed diagnoses including chronic obstructive pulmonary disease, conduct disorder, generalized muscle weakness, contractures of multiple sites, and schizophrenia. A care plan initiated 09/27/22 indicated Resident #4 had activity of daily living (ADL) self-care performance deficit. Resident #4 required a hoyer for all transfers with two assists. Resident #4 was totally dependent on staff for all ADLs including bathing. Aide documentation in the electronic health record revealed between 07/20/25 and 08/17/25 staff documented showers were not attempted due to environmental limitations on 07/27/25 and 08/17/25. A shower was not attempted on 07/20/25 due to medical condition or safety concerns. However, a shower sheet and body/skin inspection form was provided for 07/27/25 indicating a shower was accepted.On 08/21/25 at 11:00 A.M. inconsistencies in documentation between the electronic health record and shower sheets were addressed with the DON who indicated she would need to educate nursing assistants on documentation.4. Review of Resident #5's medical record revealed diagnoses including Parkinson's disease, dementia, psychosis, type two diabetes mellitus, anxiety disorder, and post-traumatic stress disorder. A care plan regarding ADL self care performance deficit initiated 06/19/23 indicated Resident #5 was totally dependent on staff for bathing. Review of bathing records between 07/24/25 and 08/17/25 revealed documentation in the electronic health record indicated bathing was not attempted due to environmental limitations on 07/27/25 and 08/17/25. However, shower sheets were provided indicated a shower was accepted on 07/27/25.On 08/21/25 at 11:00 A.M. inconsistencies in documentation between the electronic health record and shower sheets were addressed with the DON who indicated she would need to educate nursing assistants on documentation.This deficiency is an incidental finding discovered during the complaint investigation.

Based on record review, observation, interview, and review of facility policy, the facility failed to provide a dignified dining experience for all residents. This affected one resident (#23) of five residents reviewed for food/nutrition. The facility census was 64. Findings include: Review of the medical record for Resident #23 revealed an admission date of 11/20/19 with diagnoses including muscle weakness, contracture of muscle of multiple sites, and transient ischemic attack. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/07/25, revealed Resident #23 had severely impaired cognition for daily decision making and was dependent on staff for eating assistance. Review of the activities of daily living (ADLs) care plan, revised 11/20/24, revealed Resident #23 had an ADL self-care performance deficit related to chronic obstructive pulmonary disease, contractures, weakness, cognitive deficit, and functional deficit. Interventions included total dependence on staff for eating with the helper doing all the effort and the resident doing none of the effort. An observation on 04/17/25 from 8:13 A.M. to 8:30 A.M. in the dining room revealed Certified Nursing Assistant (CNA) #550 stood over Resident #23 as CNA #550 fed Resident #23. CNA #550 remained standing while feeding throughout the observation. An interview was conducted on 04/17/25 at 8:23 A.M. with CNA #550 who verified she was standing while feeding Resident #23. CNA #550 stated she always stood while providing feeding assistance to residents. Review of the facility policy titled Routine Resident Care, not dated, revealed care necessary for quality of life promoting dignity and independence would be provided by facility staff, including assisting with eating and hydration. This deficiency represents non-compliance investigated under Complaint Numbers OH00164146 and OH00162382.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review and review of facility policy, the facility failed to ensure privacy with mail correspondence for Resident #41. This affected one resident (#41) of one resident reviewed for privacy with mail. The facility census was 64. Findings include: Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], and was his own responsible party. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15 indicating he was cognitively intact. Interview with Resident #41 on 04/17/25 at 9:26 A.M. revealed staff opened his mail on several occasions without his permission. The Activity Director #555 who was also present during this interview, confirmed that staff opened resident #41's mail if it looked like insurance or a bill. Interview with the Social Services Designee (SSD) #558 on 04/17/25 at 11:19 A.M. revealed she and the Business Office Manager (BOM) #534 went through the mail then gave it to the activities department to deliver. Interview with the BOM on 04/17/25 at 11:36 A.M. revealed the mail was brought to the SSD or BOM. The BOM stated she went through the mail and gave it to the activities department to deliver. The BOM confirmed she opened some mail when she first started but didn't any longer. Review of an undated facility policy titled Resident Rights stated residents have the right to have privacy in sending and getting mail and email.

Based on record review and interview, the facility failed to ensure the do not resuscitate (DNR) authorization form was completed in its entirety for Resident #51. This affected one resident (#51) of 22 residents reviewed for advanced directives. The facility census was 64. Findings include: Review of the medical record for Resident #51 revealed an admission date of 05/06/24 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, acute kidney failure, and major depressive disorder. Review of the uploaded documents in Resident #51's electronic health record revealed a do not resuscitate (DNR) authorization form signed and dated 03/22/24. The patient name, patient address, patient birthdate, and patient gender fields were all blank. The signature of the resident or representative was unable to be deciphered. There was no clear indication on the authorization as to whom the authorization was intended for. On 04/21/25 at 8:58 A.M., an interview with the Administrator verified there was no identifying information on the DNR authorization form and stated the form should have included the resident's name. The Administrator was unable to determine which resident the form was intended for.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the Notice of Medicare Non-Coverage was acknowledged by the resident representative for residents with cognitive impairment. This affected two residents (#29 and #57) of five residents reviewed for beneficiary notices. The facility census was 64. Findings include: 1. Review of Resident #29's medical records revealed an admission date of 09/24/24 with diagnosis including dementia. Resident #29 resided on the secured unit, and a niece was listed as Resident #29's representative. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 had impaired cognition. Review of Resident #29's Notice of Medicare Non-Coverage revealed a date of non coverage of 10/11/24. Under the additional information section on the document was a hand written note dated 10/09/24 authored by Social Services Designee (SSD) #558 indicating a call was placed to Resident #29's niece and a message was left regarding last of day of coverage of 10/11/24. Below the additional information section the form stated please sign below to indicate you have received and understood this notice. I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO. The signature of patient or representative and date sections were blank indicating the notice had not been acknowledged by Resident # 29's representative. An interview on 04/22/25 at 10:59 A.M. with SSD #558 confirmed Resident #29's Notice of Medicare Non-Coverage was not signed and no additional efforts had been made to contact Resident #29's niece to confirm date of non coverage and notify of the right to appeal. SSD #558 stated she should have made additional attempts to contact Resident #29's representative as Resident #29 was unable to sign and understand the notice. 2. Review of Resident #57's medical records revealed an admission date of 11/27/24. Diagnoses included dementia and cognitive deficits. Resident #57 resided on the secured unit, and her grandson was assigned Power of Attorney (POA). Review of the MDS 3.0 assessment dated [DATE] revealed Resident #57 had impaired cognition. Review of Resident #57's Notice of Medicare Non-Coverage revealed a date of non coverage of 12/24/24 and a handwritten note authored by SSD #558 under the additional information section of the form included Resident #57's grandson had been contacted to explain discontinuation from speech therapy, the appeal process which he declined and Resident #57 was unable to sign the notice due to diagnoses of dementia, however Resident #57's signature was on on the form. Interview on 04/22/25 at 10:59 A.M. with SSD #558 confirmed she had authored the additional information section regarding Resident #57 was unable to sign due to diagnoses of dementia. SSD #558 verified the paperwork had Resident #57's signature and not the POA signature. SSD #558 stated she should not have allowed Resident #57 to sign acknowledgement of the Notice of Medicare Non-Coverage because Resident #57 would not understand what was being acknowledged and the grandson was the POA so his signature was required to acknowledge he was notified of non-coverage and the right to appeal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility policy, the facility failed to ensure admission paperwork was signed as required. This affected one resident (#214) of five residents reviewed for admission. The facility census was 64. Findings include: Review of the medical record for Resident #214 revealed an admission date of 03/25/25 with diagnoses including type two diabetes mellitus, obstructive sleep apnea, respiratory failure with hypoxia, anxiety disorder, and hypertension. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 04/01/25, indicated Resident #214 admitted on [DATE] and had no cognitive impairment. Review of the admissions packet provided by the Administrator on 04/22/25 for Resident #214 revealed the admissions agreement, responsible party/resident representative agreement, agreement to arbitrate disputes, assignment of benefits, Medicare secondary payer determination, photograph consent, authorization to share medical information, vendor consultation consent, receipt of information, medical marijuana facility consent, patient authorization and consent for care, and admissions checklist were all signed on 04/22/25, which was 28 days after admission. On 04/22/25 at 3:15 P.M., an interview with the Administrator verified Resident #214's admissions paperwork was dated 04/22/25 and that admissions paperwork should have been completed at the time of admission. The Administrator stated the facility did not have a full time admissions coordinator and admissions paperwork was to be completed with residents by Mobile Admissions Coordinator #585 or the Administrator. Review of the facility's policy titled Resident admission Policy, dated 10/05/20, revealed the Admissions Director or manager on duty would meet with residents or resident representatives to complete and sign all admission paperwork within 48 hours of the resident's admission and the Administrator would sign off on all completed admissions packets within 48 hours of the resident's admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of facility policy, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the residents' status. This affected three residents (Residents #20, #21, and #38 ) out of 22 residents reviewed for accurate MDS assessments. The facility census was 64. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 07/13/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cognitive communication deficit, depression, and pseudobulbar affect. Review of Resident #38's quarterly MDS 3.0 assessment, dated 03/14/25, revealed Resident #38 was moderately impaired cognitively, had inattention behavior which was continuously present and did not fluctuate, was dependent on staff for transfers, did not walk, was dependent on staff to wheel her manual wheelchair, and had no falls since the prior MDS assessment, which was a quarterly assessment dated [DATE]. Further review of Resident #38's medical record revealed on 01/05/25 the resident had an unwitnessed fall and was found on knees in room hugging the mattress and on 01/10/25 had another unwitnessed fall and was found in room sitting on her buttocks. Interview on 04/21/25 at 3:21 P.M. with MDS Registered Nurse (RN) #504 confirmed Resident #38's quarterly MDS 3.0 assessment dated [DATE] had been incorrectly coded since Resident #38 had falls on 01/05/25 and 01/10/25 which occurred since the previous MDS assessment dated [DATE]. 2. Review of the medical record for Resident #21 revealed an admission date of 12/04/23. Diagnoses included chronic obstructive pulmonary disease (COPD), obesity, and a history of pulmonary embolism. Review of Resident #21's physician's orders revealed an order dated 12/05/23 for oxygen at two liters per minute at bedtime for decreased pulse ox. Review of Resident #21's quarterly MDS 3.0 assessment, dated 03/13/25, revealed the resident was cognitively intact, had no behaviors including rejection of care, experienced shortness of breath while lying flat, and was not on any oxygen therapy. Review of Resident #21's March 2025 Treatment Administration Record (TAR) revealed the resident had received oxygen at two liters per minute at bedtime during the assessment reference period. Review of Resident #21's care plan, initiated on 03/15/24, revealed the resident had COPD with shortness of breath while lying flat with an intervention to provide oxygen therapy as ordered. Interview on 04/21/25 at 3:26 P.M. with MDS RN #504 stated, after reviewing Resident #21's medical record, Resident #21 had received oxygen therapy during the 03/13/25 MDS assessment reference period and confirmed the assessment had been incorrectly coded. 3. Review of the medical record for Resident #20 revealed an admission date of 07/18/23. Diagnoses included morbid obesity, dependence on supplemental oxygen, bipolar disorder, schizoaffective disorder, atherosclerotic heart disease, and anxiety disorder. Review of Resident #20 physician orders revealed an order dated 04/17/24 for oxygen at two (liters per minute) via NC (nasal cannula) continuous. Review of Resident #20's quarterly MDS 3.0 assessment, dated 03/14/25, revealed the resident was cognitively intact, refused to transfer out of the bed, was short of breath while lying flat, and had not received oxygen therapy during the assessment reference period. Review of Resident #20's care plan initiated 09/17/24 revealed the resident was at risk for impaired oxygen exchange related to requirement of oxygen use. Interventions included oxygen via nasal cannula as ordered. Review of Resident #20's March 2025 TAR revealed the resident had been receiving oxygen at two liters per minute continuously during the quarterly 03/14/25 reference period with no refusals. Interview on 04/21/25 at 3:17 P.M. with MDS RN #504 confirmed, after reviewing Resident #20's medical record, Resident #20 had received oxygen therapy during the 03/14/25 quarterly MDS assessment's reference period, and the MDS assessment had been incorrectly coded. Review of the facility's undated policy titled Clinical Documentation Standards revealed nurses would follow the basic standard of practice for documentation which included but was not limited to providing a timely and accurate account of resident information in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a comprehensive care plan to identify triggers and effective interventions related to a diagnosis of Post-Traumatic Stress Disorder (PTSD) for Resident #42. This affected one resident (#42) of 22 residents reviewed for care plans. The facility census was 64. Findings include: Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with a diagnosis of PTSD, anxiety, unspecified psychosis and depression. Resident #42's wife was listed as the resident representative and Power of Attorney (POA) for Resident #42. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS also revealed Resident #42 demonstrated verbal and physical behavior symptoms directed at others one to three days per week. Review of the care plan for Resident #42, with a date initiated of 06/19/23 and date revised of 03/30/25, revealed there was no part of the care plan developed to address the diagnosis of PTSD to identify triggers and interventions to treat the PTSD. Interview with Resident #42's wife on 04/14/25 at 3:07 P.M. revealed Resident #42 was diagnosed with PTSD after serving as a medic in the Vietnam war and his triggers were loud noises, violence on television and being handled. Resident #42's wife confirmed Resident #42 had cognitive impairment and she had not been asked to help develop a care plan to address his PTSD. Interview with Director of Nursing on 04/23/25 at 3:13 P.M. confirmed a comprehensive care plan for PTSD was absent from Resident #42's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure indwelling urinary catheters were emptied in a timely manner to prevent back flow of urine for Resident #16. This affected one resident (#16) of three residents observed for catheters. The facility identified nine residents (#16, #51, #5, #2, #19, #45, #32, #53 and #31) as having indwelling urinary cathetars. The facility census was 64. Findings include: Review of Resident #16's medical records revealed an admission date of 04/10/24. Diagnoses included need for personal care assistance and open wound of the lower back and pelvis. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 had intact cognition. Resident #16 required maximum assistance with toileting and had an indwelling catheter for urination and was incontinent of bowel. Review of the care plan dated 02/28/25 revealed Resident #16 had a urinary catheter. Interventions included provide catheter care every shift and as needed. Review of current physician orders for April 2025 revealed to document output every shift. Review of output documentation revealed no documented output prior to 04/16/25 at 3:40 P.M. Observation on 04/16/25 at 8:31 A.M. revealed Resident #16 was sleeping in her bed and the urinary catheter bag was observed to be completely filled up with urine. An interview was conducted on 04/16/25 at 8:31 A.M. during the observation of Resident #16 with Licensed Practical Nurse (LPN) #541 who confirmed Resident #16's full catheter bag. LPN #541 further confirmed there was an amount of 2000 cc's of urine in Resident #16's bag. LPN #541 stated catheter bags were to be emptied before they had become full as to prevent any backflow of urine. At the time of the observation and interview with LPN #541, LPN #541 had informed the Director of Nursing (DON) of Resident #16's full urinary catheter, the DON observed Resident #16's full catheter bag and had proceeded to empty the bag.

Based on record review, interview, and review of facility policy, the facility failed to ensure weekly weights were being obtained as ordered by the physician to monitor nutrition status for Resident #38 and #42. This affected two residents (#38 and #42) out of four residents reviewed for nutrition. The facility census was 64. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 07/13/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction, cognitive communication deficit, depression, and severe protein calorie malnutrition. Review of Resident #38's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/14/25, revealed the resident was moderately impaired cognitively, exhibited continuous inattention behavior; required partial/moderate assistance for eating; had a significant weight loss which was not prescribed; and was on a therapeutic diet. Review of a weight change progress note dated 03/19/25 at 2:54 P.M. revealed Resident #38's current weight of 215.3 pounds triggered a significant weight loss of 14 percent weight loss over 180 days. Recommendations included weekly weights. Review of Resident #38's physician's orders revealed an order dated 03/19/25 for weekly weights every Wednesday for four weeks (start date of 03/19/25 and end date of 04/09/25). Review of Resident #38's March 2025 Medication Administration Record (MAR) revealed weekly weights were signed off as completed on 03/19/25 and on 03/26/25 but no actual measurement of weight was documented. Review of Resident #38's April 2025 MAR revealed weekly weights were signed off as completed on 04/02/25 and 04/09/25 but no actual measurement of weight was documented. Further review of Resident #38's weights in the medical record revealed the resident's weight had been obtained on 03/20/25 and 04/04/25. There were no weights for 03/26/25 and 04/09/25. Interview on 04/23/25 at 10:16 A.M. with Registered Dietitian (RD) #578 verified weekly weights had not been obtained as ordered between 03/19/25 and 04/09/25 for Resident #38. 2. Review of the medical record for Resident #42 revealed an admission date of 06/16/23 with diagnoses including Parkinson's disease, dementia, type two diabetes mellitus, anxiety disorder, and post-traumatic stress disorder. Review of the nutrition note dated 03/13/25 at 2:44 P.M. revealed Resident #42 had experienced a significant weight loss of five percent in one month and weekly weights were ordered to monitor weight trends. Review of the physician's orders for Resident #42 dated 03/13/25 revealed an order for weekly weights due to weight loss (ordered on 03/13/25 with an end date of 04/16/25). Review of Resident #42's MAR for March and April 2025 revealed weekly weights were signed off as completed on 03/19/25, 03/26/25, 04/02/25, 04/09/25, and 04/16/25 but no actual measurement of weight was documented. Review of the Resident #42's documented weights in the medical record revealed weights were documented on 03/20/25 and 04/04/25. There were no other weights recorded between 03/19/25 and 04/16/25. On 04/22/25 at 5:18 P.M., an interview with the Director of Nursing (DON) verified weekly weights were not obtained as ordered between 03/19/25 and 04/16/25 for Resident #42. Review of the undated facility policy titled Resident Height and Weight revealed weights would be obtained monthly or as ordered by the physician or practitioner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #26 received proper and physician ordered care of a feeding tube site to prevent potential for skin irritation and infection. This affected one resident (#26) of two residents reviewed for feeding tubes. The facility census was 64. Findings include: Review of Resident #26's medical records revealed an admission date of 12/02/24. Diagnoses included surgical interventions of the digestive system. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 had intact cognition. Review of the care plan dated 03/20/25 revealed Resident #26 required the use of a feeding tube. Interventions included check placement of feeding tube and monitor tube feedings. Review of physician orders for April 2025 revealed an order dated 12/02/24 to cleanse Resident #26's feeding tube site with normal saline and apply drain gauze at bed time. Observation on 04/21/25 at 12:02 P.M. revealed Resident #26's tube feeding site had a soiled, undated gauze dressing around the site. Interview with Licensed Practical Nurse (LPN) #538 at the time of observation revealed she had changed Resident #26's tube feed dressing on 04/17/25, which was the last day she had worked with Resident #26. Interview with Resident #26 at time of observation revealed LPN #538 was the last one who had changed his tube feeding dressing several days ago.

Based on observation, interviews, record reviews, and review of facility policy, the facility failed to ensure oxygen tubing was changed weekly. This affected three residents (#5, #20, and #21) out of three residents reviewed for respiratory care. The facility identified eleven residents (#5, #9, #17, #19, #20, #21, #23, #25, #27, #31, and #43) as having a physician order for oxygen. The facility census was 64. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of 12/04/23. Diagnoses included chronic obstructive pulmonary disease (COPD), obesity, and a history of pulmonary embolism. Review of Resident #21's physician orders revealed orders dated 12/05/23 for oxygen at two liters per minute at bedtime for decreased pulse ox (a device used to measure blood oxygen and pulse) and to change oxygen tubing every week and PRN (as needed). Review of Resident #21's care plan, initiated on 03/15/24, revealed the resident had COPD with shortness of breath while lying flat. Interventions included elevate head of bed as needed to prevent shortness of breath while lying flat, monitor vitals and report abnormal findings to medical provider, and oxygen therapy as ordered. Change tubing per facility policy. Observation on 04/14/25 at 10:00 A.M. revealed Resident #21's oxygen tubing was dated 04/06/25. Interview on 04/14/25 at 10:37 A.M. with Certified Nursing Assistant (CNA) #550 confirmed Resident #21's oxygen tubing was dated 04/06/25 and stated she thought oxygen tubing should be changed weekly. 2. Review of the medical record for Resident #20 revealed an admission date of 07/18/23. Diagnoses included morbid obesity, dependence on supplemental oxygen, bipolar disorder, schizoaffective disorder, atherosclerotic heart disease, and anxiety disorder. Review of Resident #20's physician orders revealed orders dated 04/17/24 for oxygen at two (liters per minute) via NC (nasal cannula) continuous and to change oxygen tubing and humidifier every seven days and PRN. Review of Resident #20's care plan initiated 09/17/24 revealed the resident was at risk for impaired oxygen exchange related to requirement of oxygen use. Interventions included monitor for signs/symptoms of respiratory distress and report to medical provider as needed, oxygen via nasal cannula as ordered, provide ear protectors to oxygen tubing if applicable, and raise head of bed to promote optimal lung expansion. Observation on 04/14/25 at 9:51 A.M. revealed Resident #20's oxygen tubing was dated 04/05/25. Interview on 04/14/25 at 10:37 A.M. with CNA #550 confirmed the oxygen tubing was dated 04/05/25 and stated she thought the oxygen tubing needed changed weekly. 3. Review of the medical record for Resident #5 revealed an admission date of 07/07/22. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and nonspecific abnormal finding of lung field, anxiety disorder, and dependence on supplemental oxygen. Review of Resident #5's physician order revealed an order dated 10/17/23 for oxygen at three liters/minute continuous through nasal canula may titrate to keep oxygen saturation level 90 percent or greater, and an order dated 07/09/22 to change oxygen tubing every week and PRN. Review of Resident #5's care plan, initiated on 07/13/22, revealed the resident has COPD with shortness of breath while lying flat, seasonal allergies, and a lung mass. Interventions included elevate head as needed to prevent shortness of breath while lying flat, observe for signs and symptoms of COPD, monitor vitals, and oxygen therapy as ordered, change tubing per facility policy. Observation on 04/14/25 at 9:21 A.M. revealed Resident #5's oxygen tubing was dated 04/05/25. Interview on 04/14/25 at 10:38 A.M. with CNA #550 confirmed the oxygen tubing was dated 04/05/25 and stated she thought the oxygen tubing needed changed weekly. Interview on 04/23/25 at 7:27 AM with the Director of Nursing (DON) confirmed oxygen tubing should be changed weekly and dated when changed. Review of undated facility policy titled Supplemental Oxygen using Nasal Cannula, revealed nasal cannula and tubing were to be changed weekly or when soiled and labeled with date when opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents were free from significant medication errors. This affected two residents (#35 and #37) of five residents reviewed for medication administration. The facility census was 64. Findings include: 1. Review of Resident #35's medical records revealed an admission date of [DATE]. Diagnoses included dementia and depression Review of Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had intact cognition. Review of the care plan dated [DATE] revealed Resident #35 had behaviors that included verbal disagreements with her roommate regarding the television. Interventions included administer medications as ordered. Resident #35 used anti-depressant medications. Interventions included provide medications per physician orders. Review of Resident #35's current physician orders for [DATE] revealed an order to administer Ativan (anti-anxiety medication) one milligram (mg) at bedtime. Review of the progress note dated [DATE] timed 11:40 P.M. authored by Registered Nurse (RN) #554 revealed Ativan was out of stock. RN #554 had contacted the pharmacy and had been informed Resident #35's Ativan script was expired and a new script was required for refill. Review of a progress note dated [DATE] timed 1:00 A.M. authored by Nurse Practitioner (NP) #701 revealed a one time dose of Ativan was ordered and to follow up with the house provider for further orders. Review of a progress note dated [DATE] timed 3:08 A.M. authored by RN #506 revealed she was awaiting a code from the pharmacy for Resident #35's Ativan. Review of a progress note dated [DATE] timed 5:12 A.M. authored by Licensed Practical Nurse (LPN) #566 revealed Resident #35's Ativan was unavailable. Pharmacy was notified and stated the medication would be delivered on the first drop. Review of a progress note dated [DATE] timed 2:57 P.M. authored by LPN #538 revealed Resident #35 had asked about her Ativan due to she had not received the medication for four nights. The progress note stated the nurse practitioner had been notified and stated she would write a new script. Review of a progress note dated [DATE] timed 1:04 A.M. authored by RN #510 revealed Resident #35's Ativan was unavailable and a script was required. Review of Resident #35's Medication Administration Record (MAR) for [DATE] revealed Ativan had not been documented as being administered on [DATE], [DATE] and [DATE]. Resident #35's Ativan had been documented as being administered on [DATE] by RN #521, however the medication had not been available at that time. Interview on [DATE] at 1:30 P.M. with LPN #538 revealed Resident #35 had approached her earlier that day and had asked about her Ativan. LPN #538 stated she had been unaware Resident #35 had not received her Ativan due to it was scheduled to be administered on the evening shifts. LPN #538 stated Resident #35 had informed her she had not received the Ativan for the last four nights. Interview on [DATE] at 10:53 A.M. with the Director of Nursing (DON) revealed she had been informed Resident #35's Ativan had not been available and was not administered, however was unable to provide an explanation as to why it had not been administered and stated she would inform the physician. Interview on [DATE] at 10:58 A.M. with Resident #35 revealed she had not had her sleeping pills for several nights. Resident #35 stated she was not sure what the sleeping pill was called, however stated the nurses had told her the medication had been out of stock. Resident #35 stated she had not slept for the past three nights due to she had not been given her medication. 2. Review of Resident #37's medical records revealed an admission date of [DATE]. Diagnoses included anxiety and dementia. Review of Resident #37's physician orders for [DATE] revealed to administer Hydroxyzine (antihistime, also used to treat anxiety) 25 milligrams (mg) in the morning and at bedtime for anxiety. Observation of medication administration on [DATE] at 7:51 A.M. with RN #554 revealed he had obtained a medication card from the medication cart that had Resident #7's name on the top for the medication Hydroxyzine in the amount of 50 mg tablets. RN #554 had popped the 50 mg Hydroxyzine out of the medication card and had added it to the other four medications that he had already had in the medication cup for Resident #37. RN #554 had approached Resident #37's doorway and upon surveyor intervention he had been asked to return to his medication cart. RN #554 was asked to verify the medication card he had used to obtain the Hydroxyzine and RN #554 had verified the medication card had belonged to Resident #7. RN #554 had then checked Resident #37's medication orders and had verified Resident #37 was ordered Hydroxyzine, however it was ordered for 25 milligrams. RN #554 had then taken the 50 mg tablet of Hydroxyzine out of Resident #37's medication cup and had placed it in another cup and stated he would administer that dose to Resident #7. RN #554 stated Resident #37's medication card was in a different spot and stated he had not looked at the name or the milligrams on the medication card prior to obtaining the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure lab work had been completed timely and according to physician order. This affected one resident (#15) of two residents reviewed for laboratory services. The facility census was 64. Findings include: Review of Resident #15's medical records revealed an admission date 08/15/23. Diagnoses included dementia, muscle weakness and need for personal care assistance. Review of Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 had impaired cognition. Review of a progress note dated 04/17/25 timed 3:24 P.M. authored by Licensed Practical Nurse (LPN) #566 revealed new orders were received to obtain a urinalysis and blood work. Review of physician orders dated 04/17/25 revealed orders for blood work and urinalysis. Review of the document titled Biomedical Laboratories dated 04/21/25 revealed Resident #15's blood specimen was collected on 04/21/25 and all results for the blood tests were pending. There was no collection for urinalysis. Interview on 04/21/25 at 8:53 A.M. with Licensed Practical Nurse (LPN) #566 and the Director of Nursing (DON) confirmed Resident #15 had orders to collect blood work and urine. LPN #566 verified the blood specimen was collected on 04/21/25 and there was no collection for urinalysis. LPN #566 stated she was unsure why the lab work had not been completed as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility diet spread sheet, and review of facility policy, the facility failed to ensure Resident #42 received foods consistent with a dysphagia advanced diet to meet individual needs. This affected one resident (#42) out of four residents reviewed for nutrition. The facility identified six residents (#14, #27, #30, #42,#43, and #266) ordered a dysphagia advanced diet. The facility census was 64. Findings include: Review of the medical record for Resident #42 revealed an admission date of 06/16/23 with diagnoses including Parkinson's disease, dementia, and Alzheimer's disease. Review of Resident #42's physician orders revealed an order dated 01/13/25 for Regular diet, Dys (dysphagia) Adv (advanced) texture, Thin liquids consistency, Fortified hot cereal QD (every day) w/(with) breakfast, Fortified mashed potatoes BID (twice a day) w/ lunch and dinner. Review of Resident #42'S annual Minimum Data Set (MDS), dated [DATE], revealed Resident #42 was severely impaired cognitively, exhibited inattention and disorganized behavior, required partial/moderate assistance from staff for eating, had no swallowing concerns during the assessment reference period, had a significant weight loss which had not been prescribed, and received a therapeutic and a mechanically altered diet. Review of Resident #42's care plan revealed the resident had a potential for altered nutrition related to being overweight, needing a mechanically altered diet per speech recommendations, and having a severe weight loss. Interventions included observe for signs and symptoms of aspiration (when anything other than air gets into the airways)/dysphagia (difficulty swallowing) such as choking, coughing, pocketing food, loss of liquids/solids from mouth when eating/drinking and difficulty/pain when swallowing, provide meals per diet order, position resident properly for eating/swallowing, and speech therapy evaluation and treat as needed. Review of the facility diet spread sheet titled Salem [NAME] Healthcare Center Diet Guide Sheet for Week Two Wednesday (04/16/25) revealed residents on a Dysphagia Advanced diet were to be served one half cup of chopped Brussel sprouts instead of whole Brussel sprouts for lunch. Observation on 04/16/25 at 12:15 P.M. revealed a family member of Resident #42 was feeding Resident #42 his lunch in the south unit dining room and was observed asking staff if Resident #42 should have been served whole Brussel sprouts. The family member indicated to the staff she was having difficulty cutting up a Brussel sprout using a spoon. Review of Resident #42's diet slip at the time of observation revealed the resident was on a Regular-Dys Advance diet and was supposed to have received chopped Brussel sprouts with the meal. An interview on 04/16/25 at 12:17 P.M. with Certified Nursing Assistant (CNA) #601 verified Resident #42 had received whole intact Brussel sprouts instead of chopped Brussel sprouts. An interview on 04/16/25 at 12:22 P.M. with Regional District Manager #602 revealed residents on a Dysphagia Advanced diet should have received chopped Brussel Sprouts instead of whole Brussel sprouts for lunch on 04/16/25. Review of the facility policy titled Meal Distribution, revised February 2023, revealed all meals would be assembled in accordance with the individualized diet order, and nursing staff would be responsible for verifying meal accuracy of resident's meals prior to delivery to the resident. This deficiency represents non-compliance investigated under Complaint Number OH00164146.

Based on observation, record review, interview and review of facility policy, the facility failed to ensure call lights were within reach for Resident #50, #56 and #60, and failed to ensure Resident #20 was reasonably accommodated to meet his shower preference. This affected four residents (#20, #50, #56 and #60) of 22 residents reviewed for accomodation of needs/preferences. The facility census was 64. Findings include: 1. Observation on 04/14/25 at 9:17 A.M. revealed Resident #56 was resting in bed with his call light draped on a light fixture above his bed not within reach. The observation was confirmed by Licensed Practical Nurse (LPN) #515 who stated call lights should be within reach of residents at all times. Resident #56 was not interviewable. Observation on 04/21/25 at 8:25 A.M. revealed Resident #56 was sleeping in bed and his call light was on the floor behind his bed. The observation was confirmed with LPN #503 and she stated call lights should be within reach of residents at all times. 2. Observation on 04/23/25 at 10:36 A.M. revealed Resident #60 was asleep in bed and the call light was pinned to a privacy curtain that was not within reach of Resident #60. Certified Nursing Assistant (CNA) #574 was present at the time of the observation and confirmed the call light was not within the resident's reach and should be in reach at all times. Review of resident council minutes for November 2024 revealed concerns related to call lights being left in inappropriate locations. 3. Review of the medical record for Resident #50 revealed an admission date of 07/12/24. Diagnoses included chronic obstructive pulmonary disease (COPD), type two diabetes, unspecified dementia, schizoaffective disorder, anxiety disorder, depression, bipolar disorder, and suicidal ideations. Review of Resident #50's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/03/25, revealed the resident was moderately impaired cognitively; exhibited behavioral symptoms not directed toward others one to three days of the assessment reference period; wandered one to three days of the assessment reference period, required supervision or touch for mobility which included walking up to 150 feet. Further review of Resident #50's medical record revealed a care plan with an initiation date of 01/24/25 which indicated the resident required a secure unit related to behaviors, elopement risk, and poor cognition. Interventions included the resident may have a long call cord light. Observation on 04/14/25 at 10:41 A.M. revealed Resident #50 was lying on her bed with no call light within reach of the resident. The call light cord was observed to be approximately two feet long and was hanging from the call system located in the middle of the right-hand wall of the room. Interview at the time of the observation with Resident #50 revealed she was unable to reach the call cord when she was lying on the bed. Interview on 04/14/25 at 10:55 A.M. with LPN #515 confirmed the call light was short and was not in reach of Resident #50. Interview on 04/15/25 at 10:16 A.M. with the Ombudsman revealed there was an open case regarding concerns with the short emergency call cords on the secure unit and the residents not being able to reach them. Interview on 04/15/25 at 1:39 P.M. with Director of Plant Maintenance (DPM) #516 stated the secured unit was recently opened and the rooms on the unit would have a long or short call cord depending on their diagnosis. Observation during an environmental tour on 04/15/25 with DPM #516 from 2:02 P.M. to 4:24 P.M. revealed there were both long and short emergency call cords in the residents rooms on the secure unit. Review of the undated facility policy titled Resident Rights revealed call light would be within reach of the resident. Review of the undated facility policy titled Secured (Locked) Unit revealed it was the policy of the facility to provide resident centered care that met the psychosocial, physical, and emotional needs and concerns of the residents. The unit would be adequately staffed to address the needs of the residents; would provide a homelike environment to the extent possible; would have secured areas for medications, cleaning supplies, treatment, and other products that might pose a potential hazard if inadvertently entered; would be quiet and away from unnecessary noise and interruptions; and would have secure areas to wander within the unit. There was nothing documented in the policy indicating the unit would have short and long emergency call cords. 4. Review of the medical record for Resident #20 revealed an admission date of 07/18/23. Diagnoses included morbid (severe) obesity, bipolar disorder, schizoaffective disorder, type two diabetes, and anxiety disorder. Review of Resident #20's quarterly MDS 3.0 assessment, dated 03/14/25, revealed the resident was cognitively intact, was dependent on staff to shower/bathe self, and the resident refused to transfer during the assessment reference period. Review of Resident #20's care plan, date initiated 08/29/23 and revised on 03/15/25, revealed Resident #20 had an ADL self care performance deficit related to morbid obesity. Resident #20 was dependent on staff for showering/bathing. There was no documentation in the care plan to indicate Resident #20 should not be showered and no documentation to indicate he preferred only bed baths. Further review of Resident #20's medical record revealed from 03/30/25 to 04/27/25 the resident either received a bed bath or refused to be bathed. The last weight recorded for Resident #20 was dated 04/04/25 and the weight was 711.0 pounds. Review of the product specification for MJM International PVCM1315 bariatric shower chair which the facility identified as being the bariatric shower chair located in the shower room on the unit where Resident #20 resided revealed the shower chair was made of PVC and had a weight capacity limit of 700 pounds. An interview with Resident #20 on 04/14/25 at 9:38 A.M. revealed he would love a shower, and if he received a shower, the facility staff would have a difficult time getting him out of the shower since it would feel so good. Resident #20 verified the staff did not shower him, they only gave him bed baths because he was told by the staff there was not a shower chair that would hold him. Interview on 04/16/25 at 7:23 A.M. with Certified Nursing Assistant (CNA) #550 revealed there was no way to safely shower Resident #20 in the shower room since the facility's bariatric shower chair would not be stable enough to support his weight. Observation of the facility's shower chairs and shower bed in all the shower rooms on 04/16/25 from 9:33 A.M. to 9:46 A.M. with Laundry and Housekeeping Manager (LHM) #603 revealed the largest shower chair was in the hall where Resident #20 resided and was made of white PVC (a synthetic resin made from the polymerization of vinyl chloride) pipe. There was a sticker on the chair indicating it was manufactured by MJM International but there was nothing on the bariatric chair indicating what the weight limit was for the chair, which was verified at the time of observation by LHM #603. Interview on 04/16/25 at 5:56 PM with the Director of Nursing (DON) confirmed the facility's bariatric shower chair had a weight limit of 700 pounds, and Resident #20 weighed more than the weight limit for the facility's bariatric shower chair. She went on to state she thought Resident #20 preferred bed baths, but if the resident wanted to take a shower, the facility did not have a safe way to shower the resident. Interview conducted on 04/17/25 approximately between 9:00 A.M. and 10:53 A.M. with DPM #516 revealed the facility could provide a bariatric shower chair to accommodate a resident who weighed between 700 and 900 pounds and it was made by the same manufacturer MJM International. Product specifications provided by the facility for MJM international Extra Wide PVC Bariatric Chair PVCM1315D8 revealed the chair was extra wide and reinforced at all stress related areas and had a weight capacity of 900 pounds. Review of the undated facility policy titled Resident Rights revealed it was the policy of the facility to provide resident centered care which would meet the physical needs of the residents and safety of the residents would be a top priority of care.

Based on observation and interview the facility failed to ensure a clean environment was maintained for Resident #56 and Resident #267 and failed to maintain comfortable water temperatures and at the required water temperature for Resident #11, #15, #19, #27, #33, #34, #52 and #54. This affected 10 residents (#11, #15, #19, #27, #33, #34, #52, #54, #56 and #54) with the potential to affect an additional 13 residents (#7, #14, #22, #23, #28, #31, #37, #42, #43, #45 #46, #60 and #114) residing on the 100 hall. The facility census was 64. Findings include: 1. Observation on 04/14/25 at 9:17 A.M. of Resident #56's room revealed Resident #56 was resting in bed and was noninterviewable due to drowsiness at the time of the observation. In Resident #56's bathroom the toilet was observed to have a large amount of black/green colored liquid stool on the toilet seat and in the toilet bowl. The observation was confirmed by Licensed Practical Nurse (LPN) #515. 2. Observation on 04/16/25 at 8:41 A.M. of Resident #267's bathroom revealed the toilet had dried stool on the toilet seat and inside the toilet bowl. The bathroom had a heavy odor of stale urine and there was a dark orange ring of residue surrounding the base of the toilet. The observation was confirmed by LPN #541. 3. Review of the facility water temperature log provided by the Director of Plant Maintenance (DPM) #516 revealed a record of water temperatures between 01/01/25 and 04/14/25. The water temperatures had been checked in two different areas for each of the four hallways on 01/01/25, 01/06/25, 01/13/25, 02/17/25, and 03/10/25. On 01/13/25 the temperature recorded in Residents #34 and #54 room (on the 100 hallway) was 92 degrees Fahrenheit (F) and in Residents #42 and #46 room (on the 100 hallway) the temperature of the water was 90 degrees F. On 01/27/25 the water temperature taken of an unidentified area of the 100 hallway was 90 degrees F. There were no recorded temperatures on the log for the weeks of 01/20/25, 02/03/25, 02/10/25, 02/24/25, 03/03/25, 03/17/25, 03/24/25, or 04/07/25. Observations were conducted on 04/15/25 from 2:02 P.M. to 4:24 P.M. during an environmental tour with DPM #516 to obtain resident room water temperatures on the 100 hallway using DPM #516's facility thermometer. The following concerns were identified: • In Resident #34 and #54's room, after running the water for approximately two minutes, DPM #516 took the temperature of the water coming out of the bathroom faucet using a facility thermometer and the water reached 93.9 degrees F as the highest temperature. The water was lukewarm to the touch. • In Residents #27 and #33's room, after running the water for approximately two minutes, DPM #516 took the temperature of the water coming out of the bathroom faucet using a facility thermometer and the water reached 93.9 degrees F as the highest temperature. The water was luke warm to the touch. • In Residents #19 and #15's room, after running the water for approximately two minutes, DPM #516 took the temperature of the water coming out of the bathroom faucet and the water reached 95.0 degrees F as the highest temperature. The water was luke warm to the touch. • In Resident #52's room, after running the water for approximately two minutes, DPM #516 took the temperature of the water coming out of the room faucet and the water reached 97.7 degrees F as the highest temperature. The water was lukewarm to the touch. Interviews at the time of the observations with DPM #516 confirmed the water coming out of the bathroom sinks on the 100 hallway was not warm enough. DPM #516 stated the temperature of the water should be between 105 and 120 degrees F. DPM #516 said he attributed the lukewarm temperatures to the hot water tank not being large enough to meet all the needs of the residents on the affected unit. DPM #516 stated the facility had recently replaced the mixing valve which had helped to increase the water temperatures on the 100 hallway. Interview on 04/15/25 at 4:35 P.M. with Resident #11, who resided on the 100 hallway, revealed her showers were just warm and she would like the water temperature to be warmer because it was not at a comfortable temperature for her. Interview on 04/24/25 at 9:22 A.M. with DPM #516 confirmed the missing weeks of recorded water temperatures. DPM #516 stated he was taking water temperatures weekly except he had missed the week of 04/07/25. DPM #516 stated he thought the program he was using to record the water temperatures was backing up his data, and he had no idea why the program hadn't backed up the water temperatures he was recording. DPM #516 confirmed there was no written evidence the water temperatures were being monitored weekly for the missing weeks of recorded water temperatures. DPM #516 confirmed the water temperatures dating back to January of 2025 to present did not meet the regulatory requirement for water temperatures. Review of undated facility policy titled Resident Rights revealed it was the policy of the facility to provide residents with resident centered care that meets the psychosocial, physical, and emotional needs of the residents. This deficiency represents non-compliance investigated under Complaint Number OH00164146.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews, review of care plan schedules, and review of facility policy, the facility failed to develop a comprehensive care plan as required for Resident #264, failed to ensure there was documented proof in the medical record that care plan meetings with required participants were being held for Residents #20 and #21, and failed to ensure fall interventions were timely updated in the care plan for Resident #38. This affected four residents (#20, #21, #38, #264) out of 22 residents reviewed for care plans. The facility census was 64. Findings include: 1. Review of the closed medical record for Resident #264 revealed an admission date of 02/26/25 and a discharge date of 03/20/25. Diagnoses included ulcerative colitis, mild protein- calorie malnutrition, anorexia, pneumonia, dysphagia, cognitive communication deficit, atherosclerotic heart disease, bipolar disease, anxiety disorder, personality disorder, Alzheimer's disease, and major depressive disorder. Review of Resident #264's discharge return anticipated Minimum Data Set (MDS) 3.0 assessment, dated 03/20/25, revealed the residents short term memory was okay but had some difficulty in new situations with daily decision making, rejection of care occurred one to three days during the assessment reference period, required setup or clean up assistance for toileting hygiene, supervision or touch assistance for lower body dressing, personal and oral hygiene and transfers, partial or moderate assistance for showering/bathing self and walking ten feet. Review of Resident #264's care plan, initiated on 03/04/25, revealed the resident had impaired cognitive function. Interventions included communicating with resident/family/caregivers regarding needs; discussing concerns regarding confusion, disease process, nursing home placement with resident/family/caregiver; and encouraging resident to be involved in daily decision making and activities as able. Further review of the medical record for Resident #264 revealed there was no evidence of an interdisciplinary meeting including the resident and/or resident representative to develop a comprehensive care plan as required for Resident #264 during his stay from 02/26/25 to 03/20/25. Review of care conference schedules for January 2025 to March 2025 revealed Resident #264 had not been scheduled for a care conference between admission on [DATE] and discharge on [DATE]. Interview on 04/21/25 at 9:11 A.M. with Social Service Designee (SSD) #558 revealed when a resident was admitted to the facility, she would schedule their care conference to be held sometime within three months of admission and would document in the progress notes when a care conference had been held. SSD #558 verified a care conference had not been held for Resident #264 since he had not been at the facility for three months, so his care plan was developed without having the care conference. Interview on 04/22/25 at 12:00 P.M. with the Director of Nursing (DON) revealed after an admission meeting, care conferences would be held quarterly. 2. Review of the medical record for Resident #20 revealed an admission date of 07/18/23. Diagnoses included bipolar disorder, schizoaffective disorder, atherosclerotic heart disease, type two diabetes, anxiety disorder, essential hypertension, and morbid (severe) obesity due to excess calories. Review of Resident #20's quarterly MDS 3.0 assessment, dated 03/14/25, revealed the resident was cognitively intact; felt down, depressed, hopeless two to six days over the last two weeks of the assessment's reference period; rejected care one to three days of the assessment reference period; was dependent for toileting hygiene, shower/bath self, and refused to transfer out of the bed during the assessment reference period. Review of Resident #20's care plan, with an initiation date of 01/10/24, revealed Resident #20 was at risk for psychosocial well-being related to schizoaffective/bipolar disorder and depression. Interventions included allow resident time to answer questions and to verbalize feelings, perceptions, and fears; and assist/encourage/support resident to set realistic self-initiated goals. Interview on 04/14/25 at 9:40 A.M. with Resident #20 revealed he hadn't had a care plan meeting since he had been at the facility. He stated he had never been invited to a care conference meeting, and no one had come to his room to hold a care conference. Further review of Resident #20's medical record revealed there was no documentation indicating a care plan meeting had been held for Resident #20 between 03/25/24 and 04/23/25. Interview on 04/21/25 at 9:11 A.M. with SSD #558 revealed care conferences were held quarterly in the conference room. She stated the facility didn't have a sign-in sheet for the meetings, but she would document in the medical record's progress notes when care conferences had been held and who had attended the meetings. She confirmed there had been no documented proof in Resident #20's medical record that care plan conferences for the resident had been held over the past 12 months. 3. Review of the medical record for Resident #21 revealed an admission date of 12/04/23. Diagnoses included type two diabetes, atherosclerotic heart disease, unstable angina pectoris, chronic obstructive pulmonary disease (COPD), obesity, anxiety disorder, and depression. Review of Resident #21's quarterly MDS 3.0 assessment, dated 03/13/25, revealed the resident was cognitively intact, had no behaviors including rejection of care, required setup or clean up for eating and oral hygiene, was dependent for bed/chair to chair transfer, and sit to lying, lying to sitting, sit to stand, toilet transfer, and walk ten feet was not attempted during the assessment reference period. Review of Resident #21's careplan, initiated 12/06/23, revealed the resident used anti-anxiety medication due to anxiety disorder. Interventions included encourage to voice feelings and discuss coping skills. Further review of Resident #21's medical record revealed the resident had a care plan meeting on 03/06/24 which the resident, dietary, activity and SSD attended the meeting. There was not another documented care plan meeting until 02/03/25 (eleven months later) when a care plan meeting was held in Resident #21's room with the SSD to discuss community living. There was no evidence all required participants were at either care plan meeting. Interview on 04/14/25 at 10:07 A.M. with Resident #21 revealed interdisciplinary care conferences were not being held for her. Interview on 04/21/25 at 9:11 A.M. with SSD #558 revealed care conferences were held quarterly in the conference room. She stated the facility didn't have a sign-in sheet for the meetings, but she would document in the medical record's progress notes when care conferences had been held and who had attended the meetings. She confirmed there had been no documented proof in Resident #21's medical record that care plan conferences for the resident had been held every three months over the past 12 months. 4. Review of the medical record for Resident #38 revealed an admission date of 07/13/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, unspecified lack of coordination, cognitive communication deficit, depression, severe protein calorie malnutrition, and unsteadiness on feet. Review of Resident #38's quarterly MDS 3.0 assessment, dated 03/14/25, revealed Resident #38 was moderately impaired cognitively, had inattention behavior which was continuously present and did not fluctuate, was dependent on staff for transfers, did not walk, was dependent on staff to wheel her manual wheelchair, and had no falls since the prior MDS assessment, which was a quarterly assessment dated [DATE]. Review of Resident #38's fall care plan, initiated on 07/13/24, revealed the resident was at risk for falls related to having a history of falls. Interventions were to assess for falls on admission /readmission, quarterly, and as needed; educate resident or resident representative, if applicable on how to operate bed control/call light/television; ensure residents room is free of potential visible hazards; ensure bed locks are engaged; and perimeter mattress to bed at all times. Further review of Resident #38's medical record revealed on 11/01/24 the resident was found on floor in room next to bed with no injuries. On 01/05/25 the resident was found kneeling on her bedside mat holding on to her mattress with the left arm with no injuries. On 01/10/25 the resident was heard yelling out from room and was observed sitting on floor with back to bed with no injuries. Review of facility document titled Fall Follow Up-V5 dated 11/04/24 revealed for Resident #38's fall on 11/01/24 the resident had been educated on how to use the call light and the bed had been placed on the lowest level to help prevent future falls. Review of facility document titled Fall Follow Up-V5 dated 01/07/25 revealed for Resident #38's fall on 01/05/25 a fall mat had been placed beside the bed to help prevent future falls with injury. Review of facility document titled Fall Follow Up-V5 dated 01/10/25 revealed for Resident #38's fall on 01/10/25 non skid footwear had been added to help prevent future falls. Interview on 04/22/25 at 4:13 P.M. with the Director of Nursing (DON) confirmed Resident #38's fall care plan, initiated 07/13/24, had not been timely updated with the new interventions from Resident #38's falls on 11/01/24, 01/05/25, and on 01/10/25. and should have been. Review of the undated facility policy Plan of Care Overview revealed the resident/representative would have the right to participate in the development and implementation of his/her own plan of care including but not limited to right to request meetings; right to identify individuals or roles to be included in the planning process; right to request revisions to care plan; right to participate in goal establishment and outcomes; and the right to the type, amount, frequency, duration of care or other factors related to the effectiveness of the plan of care; and right to be informed in advance of changes to the plan of care. The nurses were expected to review and revise the care plan of the residents they provide care for as the resident's condition warrants. This deficiency represents non-compliance investigated under Complaint Number OH00162382.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Resident #114 received staff assistance for showering, and failed to ensure timely incontinence care was provided for Resident #21, #23 and #42. This affected four residents (#114, #21, #23 and #42) of five residents reviewed for assistance with activity of daily living (ADL) needs. The facility census was 64. Findings include: 1. Review of the medical record revealed Resident #114 had an admission date of 03/26/25 with diagnoses including multiple sclerosis, epilepsy, and paralytic syndrome. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #114 was dependent for showering and bathing. Review of Resident #114's care plan, date initiated 03/26/25, revealed Resident #114 had an ADL self-care performance deficient related to multiple sclerosis, schizophrenia and partial quadriplegia. Interventions included assistance of two or more helpers with bathing/showering due to total dependence on staff. An interview with Resident #114 on 04/14/25 at 2:16 P.M. revealed she hadn't had a shower in a week since moving to a new room, and as a result she was unable to wash her hair and her back. She further stated she asked her aide for a shower on dayshift and nightshift but was told she wasn't on the shower schedule so she could not get a shower. A follow up interview with Resident #114 on 4/15/25 at 2:17 P.M. revealed she still didn't have a shower and would like to have one. She stated she asked midnight shift and day shift and was told both times she was not on the list to be showered. An interview with Certified Nursing Assistant (CNA) #560 on 04/15/25 at 2:34 P.M. revealed there was a shower schedule for residents and if they were not on the shower schedule then they did not get a shower. CNA #560 stated Resident #114 was not on the shower schedule for Resident #114's hall so she had not given her a shower. CNA #560 showed the surveyor the shower schedule and verified Resident #114's name was not on shower schedule. CNA #560 stated she was unsure whose job it was to put residents on the schedule. CNA #560 stated she was unsure how long it would take to get any resident onto a shower schedule or what the process was for adding residents to the shower schedule. An interview with Resident #114 and CNA #502 on 04/16/25 at 10:36 A.M. revealed Resident #114 wet herself while outside this morning. CNA #502 confirmed and stated she got Resident #114 cleaned up afterward but did not give her a shower after her accident. CNA #502 also stated she was unsure how to get Resident #114 on the shower list. 2. Review of Resident #23's medical records revealed an admission of 11/20/19. Diagnoses included muscle weakness, need for personal care assistance and wheelchair dependent. Review of the MDS assessment dated [DATE] revealed Resident #23 had no cognition score due to Resident #23 was rarely understood. Resident #23 was dependent with toileting, bathing and personal hygiene and was incontinent of bowel and bladder. Review of the care plan dated 02/28/25 revealed Resident #23 was incontinent of bowel and bladder. Interventions included provide incontinence care as needed. Observation of incontinence care on 04/22/25 at 9:18 A.M. for Resident #23 with CNA #543 and CNA #700 revealed Resident #23 was in a wheelchair in his room. CNA #543 stated Resident #23 had been up in his wheelchair since she had arrived to start her shift at 6:00 A.M. and stated she had not provided Resident #23 with incontinence care yet. Observation revealed CNA #543 and CNA #700 had used a hoyer lift (mechanical lift) to get Resident #23 out of his wheelchair. Resident #23's hoyer pad, pants, and shirt were observed to have been saturated with urine. Interviews with CNA #542 and CNA #700 confirmed Resident #23 was saturated with urine and neither were able to state when Resident #23 had last received incontinence care and stated residents should be checked for incontinence at least every two hours. Resident #23 was not interviewable. 3. Review of Resident #42's medical records revealed an admission date of 06/16/23. Diagnoses included muscle weakness, need for personal care assistance and dementia. Review of the care plan dated 03/31/25 revealed Resident #42 was incontinent of bowel and bladder. Interventions included provide incontinence care as needed. Review of the MDS assessment dated [DATE] revealed Resident #42 had impaired cognition. Resident #42 was incontinent of bowel and bladder. Observation of incontinence care on 04/22/25 at 9:26 A.M. for Resident #42 with CNA #543 and CNA #700 revealed Resident #42 was in a wheelchair in his room. CNA #543 stated Resident #42 had been up since she had arrived to start her shift at 6:00 A.M. and stated she had not provided Resident #42 with incontinence care yet. Observation further revealed Resident #42's incontinence brief was saturated with stale smelling dark urine. CNA #543 and CNA #700 confirmed the observation and stated residents should be checked for incontinence at least every two hours and both were unable to state when Resident #42 had last received incontinence care. Resident #42 was not interviewable. [NAME] 4. Record review for Resident #21 revealed an admission date of 12/04/23. Diagnosis included obesity, muscle weakness and the need for assistants with personal care. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #21 was cognitively intact. Resident #21 required substantial/maximal assistants for bed mobility, dependent for transfers to/from wheelchair and dependent for toileting hygiene. Resident #21 was always incontinent of urine and frequently incontinent of bowels. Record review of the care plan dated 12/05/23 revealed Resident #21 had an activity of daily living (ADL) self-care performance deficit due to immobility and morbid obesity. Interventions included for toileting hygiene, Resident #21 was totally dependent of two or more helpers who do all the effort. Observation on 04/23/25 at 11:06 A.M. with CNA #524 and #574 complete incontinent care for Resident #21 revealed Resident #21 was lying in bed. Resident #21 had a strong foul odor of urine. Observation revealed Resident #21's sheet and bath blanket Resident #21 was lying on was saturated with urine half way up her back and to her mid lower thighs. The brief was totally saturated and the blanket covering her was wet with urine. CNA #524 and #574 confirmed Resident #21 had a strong odor of urine and Resident #21's bedding and brief was saturated. Resident #21 revealed the last time she was checked or changed was 5:00 A.M. CNA #524 confirmed she was Resident #21's primary caregiver and confirmed this was the first time she checked or changed Resident #21 on her shift. CNA #524 confirmed she started her shift at 6:00 A.M. An interview on 04/23/25 at 11:27 A.M. with the Director of Nursing (DON) revealed each resident who was incontinent of the bowel or bladder would be checked every two hours to verify if they were incontinent, then changed if needed. If the resident was sleeping, they would still need to be checked. An interview on 04/23/25 at 11:43 A.M. with Resident #21 revealed she stated, they don't come in and change me like they should. Resident #21 revealed she never refused to be changed, when CNA #524 brought her breakfast tray in around 8:00 A.M. she asked to be changed. CNA #524 said she had to wait to get help, so she would do it after breakfast. Resident #21 revealed she ate her breakfast then fell back to sleep while waiting to be changed. Resident #21 stated, it makes me feel disgusting, it happens every day. An interview on 04/23/25 at 11:46 A.M. with CNA #524 revealed she stated, I did take her (Resident #21) breakfast tray in at 8:00 A.M., and she (Resident #21) did ask to be changed. I told her I would have to wait to get someone, we can't do her with one, it takes a while to find someone, the other aids were busy. Review of the facility policy titled, Routine Resident Care, undated, revealed it is the policy of the facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social, and spiritual needs and honor resident lifestyle preferences while in the care of the facility. This deficiency represents non-compliance investigated under Complaint Number OH00164146 and OH00162382.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure therapeutic activities as scheduled were being provided to residents on the secured unit. This had the potential to affect all 13 residents (#3, #8, #10. #18, #29, #30,#48, #55, #50, #56, #58, #59, #61) who resided on the secured unit. In addition, the facility failed to ensure Resident #20 was provided one-to-one activities of interest, and Resident #50 was provided routine therapeutic activities for socialization. This affected two residents (#20 and #50) of three residents reviewed for activities. The facility census was 64. Findings include: 1. Review of the April 2025 activity calendar posted on the wall in the hallway of the secure unit revealed activities scheduled on the unit for 04/16/25 included chair yoga at 9:00 A.M., chronicles /brain games at 9:30 A.M., games with friends at 10:00 A.M., guess your weight at 10:30 A.M., cards with friends at 1:30 P.M., sit and chat at 2:30 P.M., socialize and snack at 3:00 P.M., and TED talk at 5:30 P.M. Observation on 04/16/25 at 10:45 A.M. revealed there was no activity being held on the secured unit. An interview on 04/16/25 at 10:51 A.M. with Certified Nursing Assistant (CNA) #563, who was working on the unit that day, verified there had not been any activities on the secure unit that morning and she was not sure why. An interview on 04/16/25 at 11:06 A.M. with CNA #550 revealed CNA #550 worked on the secured unit and other units in the facility, and CNA #550 stated most of the time scheduled activities were not being held on the secured unit. Observation of the secure unit on 04/16/25 at 5:33 P.M. revealed there were two residents sitting in the secure unit lounge and two residents walking up and down the hallway. There was no TED talk being held. At the time of the observation, CNA #563 confirmed the activity at 5:30 P.M. was not being held, and stated that since there had been an outing that day, the only activity which had been held on the unit that day was snacks being passed out 30 minutes after lunch. Interview on 04/21/25 with Activity Director (AD) #555 revealed when there were outings scheduled, the whole activity team would go on the outings, and when they go out on outings, the activities staff would put out self-initiated activities for the residents for the day. AD #555 stated the activity staff were only at the facility until 5:00 P.M., and activities held after 5:00 P.M. were the responsibility of the receptionist and the aides, but the receptionist position was currently vacant and the facility had new aides who may not have known they were supposed to do the activities scheduled after 5:00 P.M. AD #555 confirmed most of the evening activities were not currently being held and activities on the secured unit on 04/16/25 were not implemented due to an outing that day. Review of the undated facility policy titled Secured (Locked) Unit revealed residents residing on the unit would be provided activities designed for cognitively impaired to decrease boredom and provide an outlet for expression. 2. Review of the medical record for Resident #20 revealed an admission date of 07/18/23. Diagnoses included bipolar disorder, schizoaffective disorder bipolar type, type two diabetes, and anxiety disorder. Review of the modification of annual Minimum Data Set (MDS) 3.0 assessment, dated 10/05/24, revealed Resident #20 felt it was somewhat important to have books, newspapers and magazines, listen to music he liked, keep up with the news, do favorite activities, and to go outside to get fresh air when the weather was good, and he felt it was not very important do things with groups of people or participate in religious activities. Review of the quarterly MDS 3.0 assessment, dated 03/14/25, revealed Resident #20 was cognitively intact, felt down, depressed, or hopeless two to six days over the last two weeks. The resident refused to transfer from bed/chair during the assessment reference period. Review of the care plan initiated on 08/29/23 revealed Resident #20 was independently capable of pursuing activities of interest without intervention from staff. Resident #20 would make informed decisions regarding group activities, events, one-on-one activities, and independent pursuits. Interventions included assist with transport to activities as needed, encourage attendance to entertainment programs, invite resident to scheduled activities, provide one-on-one room visits if unable to attend out of room events, provide a schedule of activities as available; and provide activity materials of interest. Further review of the medical record for Resident #20 revealed that under the Tasks: Activity Participation, dated 03/23/25 to 04/16/25, it was documented Resident #20 received 1:1/Conversation/Social Time/Family Visit only one day which was 04/01/25. For the remainder of the days within that date range, Resident #20 participated in beverage/snack cart/socials four days on 03/23/25, 03/26/25, 04/11/25, and 04/16/25, and eleven days of relaxation/self-directed activities on 03/24/25, 03/25/25, 03/26/25, 03/27/25, 03/28/25, 03/30/25, 03/31/25, 04/02/25, 04/03/25, 04/04/25 and 04/05/25 . An interview on 04/14/25 at 9:36 A.M. with Resident #20 revealed the activity staff did not provide him one-to-one activities that met his interests. Resident #20 stated the activity staff would bring a daily chronicle but did not provide an actual one-to-one activity. Resident #20 stated he would like to have one-to-one interaction with the activity staff so he had someone to have daily conversations with because all he had to do in his room was either watch television or visit with his mom. An interview on 04/21/25 at 10:19 A.M. with AD #555 revealed Resident #20's activity program consisted of one-to-one activities because he preferred to stay in his room and not attend group activities. When asked if AD #555 had a record of one-to-one activities provided to Resident #20, AD #555 stated one-to-one activities were not being documented so there was no record to show that Resident #20 was being provided any activities that met his interests. Review of facility policy titled Activities Program, revealed it was the policy to provide resident center care that met the psychological, physical, and emotional needs and concerns of the residents. The activity program would be scheduled daily and would consist of individual and small and large group activities which are designed to meet the needs and interests of each resident which included individualized activities. 3. Review of the medical record for Resident #50 revealed an admission date of 07/12/24. Diagnoses included chronic kidney disease, chronic obstructive pulmonary disease, type two diabetes mellitus, dementia, schizoaffective disorder, anxiety disorder, depression, adult failure to thrive, bipolar disorder, and suicidal ideations. Review of the modification of Resident #50's admissions MDS 3.0 assessment, dated 07/19/24, revealed it was somewhat important to have books, newspapers, and magazines to read, to listen to music, keep up with the news, to get fresh air when the weather was good, and to participate in religious services. The resident indicated it was not important at all to be around animals such as pets. Review of the care plan, initiated 07/15/24, revealed Resident #50 was self-directed for activities in and out of room daily and was dependent on staff for activities, cognitive stimulation, and socialization. Interventions included assist with transport to activities as needed; assure the activities are compatible with resident's physical and cognitive capabilities, encourage attendance to entertainment programs, large and small group activities, volunteer demonstrations and religious activities, and provide a schedule of activities available. An interview on 04/14/25 at 10:46 A.M. with Resident #50 revealed she was alert and able to carry on reciprocle conversation. Resident #50 stated she felt like she was locked on the unit, and there was nothing for her to do. Observation on 04/16/25 at 10:45 A.M. revealed there was no activity being held on the unit and Resident #50 was lying in her bed. Interview at the time of the observation with Resident #50 revealed she hadn't attended any activities that morning since no one had come down to invite her to the activity. Interview on 04/16/25 at 10:51 A.M. with Certified Nursing Assistant (CNA) #563, who was working on the unit that day, revealed there had not been any activities on the secure unit that morning and she was not sure why. Observation of the secure unit on 04/16/25 at 5:33 P.M. revealed there were two residents sitting in the secure unit lounge and two residents walking up and down the hallway. There was no TED talk being held. At the time of the observation, CNA#563 confirmed the activity at 5:30 P.M. was not being held, and stated that since there had been an outing that day, the only activity which had been held on the unit that day was snacks being passed out 30 minutes after lunch. Interview on 04/16/25 at 11:06 A.M. with CNA #550, who would work on secure unit at times, revealed most of the time scheduled activities were not being held on the secured unit. Interview on 04/21/25 with Activity Director (AD) #555 confirmed activities on the secured unit were not being provided as scheduled on the activity calendar for the secured unit, and activities held after 5:00 P.M. were the responsibility of the receptionist and the aides, but the receptionist position was currently vacant and the facility had new aides who may not have known they were supposed to do the activities scheduled after 5:00 P.M. AD #555 confirmed most of the evening activities were not currently being held and activities on the secured unit on 04/16/25 were not implemented due to an outing that day. Review of the undated facility policy titled Secured (Locked) Unit revealed residents residing on the unit would be provided activities designed for cognitively impaired to decrease boredom and provide an outlet for expression.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, the facility failed to ensure smoking materials were in a secured area when not in use for Resident #26 and Resident #41, failed to ensure fall interventions were implemented after a fall for Resident #38, and failed to ensure water was at a safe temperature for Resident #36 and #267. This affected five residents (#26, #41, #38, #36, and #267) of seven residents reviewed for accidents/hazards. The facility census was 64. Findings include: 1. Review of Resident #26's medical records revealed an admission date of 12/02/24. Diagnoses included tobacco use. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 had intact cognition and was independent with ambulation. Review of the care plan dated 03/20/25 revealed Resident #26 used nicotine products. Interventions included educate resident on designated smoking area and provide safe smoking devices if required. Review of the smoking assessment dated [DATE] revealed Resident #26 was an independent smoker. Observation on 04/14/25 at 1:40 P.M. revealed Resident #26 was ambulating in the hallway and he had pulled a cigarette and a lighter out of his pocket and had proceeded to walk outside towards the smoking area. An interview with Licensed Practical Nurse (LPN) #566 at 1:43 P.M. on 04/14/25 revealed residents smoking materials were to be secured and stated even if residents are considered independent smokers they were still not permitted to keep smoking materials in their possession. During this interview LPN #566 had entered Resident #26's room and had asked if he had smoking materials on him and Resident #26 stated he did. LPN #566 proceeded to remove the smoking materials from Resident #26 and educated Resident #26 about turning his smoking materials into the nurse for safety. 2. Review of Resident #41's medical records revealed an admission date of 08/08/24. Diagnoses included muscle weakness, lack of coordination and need for personal care assistance. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #41 required set up assistance with ambulation. Review of the care plan dated 02/20/25 revealed Resident #41 used nicotine products. Interventions included provide safe smoking devices if required. Review of the smoking assessment dated [DATE] revealed Resident #41 was an independent smoker. An interview on 04/14/25 at 1:43 P.M. with LPN #566 revealed Resident #41 was also considered an independent smoker and he likely had his smoking materials on him. On 04/14/25 at 3:03 P.M. an interview with the Director of Nursing (DON) revealed Resident #41 was checked to see if he had any smoking materials on him and the DON had to confinscate smoking materials from Resident #41 and educate Resident #41 on not keeping his smoking materials in his possession. Review of facility policy titled Resident Smoking Guidelines undated revealed staff will store smoking materials in a secured area when not in use, and will be maintained by the facility staff and provided to the resident on request. 3. An observation was conducted during tour of the physical environment on 04/15/25 from 2:02 P.M. to 4:18 P.M. with Director of Plant Maintenance (DPM) #516 on the 400 hallway. DPM #516 was observed taking water temperatures from the bathroom faucet in the room of Resident #36 and #267 using a calibrated facility thermometer. After letting the water run for approximately two minutes, DPM #516 read the water temperature at 130 degrees Fahrenheit (F). The water felt hot to touch and DPM #516 verified the water was too hot and immediately shut off the water on the 400 hallway and went to call the [NAME]. Review of the facility document titled Log Book Documentation Inspect Air and Water Temperatures, dated 01/01/25 to 04/14/25 revealed the facility wasn't consistently checking the facility water temperatures on a weekly basis. Review of the recorded temperatures revealed the water temperatures had been checked on 01/01/25, 01/06/25, 01/13/25, 01/27/25, 02/17/25, and 03/10/25. The water temperatures ranged between 90 degrees F to 118 degrees F. There were no recorded temperatures on the log for the weeks of 01/20/25, 02/03/25, 02/10/25, 02/24/25, 03/03/25, 03/17/25, 03/24/25, or 04/07/25. An interview on 04/15/25 at 4:24 P.M. with DPM #516 revealed he stated the water temperatures should be between 105 and 120 degrees F. An interview on 04/15/25 at 4:40 P.M. with Resident #36 revealed she stated the water is very hot and I have to add cold water so I don't burn my hand. An interview on 04/16/25 at 12:07 P.M. with Certified Nursing Assistant (CNA) #550 revealed she had given a shower to Resident #25 on Monday (4/14/25) , who resided on the 400 hall, and CNA #550 said she had to make sure to add enough cold water because the hot water was too hot and the resident could have been burnt if she had not added enough cold water. An observation on 04/16/25 from 4:14 P.M. to 4:20 P.M. on the 400 hallway with DPM #516 revealed he was using the calibrated facility thermometer to take water temperatures from the bathroom faucet for Resident #36 and Resident #267 and the water temperature was 105 degrees F. An interview with DPM #516 during the observation revealed he had to make an adjustment on the hot water tank in order for the water temperature to be back in compliance. An interview on 04/23/25 at 7:27 A.M. with the DON verified there had been no residents who had been burned by hot water in the facility. An interview on 04/24/25 at 9:22 A.M. with DPM #516 confirmed the missing weeks of recorded water temperatures. He stated he was taking water temperatures weekly except he had missed the week of 04/07/25. He stated he thought the digital program he was using to record the water temperatures was backing up his data, and he had no idea why the program hadn't backed up the water temperatures he was recording. He confirmed there was no proof water temperatures were being taken weekly with the missing weeks of recorded water temperatures. Review of the undated facility policy Resident Rights revealed safety of residents, visitors, and employees was a top priority of care. 4. Review of the medical record for Resident #38 revealed an admission date of 07/13/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction (a stroke), unspecified lack of coordination, cognitive communication deficit, depression, severe protein calorie malnutrition, and unsteadiness on feet. Review of Resident #38's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/14/25, revealed the resident was moderately impaired cognitively, exhibited inattention behavior which was continuously present and did not fluctuate; was dependent on staff for transfers and had not attempted to walk ten feet during the assessment reference period. Review of Resident #38's fall care plan, initiated on 07/13/24, revealed the resident was at risk for falls related to having a history of falls. Interventions were to assess for falls on admission /readmission, quarterly, and as needed; educate resident or resident representative, if applicable on how to operate bed control/call light/television; ensure residents room is free of potential visible hazards; ensure bed locks are engaged; and perimeter mattress to bed at all times. Further review of Resident #38's medical record revealed on 01/05/25 the resident was found kneeling on her bedside mat holding on to her mattress with the left arm with no injuries. Review of facility document Post Fall Evaluation - V4, dated 01/05/25, revealed Resident #38 had an unwitnessed fall with no injuries on 01/05/25 at 3:40 P.M. The resident was not experiencing any pain and had no skin concerns. When asked what happened the resident stated she didn't know . When asked if she rolled out of bed the resident replied yes. The suspected root cause was noted to be no safety awareness. The facility's immediate intervention to prevent falls was to check on the resident every one hour for the night and the Director of Nursing (DON) would discuss an appropriate intervention the next morning. Further review of Resident #38's medical record revealed there was no documented proof one hour checks had been completed during the night of 01/05/25. Interview on 04/22/25 at 4:13 PM with the DON verified the one hour checks for Resident #38 should have been put in place, but there was no proof it had been done.

Based on medical record reviews, interviews, review of signed arbitration agreements, and review of facility policy, the facility failed to ensure the arbitration agreements were explained in a way the residents understood prior to the residents signing the agreement. This affected five residents (#20, #21, #26, #51 and #214) out of five residents reviewed for arbitration agreements and had the potential to affect all 26 residents (#1, #11, #15, #16, #17, #20, #21, #26,#32, #34, #38, #39, #41, #42, #43, #44, #48, #50, #51, #52, #53, #54,#55,#57,#58, #214) the facility identified as having signed an arbitration agreement. The facility census was 64. Findings include: 1. Review of the medical record for Resident #214 revealed an admission date of 03/25/25. Diagnoses included type two diabetes, obstructive sleep apnea, respiratory failure, morbid obesity, generalized anxiety disorder, chronic obstructive pulmonary disease (COPD), and major depressive disorder. Resident #214 was her own resident representative. Review of Resident #214's admission Minimum Data Set (MDS) 3.0 assessment, dated 04/01/25, revealed the resident had adequate hearing, was able to make herself understood, was able to express ideas and wants, had clear comprehension, adequate vision, and was cognitively intact. Review of the facilities arbitration agreement titled Agreement to Arbitrate Disputes located in the Resident #214's admission packet revealed arbitration was a private process where disputing parties would agree that one or several individuals could decide a dispute, between the resident and the facility, after receiving evidence and hearing arguments, rather than a judge or jury deciding in a court of law. Instead of a judge or jury, arbitration involved one or more arbitrators who were usually attorneys or other professionals. The arbitration agreement was a legally binding agreement, could be enforced by a court of law, and could only be appealed on very narrow grounds. The resident had the right to rescind the arbitration agreement within 30 days of signing the agreement. The arbitration agreement had been signed by Resident #214, with an electronic signature, on 04/22/25. Interview on 04/22/25 at 3:50 P.M. with Resident #214 revealed after the resident had reviewed her signed arbitration agreement, dated 04/22/25 (the same day of the interview), the resident stated she didn't know what an arbitration agreement was. She went on to state that if something were to happen to her, she would like to pursue a lawyer in the court of law, and if she understood what she was signing, she would not have agreed to the arbitration agreement. 2. Review of the medical record for Resident #26 revealed an admission date of 12/02/24. Diagnoses included chronic obstructive pulmonary disease, essential hypertension (high blood pressure), gastroesophageal reflux disease (GERD), bipolar disorder, and anxiety disorder. Resident #26 was his own responsible party. Review of Resident #26's quarterly MDS 3.0 assessment revealed the resident had adequate hearing, was able to express ideas and wants, had clear comprehension, adequate vision, and was cognitively intact. Review of the facilities arbitration agreement titled Agreement to Arbitrate Disputes located in the Resident #26's admission packet revealed arbitration was a private process where disputing parties would agree that one or several individuals could decide a dispute, between the resident and the facility, after receiving evidence and hearing arguments, rather than a judge or jury deciding in a court of law. Instead of a judge or jury, arbitration involved one or more arbitrators who were usually attorneys or other professionals. The arbitration agreement was a legally binding agreement, could be enforced by a court of law, and could only be appealed on very narrow grounds. The resident had the right to rescind the arbitration agreement within 30 days of signing the agreement. The arbitration agreement had been signed by Resident #26 on 01/22/25. Interview on 04/16/25 at 9:04 A.M. with Resident #26 revealed when asked what his understanding of the arbitration process was when a dispute arose between the facility and the resident, the resident replied I don't know what that is. When asked if there was anything he would have liked to have known prior to signing the arbitration agreement, the resident replied I wish I knew what it was. When asked if the arbitration agreement had been explained in a way the resident understood, the resident replied, I don't even know what it is. 3. Review of the medical record for Resident #51 revealed an admission date of 05/06/24. Diagnoses included acute kidney failure, chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease (COPD), major depressive disorder, and anxiety disorder. Resident #51 was his own resident representative. Review of Resident #51's quarterly MDS 3.0 assessment, dated 04/06/25, revealed the resident had adequate hearing, the ability to express wants and needs, clear comprehension, adequate vision, and was moderately impaired cognitively. Review of the facilities arbitration agreement titled Agreement to Arbitrate Disputes located in the Resident #51's admission packet revealed arbitration was a private process where disputing parties would agree that one or several individuals could decide a dispute, between the resident and the facility, after receiving evidence and hearing arguments, rather than a judge or jury deciding in a court of law. Instead of a judge or jury, arbitration involved one or more arbitrators who were usually attorneys or other professionals. The arbitration agreement was a legally binding agreement, could be enforced by a court of law, and could only be appealed on very narrow grounds. The resident had the right to rescind the arbitration agreement within 30 days of signing the agreement. The arbitration agreement had been signed by Resident #51 on 01/21/25. Interview on 04/16/25 at 9:18 A.M. with Resident #51 revealed when asked what his understanding of the arbitration process was when a dispute arose, he stated I don't know what it is. I never heard of it. When asked if the arbitration agreement was explained in a way that he understood, Resident #51 replied I don't know what it is. 4. Review of the medical record for Resident #20 revealed an admission date of 07/18/23. Diagnoses included morbid obesity, dependence on supplemental oxygen, bipolar disorder, schizoaffective disorder, atherosclerotic heart disease, and anxiety disorder. Resident #20 was his own responsible party. Review of Resident #20's quarterly MDS assessment, dated 03/14/25, revealed the resident had adequate hearing, the ability to express ideas and wants, clear comprehension, adequate vision, and was cognitively intact. Review of the facilities arbitration agreement titled Agreement to Arbitrate Disputes located in the Resident #20's admission packet revealed arbitration was a private process where disputing parties would agree that one or several individuals could decide a dispute, between the resident and the facility, after receiving evidence and hearing arguments, rather than a judge or jury deciding in a court of law. Instead of a judge or jury, arbitration involved one or more arbitrators who were usually attorneys or other professionals. The arbitration agreement was a legally binding agreement, could be enforced by a court of law, and could only be appealed on very narrow grounds. The resident had the right to rescind the arbitration agreement within 30 days of signing the agreement. The arbitration agreement had been signed by Resident #20, with an electronic signature, on 07/19/23. Interview on 04/16/25 at 9:09 A.M. with Resident #20 revealed when asked what his understanding of the arbitration was when a dispute arose between the facility and the resident, the resident stated, I don't know. He stated he did not understand that he had given up his right to litigation in a court proceeding. When asked if he felt he was obligated, required, forced, or pressures to sign the binding agreement, the resident replied they just said 'sign, sign, sign'. I wouldn't have signed something like that. 5. Review of medical record for Resident #21 revealed an admission date of 12/04/23. Diagnoses included chronic obstructive pulmonary disease (COPD), obesity, and a history of pulmonary embolism (a blood clot in the lungs with shortness of breath being a common symptom). Resident #21 was her own responsible party. Review of Resident #21's quarterly MDS 3.0 assessment, dated 03/13/25, revealed the resident had adequate hearing, was able to express ideas and wants, had clear comprehension and adequate vision, and was cognitively intact. Review of the facilities arbitration agreement titled Agreement to Arbitrate Disputes located in the Resident #21's admission packet revealed arbitration was a private process where disputing parties would agree that one or several individuals could decide a dispute, between the resident and the facility, after receiving evidence and hearing arguments, rather than a judge or jury deciding in a court of law. Instead of a judge or jury, arbitration involved one or more arbitrators who were usually attorneys or other professionals. The arbitration agreement was a legally binding agreement, could be enforced by a court of law, and could only be appealed on very narrow grounds. The resident had the right to rescind the arbitration agreement within 30 days of signing the agreement. The arbitration agreement had been signed by Resident #21, with an electronic signature, on 12/04/23. Interview on 04/16/25 at 11:38 A.M. with Resident #21 revealed when asked what her understanding of the arbitration process was when a dispute arose between the facility and the resident, the resident replied, I don't know what that is. When asked if she understood that she was giving up the right to litigation in a court proceeding, she replied she didn't understand. When asked if there was anything she would have liked the facility to explain better in regard to the arbitration agreement, she stated she would have liked for them to have explained the arbitration agreement better. Interview on 04/22/25 at 11:49 A.M. with Mobile admission Director (MAD) #604 revealed the Administrator and herself were completing admission agreements with the residents, however, she was currently completing most of the admission agreements. She stated the facility was in the process of hiring an admissions director for the facility. She stated the arbitration agreement conversation would take place when the admission agreement was being signed. When explaining the arbitration agreement with the residents, she stated she would ask the residents if they understood the concept of arbitration and would explain how an arbitration agreement worked in the long term setting. She stated she would go back within the conversation and ask the residents if they understood the arbitration process but didn't document if they understood the arbitration agreement. She stated she did not go back to ask the residents who have signed an arbitration agreement if they still understood the arbitration agreement within the 30 days of signing the arbitration agreement, which would give the resident time to rescind the agreement. MAD #604 revealed it didn't surprise her that the residents were stating they didn't understand the arbitration agreement since most folks don't pay attention to what they are signing in general. Review of facility policy titled Resident admission Policy, revised 10/05/20, revealed the Admissions Director or Manager on Duty or designee would meet with resident/resident representative to complete and all admission paperwork, within 48 hours of the resident's admission and all questions regarding residency, services and rates for services would be answered prior to or before completion of signing the admission agreement, which included the arbitration agreement.

Based on observation, interview, and review of facility policy, the facility failed to ensure all residents at all times on the secured unit were able to communicate their needs using a call system that would relay an audible sound directly to a staff member or to a centralized staff work area on the secured unit. This had the potential to affect all 13 residents (#3, #8, #10, #18, #29,#30, #49, #50, #55, #56, #57, #58, and #61) living on the secured unit. The facility census was 64. Findings include: Observations during an environmental tour on 04/15/25 between 2:02 P.M. and 4:24 P.M. with Director of Plant Maintenance (DPM) #516 revealed when a call light was pressed in Residents #8 and #58's room on the secure unit, the light outside the room lit up but there was no audible sound coming from the call system unit at the nurse's station. Licensed Practical Nurse (LPN) #503 ,who was sitting at the nurse's station where the call system unit was sitting on the counter, confirmed the light outside the room had come on but she heard no audible sound coming from the call system unit. LPN #503 stated the reason why there was no sound coming from the call system was because the volume on the unit had been turned down. Once LPN #503 turned up the volume on the call system unit, there was an audible sound coming out of the system when a call light was activated. LPN #503 verified if the volume was turned down, any of the resident call lights on the unit would not audibly notify staff the call light was activated. Interview on 04/15/25 at 2:57 P.M. with DPM #516 revealed he had noticed on other occassions the call system units had the sound turned off or way down so it could not be heard on the unit by staff. Review of undated facility policy titled Resident Rights revealed residents had the right to have a method to communicate needs to staff. This deficiency represents non-compliance investigated under Complaint Number OH00164146

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the Payroll Based Journal (PBJ) and facility assessment, the facility failed to provide sufficient nursing staff to meet the total care needs of all residents for their highest practicable physical, mental and psychosocial well -being. This affected four residents (#21, #23, #38 and #42) of five residents reviewed for assistance with activity of daily living (ADL) needs and had the potential to affect all residents in the facility. The facility census was 64. Findings included: 1. Review of the Payroll Based Journal (PBJ) Staffing Report for Fiscal Year Quarter four (07/01/24 to 09/30/24) for the facility revealed a concern triggered for a one-star staffing rating indicating inadequate staffing hours. Review of the Facility Assessment (FA), dated 04/03/25, as provided by the Administrator revealed persons involved in completing the assessment were not identified by first or last name on the FA and there was no documentation to indicate if and when the FA had been reviewed by the Quality Assurance and Performance Improvement (QAPI) committee. The average census was identified as 61 residents. On page 10 was listed Physical Disabilities and the number of residents requiring staff assistance for ADLs based on current census which indicated out of a total of 61 residents 59 needed staff assistance for toileting hygiene, and 53 needed a minimum of set-up/clean-up assistance or a higher degree of assistance with eating. In Part 3, section 3.1 of the FA, the staffing plan did not address the number of direct care staff across all shifts needed to address resident acuity/care needs, as the section addressing staffing of aides and nurses on each unit was blank and instead gave a report of the fourth quarter staffing reported in the payroll based journal. The section on Staff Survey and Individual Staff Assignments was left blank. An interview on 04/14/25 at 8:21 A.M. with Licensed Practical Nurse (LPN) #538 revealed staffing was a concern because sometimes there were only two nurses in the facility and when there were only two nurses LPN #538 was unable to complete resident treatments. An interview on 04/14/25 at 8:43 A.M. with Certified Nursing Assistant (CNA) #601 revealed at times there will only be one CNA on the behavior unit and that was not enough to monitor and care for the residents. An interview on 04/14/25 at 11:10 A.M. with CNA #550 revealed there was usually one aide on the 400 hall so CNA #550 could not perform timely resident care. An interview on 04/16/25 at 7:23 A.M. with CNA #550 revealed because there are not enough staff there are days the residents who need every two hour checks for incontinence care will have to wait for three and a half hours before CNA #550 can find the time to go and change them. An interview on 04/16/25 at 7:53 A.M. with LPN #503 revealed when there are two nurses for the whole facility LPN #503 is unable to get medications passed on time to the residents. LPN #503 stated sometimes there is a third nurse to help pass medications until 10:00 A.M. but then that nurse leaves. An observation on 04/17/25 from 5:15 A.M. to 6:00 A.M. of the nursing staff in the facility compared to the posted schedule revealed there were two nurses and four CNA present in the facility. The posted schedule indicated there were three nurses consisting of one LPN from 6:00 P.M. to 10:30 P.M., one LPN from 6:00 P.M. to 6:30 A.M., one Registered Nurse (RN) from 6:00 P.M. to 6:30 A.M. and five CNA from 6:00 P.M. to 6:00 A.M. An interview on 04/17/25 at 5:18 A.M. with Registered Nurse (RN) #510 revealed there were two CNAs and one nurse for the 100/200 halls because the third CNA had left early. When asked if there was sufficient staff to meet all the resident care needs RN #510 replied we try our best. An interview on 04/17/25 at 5:21 A.M. with CNA #560 revealed there was not enough help on the 100/200 halls and more CNAs were needed because most of the residents needed a mechanical lift transfer which required at least two staff. CNA #560 stated with only two CNA on the 100/200 hall the staff can't get the residents up, can't get check and changes/incontinence care done and can't get showers completed. An interview on 04/17/25 at 6:00 A.M. with CNA #570 revealed she worked all shifts in the facility and when night shift is working short the residents have to wait for day shift to start before the care can be provided. CNA #570 stated when residents can get up and get showered was based on staff availability so showers do not get done as scheduled. An interview on 04/17/25 at 8:34 A.M. with LPN #541 revealed sometimes they are the only staff member on the 100/200 halls because the CNA are feeding residents. An interview on 04/17/25 at 8:40 A.M. with the Director of Nursing (DON) revealed staffing levels in the facility meet the minimum required 2.5 hours of direct care. The DON verified the night shift had four CNA and two nurses in the facility which did not match the daily posted schedule. An interview on 04/22/25 at 9:18 A.M. with CNA #543 revealed there were only two CNA on the 100/200 hall so there were several residents who had not been provided incontinence care yet. CNA #543 stated there needed to be three to four CNA on the 100/200 hall because there were over 30 residents who needed assistance. An interview on 04/23/25 at 12:29 P.M. with the Administrator verified the Facility Assessment was incomplete and did not have a staffing plan to address resident acuity needs. 2. Review of Resident #23's medical records revealed an admission of 11/20/19. Diagnoses included muscle weakness, need for personal care assistance and wheelchair dependent. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had no cognition score due to Resident #23 was rarely understood. Resident #23 was dependent with toileting, bathing and personal hygiene and was incontinent of bowel and bladder. Review of the care plan dated 02/28/25 revealed Resident #23 was incontinent of bowel and bladder. Interventions included provide incontinence care as needed. Observation of incontinence care on 04/22/25 at 9:18 A.M. for Resident #23 with Certified Nursing Assistant (CNA) #543 and CNA #600 revealed Resident #23 was in a wheelchair in his room. CNA #543 stated Resident #23 had been up in his wheelchair since she had arrived to start her shift at 6:00 A.M. and stated she had not provided Resident #23 with incontinence care yet. Observation revealed CNA #543 and CNA #600 had used a hoyer lift (mechanical lift) to get Resident #23 out of his wheelchair. Resident #23's hoyer pad, pants, and shirt were observed to have been saturated with urine. Interviews with CNA #543 and CNA #600 confirmed Resident #23 was saturated with urine and neither were able to state when Resident #23 had last received incontinence care and stated residents should be checked for incontinence at least every two hours. CNA #543 stated there were not enough staff to complete her assigned duties timely. Resident #23 was not interviewable. 3. Review of Resident #42's medical records revealed an admission date of 06/16/23. Diagnoses included muscle weakness, need for personal care assistance and dementia. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #42 had impaired cognition. Resident #42 was incontinent of bowel and bladder. Review of the care plan dated 03/31/25 revealed Resident #42 was incontinent of bowel and bladder. Interventions included provide incontinence care as needed. Observation of incontinence care on 04/22/25 at 9:28 A.M. for Resident #42 with CNA #543 and CNA #600 revealed Resident #42 was in a wheelchair in his room. CNA # 543 stated Resident #42 had been up since she had arrived to start her shift at 6:00 A.M. and stated she had not provided Resident #42 with incontinence care yet. Observation further revealed Resident #42's incontinence brief was saturated with stale smelling dark urine. CNA #543 and CNA #600 confirmed the observation and stated residents should be checked for incontinence at least every two hours and both were unable to state when Resident #42 had last received incontinence care. CNA #543 stated were not enough staff to complete her assigned duties timely. Resident #42 was not interviewable. 4. Review of the medical record for Resident #38 revealed an admission date of 07/13/24. Diagnoses included hemiplegia and hemiplegia following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction, cognitive communication deficit, depression, and severe protein calorie malnutrition. Review of Resident #38's quarterly MDS 3.0 assessment, dated 03/14/25, revealed the resident was moderately impaired cognitively, exhibited continuous inattention behavior; required partial/moderate assistance for eating; had a significant weight loss which was not prescribed; and was on a therapeutic diet. Review of a weight change progress note dated 03/19/25 at 2:54 P.M. revealed Resident #38 current weight of 215.3 pounds triggered a significant weight loss of 14 percent weight loss over 180 days with poor intake of meals. Review of Resident #38's care plan, initiated on 07/24/24, revealed the resident had a potential for altered nutrition status/ nutrition related problems due to having a significant weight loss and being obese. Interventions included provide food in individual bowls to enhance independence in feeding ability; resident to be in the dining room for all meals; assistance with meals as needed; and provide diet and supplements per medical provider's orders. Observations on 04/15/25 from 8:07 A.M. until 9:01 A.M. revealed Resident #38 was sitting in the dining room at a table by herself with food in bowls placed in front of her. There were two certified nursing assistants feeding other residents in the dining room. Resident #38 was observed making no attempt to feed herself. The resident was either watching other residents feed themselves or was dozing off. At 8:52 A.M. Certified Nursing Assistant (CNA) #505 came over to assist Resident #38 with her meal. An interview on 04/15/25 at 8:55 A.M. with CNAs #505 revealed there were two staff members in the dining room to feed four residents and assist a couple of residents. CNA #505 confirmed residents were not being fed or assisted in a timely manner, which included Resident #38, due to not enough staff to provide assistance. 5. Record review for Resident #21 revealed an admission date of 12/04/23. Diagnosis included obesity, muscle weakness and the need for assistants with personal care. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #21 was cognitively intact. Resident #21 required substantial/maximal assistants for bed mobility, dependent for transfers to/from wheelchair and dependent for toileting hygiene. Resident #21 was always incontinent of urine and frequently incontinent of bowels. Record review of the care plan dated 12/05/23 revealed Resident #21 had an activity of daily living (ADL) self-care performance deficit due to immobility and morbid obesity. Interventions included for toileting hygiene, Resident #21 was totally dependent of two or more helpers who do all the effort. Observation on 04/23/25 at 11:06 A.M. with CNA #524 and #574 complete incontinent care for Resident #21 revealed Resident #21 was lying in bed. Resident #21 had a strong foul odor of urine. Observation revealed Resident #21's sheet and bath blanket Resident #21 was lying on was saturated with urine half way up her back and to her mid lower thighs. The brief was totally saturated and the blanket covering her was wet with urine. CNA #524 and #574 confirmed Resident #21 had a strong odor of urine and Resident #21's bedding and brief was saturated. Resident #21 revealed the last time she was checked or changed was 5:00 A.M. CNA #524 confirmed she was Resident #21's primary caregiver and confirmed this was the first time she checked or changed Resident #21 on her shift. CNA #524 confirmed she started her shift at 6:00 A.M. An interview on 04/23/25 at 11:27 A.M. with the Director of Nursing (DON) revealed each resident who was incontinent of the bowel or bladder would be checked every two hours to verify if they were incontinent, then changed if needed. If the resident was sleeping, they would still need to be checked. An interview on 04/23/25 at 11:43 A.M. with Resident #21 revealed she stated, they don't come in and change me like they should. Resident #21 revealed she never refused to be changed, when CNA #524 brought her breakfast tray in around 8:00 A.M. she asked to be changed. CNA #524 said she had to wait to get help, so she would do it after breakfast. Resident #21 revealed she ate her breakfast then fell back to sleep while waiting to be changed. Resident #21 stated, it makes me feel disgusting, it happens every day. An interview on 04/23/25 at 11:46 A.M. with CNA #524 revealed she stated, I did take her (Resident #21) breakfast tray in at 8:00 A.M., and she (Resident #21) did ask to be changed. I told her I would have to wait to get someone, we can't do her with one, it takes a while to find someone, the other aids were busy. Review of the facility policy titled, Routine Resident Care, undated, revealed it is the policy of the facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social, and spiritual needs and honor resident lifestyle preferences while in the care of the facility. This deficiency represents non-compliance investigated under Complaint Number OH00164146 and OH00162382.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, job description review, and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This had the potential to affect all 64 residents who resided in the facility. Findings include: Review of facility document titled Position Description for position of Executive Director revealed the Administrator had signed the job description on 05/02/23. The description revealed the purpose of this position was to provide leadership to all staff to assure that care standards were met and the highest degree of quality resident care was provided at all times. The position description indicated the executive director must function as both a team member, team leader, and supervisor to ensure that work was accomplished and quality of care was delivered and had the authority, responsibility, and accountability for the overall operation of the facility. Major accountabilities and supporting actions of the position included but was not limited to: monitor operations to provide assurance of compliance with standards of practice, responsible for reviewing/evaluating and monitoring all staff on a regular basis to assure competence, achievement of goals, supervise and ensure care was provided in accordance with applicable standards of practice, state practice acts, and state and federal regulations. Review of facility document titled Position Description for position of Director of Nursing Services revealed the Director of Nursing (DON) had signed job description on 03/17/25. The description revealed the purpose of the position was to provide leadership to the nursing staff to assure that care standards were met and the highest degree of quality resident care was provided at all times. The position must function as a team member, team leader, and supervisor to ensure that work was accomplished and quality of care was delivered. Job duties and responsibilities included but were not limited to: make sure there was sufficient nursing levels to ensure delivery of quality resident care, ensure all nursing staff followed established department policies, monitor job performance to assure the staff were performing their work assignments within acceptable nursing standards, develop and maintaining a good working rapport with inter-department personnel as well as other departments to assure that the department services and activities could be maintained to meet the needs of the residents, assist in evaluating employee performance, inspect the nursing service areas and practices for compliance with current applicable regulations, assume the authority, responsibility, and accountability of directing the nursing service department, ensure all resident care would be provided in a dignified and respectful manner, supervise and may participate in the development of a written care plan and may review resident care plans for appropriate resident problems, approaches, goals, and revisions, ensure that a clean, comfortable and safe environment for residents was maintained at all times and resident needs were met, supervise and ensure care provided was in accordance with applicable standards of practice, state practice acts, and state and federal regulations During the annual and complaint survey, observations, record reviews and interviews resulted in concerns related to the overall operation of the facility including but not limited to sufficient staffing, completion of performance evaluation for nursing services, completion of the facility assessment, monitoring the function of resident call system, monitoring of safe and comfortable water temperatures, and therapeutic activities. The facility failed to provide evidence administrative staff, including the Administrator and/or DON had effective systems in place to timely identify and correct quality, care and environmental concerns as follows: A.The facility failed to ensure adequate staff to provide timely and adequate care for residents. Review of the Payroll Based Journal (PBJ) Staffing Report for Fiscal Year Quarter four (07/01/24 to 09/30/24) for the facility revealed a concern triggered for a one-star staffing rating indicating inadequate staffing hours. Review of the Facility Assessment (FA), dated 04/03/25, as provided by the Administrator revealed In Part 3, section 3.1 of the FA, the staffing plan did not address the number of direct care staff across all shifts needed to address resident acuity/care needs, as the section addressing staffing of aides and nurses on each unit was blank and instead gave a report of the fourth quarter staffing reported in the payroll based journal. The section on Staff Survey and Individual Staff Assignments was left blank. 1.Observation of incontinence care on 04/22/25 at 9:18 A.M. for Resident #23 with Certified Nursing Assistant (CNA) #543 and CNA #600 revealed Resident #23 was in a wheelchair in his room. CNA #543 stated Resident #23 had been up in his wheelchair since she had arrived to start her shift at 6:00 A.M. and stated she had not provided Resident #23 with incontinence care yet. Observation revealed CNA #543 and CNA #600 had used a hoyer lift (mechanical lift) to get Resident #23 out of his wheelchair. Resident #23's hoyer pad, pants, and shirt were observed to have been saturated with urine. Interviews with CNA #543 and CNA #600 confirmed Resident #23 was saturated with urine and neither were able to state when Resident #23 had last received incontinence care and stated residents should be checked for incontinence at least every two hours. CNA #543 stated there had not been enough staff at time to complete her assigned duties timely. Resident #23 was not interviewable. 2. Observation of incontinence care on 04/22/25 at 9:28 A.M. for Resident #42 with CNA #543 and CNA #600 revealed Resident #42 was in a wheelchair in his room. CNA # 543 stated Resident #42 had been up since she had arrived to start her shift at 6:00 A.M. and stated she had not provided Resident #42 with incontinence care yet. Observation further revealed Resident #42's incontinence brief was saturated with stale smelling dark urine. CNAs #543 and #600 confirmed the observation and stated residents should be checked for incontinence at least every two hours and both were unable to state when Resident #42 had last received incontinence care. CNA #543 stated there had not been enough staff at time to complete her assigned duties timely. Resident #42 was not interviewable. 3. Observations on 04/15/25 from 8:07 A.M. until 9:01 A.M. revealed Resident #38 was sitting in the dining room at a table by herself with food in bowls placed in front of her. There were two certified nursing assistants feeding other residents in the dining room. Resident #38 was observed making no attempt to feed herself. The resident was either watching other residents feed themselves or was dozing off. At 8:52 A.M. CNA #505 came over to assist Resident #38 with her meal. Interview on 04/15/25 at 8:55 A.M. with CNA #505 stated there were only two staff members in the dining room to feed four residents and assist a couple of residents. She confirmed residents were not being fed or assisted in a timely manner, which included Resident #38. 4. Observation on 04/23/25 at 11:06 A.M. with CNA #524 and #574 complete incontinence care for Resident #21 revealed Resident #21 was lying in bed. Resident #21 had a strong foul odor of urine. Observation revealed Resident #21's sheet and bath blanket Resident #21 was lying on was saturated with urine half way up her back and to her mid lower thighs. The brief was totally saturated and the blanket covering her was wet with urine. CNA #524 and #574 confirmed Resident #21 had a strong odor of urine and Resident #21's bedding and brief was saturated. Resident #21 revealed the last time she was checked or changed was 5:00 A.M. CNA #524 confirmed she was Resident #21's primary caregiver and confirmed this was the first time she checked or changed Resident #21 on her shift. CNA #524 confirmed she started her shift at 6:00 A.M. An interview on 04/23/25 at 11:43 A.M. with Resident #21 revealed she stated, they don't come in and change me like they should. Resident #21 revealed she never refused to be changed, when CNA #524 brought her breakfast tray in around 8:00 A.M. she asked to be changed. CNA #524 said she had to wait to get help, so she would do it after breakfast. Resident #21 revealed she ate her breakfast then fell back to sleep while waiting to be changed. Resident #21 stated, it makes me feel disgusting, it happens every day. An interview on 04/23/25 at 11:46 A.M. with CNA #524 revealed she stated, I did take her (Resident #21) breakfast tray in at 8:00 A.M., and she (Resident #21) did ask to be changed. I told her I would have to wait to get someone, we can't do her with one, it takes a while to find someone, the other aids were busy. Additional staff interviews conducted intermittently during the survey from 04/14/25 at 8:15 A.M. to 04/22/25 at 9:18 A.M. with eight direct care staff (Licensed Practical Nurse #538, #503, #541 and CNA #601, #550, #560, #570 and #543) revealed all of them voice concerns related to insufficient staffing affecting resident care regarding lack of timely resident checks, incontinence care, showers, medication pass and treatments. B.The facility failed to conduct performance evaluations for Certified Nursing Assistants (CNAs) who were due for required performance evaluations. Review of four employee files who were due for performance evaluations revealed CNAs #502, # 551, #552, and #562 had not had their performance evaluations. An interview on 04/23/25 at 11:10 A.M. with the Human Resource Manager confirmed the findings of performance evaluations absent from CNA #552, #502, #551 and #562 employee files. C. The facility failed to ensure the facility assessment was completed thoroughly and accurately. Review of the facility assessment, dated 04/03/25, revealed the following concerns: • there was no indication who participated in the review and revision of the facility assessment. • multiple sections of the facility assessment were incomplete as evidenced by blank spaces where information was needed to prepare a complete and thorough facility assessment. • the certified bed capacity was incorrectly listed as 90 certified beds On 04/23/25 at 12:29 P.M., an interview with the Administrator stated she had no involvement in completing the facility assessment revision and it was completed by a corporate staff member, whom she was unable to name. The Administrator verified the revision date was listed as 04/03/25, confirmed the multiple blank spaces throughout the facility assessment, and confirmed the certified bed capacity should have been listed as 80 not 90. On 04/23/25 at 12:54 P.M., an interview with the Administrator stated she personally completed the 2025 facility assessment, which contradicted her previous statement that she had no involvement. The Administrator also stated she received input from the Director of Nursing (DON) when completing the facility assessment. On 04/23/25 at 1:00 P.M., an interview with the DON stated she did not recall being involved in revising the facility assessment. The DON confirmed the revision date for the facility assessment of 04/03/25 was after she became the DON and verified the missing and incorrect information in the provided facility assessment. D. The facility failed to ensure the resident's call system unit on the secured unit had an audible sound at all times so residents on the secured unit could call staff for assistance when needed. Observations during an environmental tour on 04/15/25 between 2:02 P.M. and 4:24 P.M. with Director of Plant Maintenance #516 revealed when a call light was pressed in Residents #8 and #58's room on the secure unit, the light outside the room lit up but there was no audible sound coming from the call system unit sitting on the nurse's station. Licensed Practical Nurse (LPN) #503 ,who was sitting at the nurse's station where the call system unit was sitting on the counter, confirmed the light outside the room had come on but she heard no audible sound coming from the emergency call system unit. LPN #503 stated the reason why there was no sound coming from the call system was because the volume on the unit had been turned down. Once LPN #503 turned up the volume on the call system unit, there was an audible sound coming out of the system when the call light was activated. LPN #503 verified if the volume was turned down, any of the resident call lights on the unit would not audibly notify staff the call light was activated. Interview on 04/15/25 at 2:57 P.M. with DPM #516 revealed he had noticed on other occassions the call system units had the sound turned off or way down so it could not be heard on the unit by staff. E. The facility failed to monitor water temperatures to ensure water was at safe and comfortable temperature at all times. Observation during an environmental tour of the water temperatures in residents' rooms on 04/15/25 from 2:02 P.M. to 4:18 P.M. with Director of Plant Maintenance (DPM) #516 revealed after the water had been running out of the bathroom faucet in Residents #36 and #267's room for approximately two minutes, DPM #516 took the facility's digital thermometer and temped the water at 130 degrees Fahrenheit (F). The water felt hot to touch and DPM #516 verified the water was too hot and immediately shut off the water on the 400 hallway and went to call the [NAME]. In Resident #34 and #54's room, after running the water for approximately two minutes, DPM #516 took the temperature of the water coming out of the bathroom faucet using a facility thermometer and the water reached 93.9 degrees F as the highest temperature. The water was lukewarm to the touch. In Residents #27 and #33's room, after running the water for approximately two minutes, DPM #516 took the temperature of the water coming out of the bathroom faucet using a facility thermometer and the water reached 93.9 degrees F as the highest temperature. The water was luke warm to the touch. In Residents #19 and #15's room, after running the water for approximately two minutes, DPM #516 took the temperature of the water coming out of the bathroom faucet and the water reached 95.0 degrees F as the highest temperature. The water was luke warm to the touch. In Resident #52's room, after running the water for approximately two minutes, DPM #516 took the temperature of the water coming out of the room faucet and the water reached 97.7 degrees F as the highest temperature. The water was lukewarm to the touch. Interview on 04/15/25 at 4:24 P.M. with DPM #516 stated the water temperatures should be between 105 and 120 degrees F. Review of the facility water temperature log provided by the Director of Plant Maintenance (DPM) #516 revealed a record of water temperatures between 01/01/25 and 04/14/25. The water temperatures had been checked in two different areas for each of the four hallways on 01/01/25, 01/06/25, 01/13/25, 02/17/25, and 03/10/25. On 01/13/25 the temperature recorded in Residents #34 and #54 room (on the 100 hallway) was 92 degrees Fahrenheit (F) and in Residents #42 and #46 room (on the 100 hallway) the temperature of the water was 90 degrees F. On 01/27/25 the water temperature taken of an unidentified area of the 100 hallway was 90 degrees F. There were no recorded temperatures on the log for the weeks of 01/20/25, 02/03/25, 02/10/25, 02/24/25, 03/03/25, 03/17/25, 03/24/25, or 04/07/25. This was confirmed by DPM #516 on 04/24/25 at 9:22 A.M. when he stated there was no proof water temperatures were being taken weekly with the missing weeks of recorded water temperatures because the program he used was not backing up the data. F. The facility failed to ensure all residents were provided therapeutic activities as scheduled and, in the evenings, to meet their needs and preferences. Review of the April activity calendar posted on the wall of hallway of the secure unit revealed activities scheduled on the unit for 04/16/25 included chair yoga at 9:00 A.M., chronicles /brain games at 9:30 A.M., games with friends at 10:00 A.M., guess your weight at 10:30 A.M., cards with friends at 1:30 P.M., sit and chat 2:30 P.M., socialize and snack at 3:00 P.M., and TED talk at 5:30 P.M. Observation on 04/16/25 at 10:45 A.M. revealed there was no activity being held on the secured unit. An interview on 04/16/25 at 10:51 A.M. with Certified Nursing Assistant (CNA) #563, who was working on the unit that day, verified there had not been any activities on the secure unit that morning and she was not sure why. Observation of the secure unit on 04/16/25 at 5:33 P.M. revealed there were two residents sitting in the secure unit lounge and two residents walking up and down the hallway. There was no Ted talk being held. At the time of the observation, Certified Nursing Assistant (CNA)#563 confirmed the activity at 5:30 P.M. was not being held. Interview on 04/21/25 with Activity Director #555 revealed the activity staff were only at the facility until 5:00 P.M., and activities held after 5:00 P.M. were the responsibility of the receptionist and the aides. She went on to state the receptionist position was currently vacant, and the facility had new aides who may not have known they were supposed to do the activities scheduled after 5:00 P.M. Activity Director #555 confirmed most of the even activities were not currently being held.

Based on review of the facility assessment and staff interview, the facility failed to ensure a complete and accurate facility assessment was developed with active involvement of the required participants. This had the potential to affect all 64 residents residing in the facility. Findings include: Review of the Facility Assessment (FA), dated 04/03/25, revealed the following concerns: There were no persons named to identify required participants involved in completing the FA, as that section was left blank. The date the assessment was reviewed with the Quality Assurance Performance Improvement (QAPI) committee was blank indicating it had not been reviewed by QAPI. On page four, line four the facility resources needed to provide competent care for residents had several blank spaces intended for identification of laboratory services, x-ray services, food services, laundry services, nursing agency, electronic medical records, staff scheduling, and other contracted services. On page six, the certified bed capacity was incorrectly listed as 90 certified beds. On page 23, there were several blank spaces including the frequency of the clinical wound nurse practitioner's assessments and treatments, the frequency of the facility's designated wound nurse assessments and treatments, and specification as to who would be responsible for completing wound treatments and progression monitoring on the weekends. On page 24, there were several blank spaces including specification of observed food practices in the facility, meal times, and open dining times and days. On page 25, there were several blank spaces including specification of spiritual or religious programs offered, when and where spiritual or religious services would be held, what equipment if any would be provided for spiritual or religious services, frequency of facility activities, and whether any culturally relevant activities would be offered. On page 27, there were several blank spaces including identification of any facility staffed behavioral health specialists and availability of the behavioral health specialist. On page 28, there were several blank spaces including dates of staff trainings on behavioral health in the previous 24 months, identification of the group providing psychological or behavioral health services, frequency of behavioral health visits, whether or not services are provided for addiction services and frequency of sessions if applicable, and specification of days or times for activities provided in the dementia care unit and general residential care unit. On page 29, there are several blank spaces including whether or not dialysis services are provided on-site, the availability of respiratory staff, and specification of the company providing ancillary services such as dental, audiology, podiatry, and optometry. On page 30, there are two blank spaces intended to specify the schedule of the facility's risk nurse and the schedule of the facility's social services staff. In Part 3, section 3.1 of the FA starting on page 34, the staffing plan did not address the number of direct care staff across all shifts needed to address resident acuity/care needs, as the section addressing staffing of aides and nurses on each unit was blank and instead gave a report of the fourth quarter staffing reported in the payroll based journal. The section on Staff Survey and Individual Staff Assignments was left blank. On page 46, the assessment includes instructions to list contracts, memoranda of understanding, and other agreements with third parties, include a description of the process for overseeing those services and how those services will meet resident needs and regulatory requirements, list health information technology resources, describe how the facility will securely transfer health information to other health care providers, describe how downtime procedures are developed and implemented, describe how the facility ensures residents and their representatives can access their records upon request and obtain copies within required time-frames, describe the evaluation process of the infection prevention and control program, and provide the facility-based and community-based risk assessment utilizing an all-hazards approach for emergency preparedness. Although the instructions and prompts were listed, this information was not included in the facility assessment itself. On 04/23/25 at 12:29 P.M., an interview with the Administrator stated she had no involvement in completing the facility assessment revision and it was completed by a corporate staff member, whom she was unable to name. The Administrator verified the revision date was listed as 04/03/25, confirmed the multiple blank spaces throughout the facility assessment, and confirmed the certified bed capacity should have been listed as 80 not 90. On 04/23/25 at 12:54 P.M., an interview with the Administrator stated she personally completed the 2025 facility assessment, which contradicted her previous statement that she had no involvement. The Administrator also stated she received input from the Director of Nursing (DON) when completing the facility assessment. On 04/23/25 at 1:00 P.M., an interview with the DON stated she did not recall being involved in revising the facility assessment. The DON confirmed the revision date for the facility assessment of 04/03/25 was after she became the DON and verified the missing and incorrect information in the facility assessment.

Based on observation, interview, record review, review of the facility policies, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to maintain infection control practices by not adhering to proper hand hygiene during care for two residents (#21 and #22). This afffected two residents (#21 and #22) of five residents reviewed for assistance with activity of daily living. Also, the facility failed to ensure a flow diagram and a written description to describe the facility's water system was included in the facility water management program (WMP) in order to minimize the growth and transmission of the bacterium Legionella. This had the potential to affect all residents residing at the facility. The facility census was 64. 1.Record review for Resident #21 revealed an admission date of 12/04/23 with diagnoses including obesity, muscle weakness and the need for assistance with personal care. An observation was conducted on 04/23/25 at 11:06 A.M. of Certified Nursing Assistant (CNA) #524 and #574 completing incontinence care for Resident #21. Resident #21's sheet and bath blanket underneath Resident #21 was saturated with urine and the blanket over her body was wet with urine. CNA #524 placed the saturated items in a disposable bag with her gloved hands. CNA #524 completed the incontinence care for Resident #21 and without changing her contaminated gloves or washing her hands after incontinence care picked up clean blankets and placed the blankets on Resident #21. CNA #524 proceeded to reposition Resident #21, opened the door, removed the glove on her right hand, left the room with the bag of soiled linen, walked down the hall to the soiled utility room, opened that door using her soiled hand, then disposed of the soiled linen into a container. CNA #524 then returned to Resident #21's room to wash her hands. CNA #524 confirmed she did not wash her hands or use hand sanitizer after providing incontinence care or before leaving Resident #21's room and touching the entrance door to the soiled utility room. CNA #524 confirmed the findings at the time of the observation. Interview on 04/23/25 at 11:27 A.M. with the Director of Nursing (DON) revealed each staff member should wash their hands after touching a resident or soiled items prior to leaving the residents room. Review of the facility policy titled, Standard Precautions dated 03/15/16 revealed practicing hand hygiene is a simple but effective way to prevent the spread of infections by breaking the chain of infection. Proper cleaning of hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming resistant to antibiotics. Examples of when to perform hand hygiene include before and after direct contact with a residents intact skin, after contact with inanimate objects, after hands move from a contaminated body site to a clean body site (example peri care) and after removing gloves. 2. Review of the medical record for Resident #22 revealed an admission date of 12/24/24 with diagnoses including severe protein-calorie malnutrition, dementia with psychotic disturbance, adult failure to thrive, muscle wasting and atrophy, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/02/25, indicated Resident #22 had a severe cognitive impairment and required set-up or clean-up assistance for eating meals. On 04/17/25 at 8:20 A.M., an observation of the dining room revealed Certified Nursing Assistant (CNA) #551 entered the dining room, sat down beside Resident #22, and began providing feeding assistance to Resident #22. CNA #551 did not wash her hands after entering the dining room or before providing feeding assistance for Resident #22. On 04/17/25 at 8:24 A.M., an interview with CNA #551 confirmed she entered the dining room and did not wash her hands prior to providing feeding assistance for Resident #22. 3. Review of the facility Water Management Program (WMP) for Legionella (the bacteria that causes Legionnaire's disease which results in a serious type of pneumonia). revealed there was no flow diagram or text description to identify the buildings water system and all locations in the water system where Legionella could potentially grow and spread . An interview on 04/15/25 at 1:39 P.M. with the Director of Plant Maintenance (DPM) #516 confirmed he had not developed a Legionella diagram assessment for the building or a text description of the facility's water system. DPM #516 stated he was flushing water fixtures which had not been used for 14 days or later to help prevent Legionnaire's disease. When asked why a flow diagram or text description had not been developed, DPM #516 stated he had been busy with everything else on the campus and hadn't had time to complete it. DPM #516 verified he had no evidence that all critical control points in the building were being monitored to prevent growth and spread of Legionella. Review of the undated facility policy titled Legionella or Legionnaire's Disease revealed Legionnaire's Disease also called Legionella Pneumonia is a rare but very serious type of pneumonia caused by the bacterium Legionella which is found naturally in fresh water environments including lakes and streams. Legionella becomes a health problem when it grows and spreads in human-made water systems including showers, faucets, unflushed eye washed stations, cooling towers for air conditioners, hot tubs, decorative fountains, hot water tanks and large plumbing systems. Surveillance for Legionella includes monitoring for appropriate levels of disinfectants in public and facility water systems. Monitoring the environment included maintenance performing routine water monitoring services, flushing eye wash stations, emergency potable water is secured and chlorination levels monitored, housekeeping maintains proper cleaning of ice machines, and reduce risk of growth by maintaining water temperatures in range. The policy did not address the need to describe the facility's water systems using flow diagrams and a text description. Review of the Centers for Disease Control and Prevention website located at https://www.cdc.gov/control-legionella/php/wmp/wmp-steps.html revealed WMPs identified hazardous conditions, and one of the steps to minimize the health impact of waterborne pathogens was describing the buildings water systems using flow diagrams and a written/text description to describe the building's water systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the self-reported incident (SRI) tracking number 250524, facility SRI investigation, medical record review, interviews, and facility policy review, the facility failed to prevent staff-to-resident physical abuse for Resident #34. This affected one resident (#34) of three residents reviewed for abuse. The facility census was 56. Findings include: Review of the medical record for Resident #34 revealed an admission date of 07/15/24 with diagnoses including type two diabetes mellitus, unspecified dementia with agitation, hypothyroidism, benign prostatic hyperplasia, ulcerative colitis, presence of an automatic implanted cardiac defibrillator, rheumatoid arthritis, weakness, and cognitive communication deficit. Review of the admission Minimum Data Set (MDS) 3.0 assessment completed on 08/07/24 revealed Resident #34 had severely impaired cognition and was dependent for eating, toileting hygiene, bathing, and transfers. Further review of the MDS revealed Resident #34 had complex medical conditions and non-Alzheimer's dementia. Review of the care plan dated 07/15/24 revealed Resident #34 had communication problems due to impaired cognition and had a mood and behavior problem. Interventions included allowing adequate time for responses, not rushing care or conversation, making eye contact, reducing environmental noises, providing consistency, allowing the resident to make informed decisions, supporting and honoring the resident's preferences and choices, and providing education as needed. Further review of the care plan revealed Resident #34 used mood stabilizing medication and staff were to maintain a consistent daily routine, observe for behaviors, limit over-stimulation, and provide a calm environment. Review of the progress note dated 08/07/24 revealed that at 5:02 A.M. Assistant Director of Nursing (ADON) #329 was notified by phone by the floor nurse that there was an altercation between Resident #34 and a staff member. The floor nurse was directed to assess Resident #34 for injuries, which had been completed with a small pink area noted on Resident #34's left cheek. The floor nurse was instructed to gather witness statements and send the state tested nurse aide (STNA) involved in the incident (STNA #312) home. Review of this progress note further revealed ADON #329 arrived at the facility at 6:00 A.M., followed-up with the resident and potential witnesses, completed a head-to-toe assessment of Resident #34, and notified the family, physician/medical director, and police of the incident. Resident #34 had no recollection of the alleged incident, and the spouse of Resident #34 declined to press charges against STNA #312. Review of the social services progress note dated 08/07/24 revealed Social Services Designee (SSD) #355 attempted to assess Resident #34's psychosocial status, but Resident #34 had no recollection of the incident. Review of the social services note dated 08/08/24 revealed SSD #355 arranged for counseling for Resident #34, and the therapist stated that Resident #34 was unable to participate in the evaluation due to confusion and cognitive impairment. Interview with Resident #34 was unable to be conducted during the on-site SRI review on 09/03/24 due to the resident passing away under the care of Hospice services on 08/31/24. Interview on 09/03/24 at 3:35 P.M with Licensed Practical Nurse (LPN) #318 confirmed she was on duty on 08/07/24 when STNA #350 approached her, followed by STNA #312, to report Resident #34 struck STNA #312 in the face, and STNA #312 struck him back. During the interview, LPN #318 confirmed she immediately assessed Resident #34 and described her findings as his face was beet red with a mark on the side of his face. Resident #34 would not speak to her, which LPN #318 reported was unlike him. LPN #318 further confirmed she notified the other nurse on duty, spoke with ADON #329 for further instruction, obtained witness statements, and directed STNA #312 to leave the premises. At the time of the interview, LPN #318 said that STNA #350 reported to her that STNA #312 struck Resident #34 more than once but was unable to provide further detail. Review of the facility incident log revealed an incident of alleged abuse for Resident #34 was logged on 08/07/24. Review of the facility's SRI investigation written witness statements from LPN #318, STNA #312, and STNA #350 revealed supportive statements by each that Resident #34 made physical contact with the face of STNA #312 and she reacted by striking him back. The witness statements from other STNAs on duty that shift revealed no knowledge to support or rebuke the alleged abuse incident. Review of the skin grid non-pressure assessment completed on 08/07/24 revealed Resident #34 had a pink area on his left cheek measuring 1.5 centimeters (cm) by 1.0 cm by 1.5 cm and his left eye was pink with yellow discharge and irritation. Review of the facility's SRI investigation findings revealed the facility substantiated the abuse stating STNA #312 struck Resident #34, but did not conclude with certainty the reddened area on Resident #34's cheek was a direct result of being struck by STNA #312 due to a concurrent diagnosis of conjunctivitis of the left eye. Interview on 09/03/24 at 4:45 P.M. with the Director of Nursing (DON) confirmed STNA #312 was suspended immediately pending investigation findings and had not returned, and indicated she is no longer employed by the facility. The DON further confirmed all staff were educated on the abuse policy and how to properly provide care to residents who displayed aggressive behaviors. Interview on 09/03/24 at 4:55 P.M. with the Executive Director (ED) and ADON #329 confirmed STNA #312 was no longer working at the facility and resigned in lieu of termination. During the interview, Resident #34's history of dementia with behaviors was confirmed with a history of striking toward staff but never making physical contact with his strikes. The Executive Director and ADON #329 also confirmed house-wide training was completed on the abuse policy and handling aggressive behaviors, and that additional re-education was provided to the nursing staff on checking resident [NAME]'s prior to rendering care. The ED also provided confirmation the facility completed staff and resident audits related to abuse and had an ad hoc quality assurance and performance improvement (QAPI) meeting, as well as daily clinical meetings, where the administrative team discussed audit findings. The ED also confirmed a behavioral specialist came to the facility on [DATE] and completed behavior health training to reinforce previous education related to the care of residents with behaviors. Interview on 09/03/24 with the DON at 5:00 P.M. confirmed weekly audits of five staff and five residents related to abuse commenced right after the reported incident on 08/07/24, and he had completed four consecutive weeks of the audits which revealed no concerns of abuse. Interviews on 09/03/24 at 5:25 P.M with Regional Director of Clinical Services (RDOCS) #335 confirmed an ad hoc meeting was held on 08/21/24 where the reported incident and plan of compliance was discussed, and she had visited the facility several times since the incident and reviewed audit progress and interacted with staff and residents with no further concerns noted. On 09/03/24 at 5:30 P.M., the ED confirmed the abuse policy had been reviewed as a part of the QAPI oversight and no changes were made to the policy. Review of the facility policy titled OHIO Abuse, Neglect, and Misappropriation, effective as of 03/06/24, revealed the facility implemented policies and procedures to screen, prevent, assess, educate, and report all types of abuse, neglect, misappropriation, and exploitation. The deficient practice was corrected on 08/08/24 when the facility implemented the following corrective actions: • STNA #312 was suspended immediately and after the investigation concluded, STNA #312 voluntarily resigned in lieu of termination as of 08/15/24. • Resident #34 was assessed by LPN #318 and report was called to ADON #329 on 08/07/24 at 5:02 A.M. • Witness statements were obtained from staff on 08/07/24. Resident #34 was not contributory to the interview attempt by LPN #318 on 08/07/24. • ADON #329 performed skin assessment on Resident #34 at 6:00 A.M. on 08/07/24. • Notifications were made to the resident's family, the Medical Director, who was the physician of record, and to the local Police Department on 08/07/24 between 6:00 A.M. and 6:40 A.M. • A police report was taken on-site by the local Police Department on 08/07/24 at 6:45 A.M., report incident number 20244027. • The DON completed a pain assessment, determining Resident #34 had no indicators of pain on 08/07/24 at 7:48 A.M. • Skin assessments were completed with no negative findings on 08/07/24 on all residents who were not interviewable by the RDOCS #335 on 08/07/24. • Interviews were conducted on all residents in the facility by SSD #355 throughout 08/07/24 and 08/08/24 with no negative findings. • Resident #34 was offered psychosocial support on 08/07/24 and 08/08/24 from the SSD and offered psychiatric services and counseling on 08/08/24. Resident #34 had no recollection of the incident and was non-contributory to offers of support. • Facility-wide, all staff training was completed during multiple sessions and via telephone on 08/07/24 on the abuse policy and handling aggressive behaviors. Nursing education was completed on 08/07/24 on reviewing the [NAME] for pertinent information before providing resident care. Training sessions were conducted by multiple managerial staff to their respective departments and included RDOCS #335, ADON/RN #329, Culinary Director #323, and Activities Director #351. • Weekly resident audits of five residents regarding abuse and safety commenced on 08/08/24 RDOCS #335 and continued weekly by the DON or designee. • Weekly staff audits regarding knowledge of abuse and reporting commenced 08/08/24 by RDOCS #335 and continued weekly by the DON or designee. • An Ad hoc QAPI meeting took place on 08/21/24 to review quality concerns and the facility's plan of compliance and audit progress related to this incident. • Week four of staff and resident abuse audits were completed on 08/27/24 with plan to continue random audits until compliance confirmed with subsequent QAPI meetings. • RDOCS #335 will continue to make monthly facility visits for three months and as needed to monitor compliance. • Results of the above audits will be reviewed monthly for three months and as needed by the QAPI Committee and revisions/changes will be made to compliance monitoring as deemed necessary by the QAPI Committee. • STNA #312 was reported to the Nurse Aide Registry on 09/04/24. This violation was an incidental finding identified during the complaint investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure pharmacy services provided for timely ordering, dispensing, acquiring, and administering of medications to meet the needs of each resident. This affected two residents (Resident #45 and Former Resident #58) out of four residents who were reviewed for medication administration. The facility census was 56. Findings include: 1. Review of the closed medical record for Former Resident (FR) #58 revealed an admission date of 03/25/24 and a discharge date of 07/18/24. admission diagnoses included spondylolysis of the lumbar region, radiculopathy of the lumbar region, dizziness, anxiety, major depression, fibromyalgia, dermatophytosis, post-traumatic stress disorder (PTSD), dissociative and conversion disorder, disorders of the bladder, and postural orthostatic tachycardia syndrome. Review of the care plan dated 03/25/24 revealed FR #58 was at risk for impaired psycho-social well-being related to dissociative conversion disorder, PTSD, depression, and anxiety, and that she used antidepressants and antianxiety medications. Interventions included maintaining a daily routine, consulting with the pharmacy, counseling services, or medical provider as needed, providing a calm environment, and providing medications per physician's orders. Review of the physician orders revealed the following: • An order dated 05/30/24 for desvenlafaxine extended release (ER) 24-hour 50 milligram (mg) (antidepressant) tablets, one tablet by mouth in the mornings for anxiety. • An order dated 06/07/24 for Auvelity ER 4-105 mg oral tablets (antidepressant), take one tablet by mouth twice daily for depression. • An order dated 07/01/24 for Estrace vaginal cream 0.1 mg per gram (hormone), insert two grams vaginally at bedtime every Monday, Wednesday, and Friday for low estrogen for three weeks. • An order dated 07/03/24 for Estrace vaginal cream 0.1 mg per gram, insert one gram vaginally at bedtime for three weeks. • An order dated 07/03/24 for fluconazole 150 mg tablet (antifungal), give one tablet by mouth every 72 hours for three administrations for a yeast infection. • An order dated 07/02/24 for saccharomyces boulardii 250 mg capsules (probiotic), give one capsule by mouth two times a day for a probiotic. Review of the progress notes revealed the following electronic medication administration record (eMAR) notes: • 07/04/24: desvenlafaxine was in route from the pharmacy. • 07/04/24: saccharomyces was in route from the pharmacy. • 07/05/24: desvenlafaxine was in route from the pharmacy. • 07/07/24: the pharmacy rejected the refill request for desvenlafaxine. • 07/07/24: Estrace vaginal cream was unavailable and on order from the pharmacy. • 07/09/24: Auvelity was not available and in route from the pharmacy. • 07/10/24: Auvelity was listed as Medication on order. Review of the medication administration record (MAR) for July 2024 revealed the following medications were not administered on the following dates and times: • Desvenlafaxine ER 24-hour 50 mg tablets, one tablet by mouth in the mornings for anxiety was not administered on 07/04/24, 07/05/24, or 07/07/24. • Estrace vaginal cream 0.1 mg per gram, insert one gram vaginally at bedtime for three weeks was not administered on 07/01/24 or 07/07/24. • Fluconazole 150 mg tablet, give one tablet by mouth every 72 hours for three administrations for a yeast infection was not administered on 07/09/24. • Auvelity ER 4-105 mg oral tablets, take one tablet by mouth twice daily for depression was not administered on the evening of 07/09/24 or the morning of 07/10/24. • Saccharomyces boulardii 250 mg capsules, give one capsule by mouth two times a day for a probiotic was not administered on 07/04/24. Interview on 08/21/24 with Licensed Practical Nurse (LPN) #304 confirmed FR #58 had voiced concern and was upset about missing doses of her antidepressant and antianxiety medications. LPN #304 further confirmed it was not uncommon to have residents miss a dose or two of medication due to the medication not arriving timely from the pharmacy. Review of the policy titled Medication Administration, dated 04/16/24, revealed medications were to be given as ordered and within the timeframe of one hour before or after the ordered administration time. 2. Review of the medical record for Resident #45 revealed an admission date of 04/01/16 with diagnoses including compression of the brain, human immunodeficiency virus (HIV), anxiety disorder, primary hypertension, major depressive disorder, panic disorder, Arnold Chiari Syndrome, prostatic hyperplasia, and third nerve palsy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #45 had intact cognition and was independent with his personal care. Further review of the MDS revealed Resident #45 was on antidepressants and had a history of anxiety, depression, and PTSD. Review of the care plan dated 08/05/22 revealed Resident #45 was at risk for constipation and interventions included administration of medications per medical provider's orders. Further review of the care plan revealed Resident #45 had a behavior disturbance, experienced mood fluctuations, and was on antidepressants. The interventions included Resident #45 receiving medications as prescribed. Review of the physician orders revealed an order dated 07/16/24 for Abilify 10 mg (antipsychotic) by mouth daily at bedtime for depression. Further review of the orders revealed an order dated 06/16/22 for SM Fiber laxative 500 mg tablets, give two tablets by mouth every morning and at bedtime for constipation. Observation on 08/20/24 at 8:10 A.M. of medication administration revealed Resident #45 did not receive the ordered SM fiber laxative tablets as ordered. Interview at the time of the medication administration with LPN #334 confirmed the facility did not have the correct medication strength in stock so the dose was not able to be administered, and she would have to order the medication from the pharmacy. A review of the eMAR revealed documentation for the fiber laxative was coded as 9 (see progress noted). Review of the eMAR progress note dated 08/20/24 revealed the medication was order and the correct dose was needed. Further review of the August 2024 eMAR revealed the dose of Abilify, 10 mg daily for depression, was not administered on 08/17/24. Review of the eMAR progress note dated 08/17/24 revealed the Abilify was on order. Review of the policy titled Medication Administration, dated 04/16/24, revealed medications were to be given as ordered and within the timeframe of one hour before or after the ordered administration time. This deficiency represents non-compliance investigated under Complaint Number OH00155770.

Based on observation, interview, medical record review, review of facility policy, and Center for Clinical Standards and Quality/Quality, Safety & Oversight Group memorandum summary, reference number QSO-24-08-NH review the facility failed to ensure proper infection control procedures were implemented and followed for Resident #13. This affected one resident (#13) of three residents reviewed for incontinence care. The facility census was 56. Findings include: Review of the medical record for Resident #13 revealed an admission date of 08/17/24 with diagnoses including left femur fracture, Alzheimer's disease, metabolic encephalopathy, cognitive communication deficit, severe protein-calorie malnutrition, history of falling, acute respiratory failure, dysphagia, and attention to gastrostomy. Review of the Functional Abilities and Goals - Admission assessment completed 08/19/24 revealed Resident #13 was dependent on others for daily self-care. Review of the admission nurses progress note dated 08/17/24 revealed Resident #13 was incontinent of bowel and bladder and received nutrition through a percutaneous endoscopic gastrostomy (PEG) tube (a feeding tube inserted through the skin into the stomach). Review of the care plan dated 08/17/24 revealed Resident #13 had the potential for altered nutrition and received enteral feedings. Interventions included providing tube feedings per orders. Further review of the care plan revealed no care planning related to enhanced barrier precautions (EBP). Review of the physician orders revealed there was no order for EBP. Observation on 08/20/24 from 2:10 P.M. to 2:25 P.M. revealed State Tested Nurse Aide (STNA) #340 did not wear a gown to provide incontinence care to Resident #13. Further observation revealed Resident #13's PEG tube was exposed and Resident #13 kept pulling on the tube during the care being provided, with STNA #340 observed removing Resident #13's hand away from the PEG tube and manually stabilizing the PEG tube several times while completing the incontinence care. Interview on 08/20/24 at 2:30 P.M. with STNA #340 confirmed Resident #13 had a feeding tube. STNA #340 further confirmed she did not believe Resident #13 was in EBP but realized she should be, because of the presence of a feeding tube. STNA #340 confirmed a gown should be worn when performing close contact resident care when a resident had a PEG tube, and she did not don a gown to perform Resident #13's incontinence care. Interview on 08/20/24 3:27 P.M with Regional Director of Clinical Services (RDOCS) #335 confirmed EBP should be observed during the provision of incontinence care for residents with feeding tubes. Review of the policy titled Standard Precautions and Transmission based Precautions, dated 06/25/21, revealed no information regarding enhanced barrier precautions. Further review of the policy revealed standard and transmission-based precautions were implemented per CDC (Centers for Disease Control and Prevention) guidelines based on the resident's clinical condition. Review of the sign the facility posts on the doors of residents who were place in EBP revealed staff were to wear a gown and gloves for high contact resident care, including providing hygiene, changing briefs, or caring for a feeding tube. Review of the Center for Clinical Standards and Quality/Quality, Safety & Oversight Group memorandum summary, reference number QSO-24-08-NH, issued 03/20/24, revealed enhanced barrier precautions (EBP) in in long-term care facilities was effective on 04/01/24 to align with nationally accepted standards. The QSO memorandum further revealed EBP was to include residents indwelling medical devices, including central lines, urinary catheters, feeding tubes, and tracheostomies, during high contact care. This deficiency was an incidental finding identified during the complaint investigation.

Based on record review, observation and interviews the facility failed to ensure all staff were wearing the appropriate Personal Protective Equipment (PPE) to help prevent the spread of COVID-19 in the facility. This had the potential to affect 32 residents who were not COVID-19 positive (#2, #4, #7, #8, #9, #14, #15, #17, #19, #20, #21, #26, #28, #29, #30, #32, #34, #35, #36, #37, #40, #41, #42, #45, #46, #48, #50, #52, #54, #55, #57,and #58) and residing in the facility at the time of the survey. The facility census was 53. Findings include: Record review of facility line list revealed there were 21 residents (#1, #5, #6, #10, #12, #18, #22, #23, #24, #25, #31, #33, #38, #39, #43, #44, #47, #49, #51, #53 and #56) currently residing in the facility and two employees who tested positive for COVID-19 from 04/05/24 to 04/08/24. Observations made on 04/09/24 upon arrival to the facility at 9:30 A.M. revealed the facility was in a current outbreak of COVID-19 with 23 residents in droplet isolation due to testing positive of COVID-19. The Administrator, receptionist and multiple other staff members who were present throughout the facility were not wearing any type of source control including N95 masks or surgical masks. Interview on 04/09/24 at 10:05 A.M. with the Director of Nursing revealed it was the expectation of the facility administration that all staff were to wear surgical masks when not on the COVID-19 unit and when on the COVID-19 unit staff were to wear N95 masks as source control measures. Interview on 04/09/24 at 10:39 A.M. with the Administrator revealed she confirmed herself, the Receptionist and multiple other staff members were not wearing any type of source control including N95 masks or surgical masks. Observation on 04/09/24 at 2:10 P.M. of Licensed Practical Nurse (LPN) #701 at the nurses station on the COVID-19 unit with her N95 mask down around her neck while she was charting on the computer with residents who were positive for COVID-19 walking around by the nurses station, and the facility van driver was walking around on the COVID-19 unit continually pulling his mask down when speaking to staff and residents. Interview on 04/09/24 at 2:10 P.M. with LPN #701 revealed she confirmed she was at the nurses station with her mask down, she stated she took it down to put on chap stick and did not put it back up. LPN #701 confirmed the facility van driver was walking around the COVID unit continually pulling his mask down to speak to staff and residents. Interviews on 04/10/24 from 10:07 A.M. to 12:08 P.M. with Residents #7, #8, #20, and #36 revealed they observed staff not wearing masks in the facility even though there was COVID-19 in the facility. This deficiency represents non-compliance investigated under Master Complaint Number OH00152768 and Complaint Number OH00151961.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, record review, and policy review, the facility failed to provide a privacy cover for a urinary catheter drainage bag. This affected one resident (Resident #6) of one resident reviewed for an indwelling urinary catheter. The facility identified four residents with indwelling urinary catheters. The census was 53. Finding include: Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including cardiac arrhythmia, chronic obstructive pulmonary disease, schizophrenia, muscle weakness, and urinary retention. Review of the 5-Day Minimum Data Set (MDS), dated [DATE], revealed Resident #6 was cognitively intact and required extensive, two-person physical assistance with dressing, toileting, bed mobility, and transfers. Review of Resident #6's Care Plan, dated 07/14/23, revealed the resident had the potential for a urinary tract infection (UTI) related to the presence of an indwelling urinary catheter for urinary retention. During observation on 07/17/23 at 11:18 A.M., Resident #6 was noted to have an indwelling urinary catheter attached to the side of his wheelchair, as he propelled through the hallway and common area. Yellow urine was collected in the urinary drainage bag and visible to others. During interview on 07/17/23 at 11:20 A. M, Resident #6 stated he would like his urinary catheter bag covered for privacy. During interview on 07/17/23 at 11:22 A.M., Licensed Practical Nurse (LPN) #100 confirmed there was no privacy covering on Resident #6's urinary catheter bag. During interview on 07/17/23 at 1:40 P.M., Corporate Registered Nurse (RN) #206 stated it was her expectation nursing staff use a privacy cover for urinary collection bags and that she would remedy the situation immediately. Review of the facility's policy titled, Catheter Drainage Bag and Tube Maintenance, undated, revealed it the policy of the facility to provide resident care that meets the psychosocial, physical, and emotional needs of the residents and a privacy bag/covered bag is an outer covering made from cloth or disposable materials that provides for dignity for the resident and prevents the spread of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident representative interview, and policy review, the facility failed to ensure resident representatives were notified about new or worsening wounds and infections. This affected two (Resident's #17 and #55) out of three residents reviewed for wounds. The census was 52. Findings include: 1. Review of the medical record for Resident #55 revealed an admission date of 07/13/21. Resident #55 passed away on 12/30/22. Resident #55 had diagnoses which included but was not limited to dementia, anxiety, adult failure to thrive, congestive heart failure, and hypertension. Review of Resident #55's annual Minimum Data Set Assessment (MDS), dated [DATE], revealed Resident #55 was moderately impaired for daily decision making. Review of Resident #55's physician orders revealed an order, dated 11/28/22, for Erythromycin Ophthalmic Ointment (medication used to treat eye infections) five milligrams per gram to be instilled three times a day in both eyes for an eye infection. Review of Resident #55's chest x-ray, dated 11/29/22, revealed Resident #55 had bilateral peripheral atelectasis/infiltrates. Review of Resident #55's medical record revealed no evidence Resident #55's Power of Attorney was notified of Resident #55's eye infection or pneumonia. Review of the wound nurse practitioner Tissue Analytics, dated 12/01/22, revealed Resident #55 had an area to the left buttock reopen which measured 1.23 centimeters (cm) by 1.24 cm by 0.1 cm deep. The area was a previous Deep Tissue Injury bilateral (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) but was ruled out as it healed. The area was currently moisture associated skin damage, and was red, moist and grainy. Review of Resident #55's physician order, dated 12/01/22, revealed to cleanse Resident #55's open area to bilateral buttocks with soap and water, and apply triad cream every shift and as needed. Leave the brief open. Review of Resident #55's medical record revealed no evidence Resident #55's responsible party was notified of the left buttock wound reopening and the treatment for the wound. Review of the wound Nurse Practitioner note, dated 12/08/22, revealed Resident #55's skin tear to right buttock had a bleeding wound bed. The periwound was fragile and had maroon discoloration. The note indicated to cleanse the area with soap and water, and triad cream every shift and as needed. The note further revealed the area had worsened and was 2.44 cm by 3.63 cm by 0.1 cm deep with scant serosanguinous drainage. Further review of the note revealed Resident #55's left buttock wound was worsening with a fragile periwound and maroon discoloration and measured 2.14 cm by 5.09 cm by 0.1 cm deep. The note revealed to change the treatment to cleanse with normal saline, triad cream to periwound, medihoney to open areas and cover with a dry dressing daily. Review of the wound Nurse Practitioner note, dated 12/22/22, revealed the right buttock skin tear worsened and the serous filled blister ruptured with partial thickness loss which measured 6.91 cm by 3.46 cm by 0.1 cm. The wound had worsening discoloration and blanchable erythema. The treatment was changed to cleanse with normal saline, triad cream to periwound, medihoney to open areas and cover with a dry dressing daily. The etiology was changed to a stage two (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) pressure ulcer. Further review of the note revealed the left buttock wound also worsened and measured 4.46 cm by 3.77 cm by 0.1 cm with maroon discoloration and the treatment was changed to cleanse with normal saline, triad cream to periwound, medihoney to open areas and cover with a dry dressing daily. Review of the wound Nurse Practitioner note, dated 12/26/22, revealed the right buttock skin tear worsened and measured 2.33 cm by 3.46 cm by 0.1 cm with worsening discoloration and blanchable erythema. The treatment was unchanged. The etiology was changed to a Stage II ( Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. ) pressure ulcer. Further review of the note revealed the left buttock wound also worsened and measured 5.52 cm by 5.71 cm by 0.1 cm deep with the etiology changed to evolving 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) with an open wound and small full thickness loss. Review of Resident #55's medical record revealed no evidence Resident #55's Power of Attorney was notified of the worsening skin conditions and changing treatments. Interview on 04/27/23 at 4:40 P.M. with Registered Nurse #128 verified Resident #55 had worsening wounds to her buttocks including a DTI and stage two pressure ulcer without evidence of Resident #55's Power of Attorney having been notified of the worsening wounds. The interview verified there was no evidence of Resident #55's Power of Attorney having been notified of the eye infection and pneumonia. Interview on 04/27/23 at 4:52 P.M. with Resident #55's Power of Attorney (POA) revealed she does not remember the facility calling her to let her know Resident #55 had pneumonia. She said the facility did not let her know her sister (Resident #55) had open areas on her buttocks. She revealed on 12/16/22, her sister (Resident #55) said her butt was hurting and they turned her over and Resident #55 had pressure ulcers. 2. Review of Resident #17's medical record revealed an admission date of 08/11/22 and readmission date of 03/15/23 with diagnoses including type two diabetes, gastroesophageal reflux disease, malignant neoplasm of prostrate, and traumatic subdural hemorrhage. Review of Resident #17's medical record revealed Resident #17's wife was his guardian. Review of the Impaired Skin Integrity Plan of Care, initiated 09/08/22, revealed Resident #17 had a suspected deep tissue injury. An intervention was to educate Resident #17 on the need to turn and reposition and ensure Resident #17 was turned and positioned. Review of the wound Nurse Practitioner note, dated 03/20/23, revealed Resident #17 had a new suspected deep tissue injury to the right heel. The area measured 3.15 cm by 2.34 cm. Skin prep was ordered to be on the heel. The note indicated to ensure there was a turning protocol and to float heels. Review of the Significant Change Minimum Data Set Assessment, dated 03/23/23, revealed Resident #17 was severely impaired for daily decison making. Review of Resident #17's medical record revealed no evidence Resident #17's guardian was notified of Resident #17's new pressure ulcer to the right heel. Interview on 04/27/23 at 6:28 P.M. with the Director of Nursing verified there was no evidence of Resident #17's guardian having been notified of the new pressure ulcer to the right heel. Review of the facility policy titled Notification of Change in Condition, undated, revealed the center must inform the resident, consult with the resident's physician and/or notify the residents' representative, authorized family member, or legal power of attorney/guardian when there is a change requiring such notification. Circumstances requiring notification included the potential to require physician intervention and a new treatment. When a change in condition is noted, the nursing staff will contact the resident representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure wound dressing were changed appropriately and failed to ensure wound treatments were completed as ordered. This affected two (Residents #6 and #17) out of three residents reviewed for pressure ulcers. The facility census was 52. Findings include: 1. Review of Resident #6's medical record revealed an admission date of 10/29/21 with diagnoses including but not limited to multiple sclerosis and pressure ulcer of the right buttock unstageable. Review of Resident #6's Impaired Skin Integrity Plan of Care, initiated 09/27/22, revealed the resident had impaired skin integrity and was at risk due to multiple sclerosis, weakness, need for assistance with activities of daily living, pain, history of pressure ulcers, poor nutrition, and excoriation to right and left elbows. Review of the quarterly Minimum Data Set Assessment (MDS), dated [DATE], revealed Resident #6 was independent for daily decision-making. Resident #6 was at risk for developing pressure ulcers with an unhealed unstageable (Full thickness tissue loss in which actual. depth of the ulcer is completely obscured by slough and/or eschar in the wound bed) pressure ulcer at the time of the assessment. Review of Resident #6's wound documentation, dated 04/26/23, revealed the resident had a right gluteal unstageable pressure ulcer which measured 1.24 centimeters (cm) by 0.77 cm by 0.5 cm with 2.5 cm tunneling deepest at 10-11 o'clock. The pressure ulcer was worsening with moderate serosanguinous malodorous drainage. A culture was ordered. The treatment was changed to Dakins moist to dry and border foam. Review of Resident #6's wound documentation, dated 04/26/23, revealed Resident #6 had an inhouse acquired left gluteal fold Stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) which reopened on 04/26/23. The pressure ulcer had scant serosanguinous drainage and was 0.95 cm by 1.29 cm by 0.1 cm deep. The treatment order was to cleanse the wound with normal saline daily and apply Santyl and border foam. Observation of Resident #6's pressure ulcer dressing change on 04/27/23 at 10:45 A.M. with Licensed Practical Nurse (LPN) #76 revealed LPN #76 brought in the supplies for the dressing change and laid them on her overbed table without cleaning the table off and wiping it down. The overbed table had a bag of popcorn on it, a glass of chocolate milk, two partially full water glasses, an electric toothbrush, glasses, a lidded thermal handled mug, a bowel of salad with a lid on it, a styrofoam cup, mail and a knife and fork. The nurse picked up a container of deodorant off the floor and placed it on the overbed table as well as a manual toothbrush. LPN #76 washed her hands and put on new gloves, and rolled the resident to her left side and removed the dressings from the coccyx, and right and left gluteal fold, including packing from the right gluteal fold. LPN #76 opened the gauze four by four's and normal saline. She cleansed the coccyx wound, right gluteal fold, then left gluteal fold, all while wearing the same pair of gloves. The LPN stated they sent a culture of Resident #6's right gluteal fold the day prior. She removed her gloves and donned another pair without handwashing. She applied Triad cream to the coccyx with the gloved fingers and applied a foam pad dressing. She went to the treatment cart in the hall and obtained additional supplies. She removed her gloves, washed her hands, and regloved. She applied Santyl to the open area on the left buttock and a foam dressing. She took off her gloves and put on new gloves but did not wash her hands. She cut the gauze in half and used half Dakins and water to pack the right gluteal fold and covered it with a foam dressing. She positioned the resident, took off her gloves, and washed her hands. Interview on 04/27/23 at 12:42 P.M. with LPN #76 verified she did not place the dressing supplies on a clean barrier. She verified she had the same gloves on when cleaning all three pressure ulcers. She also verified she did not consistently wash her hands between changing gloves. 2. Review of Resident #17's medical record revealed an admission date of 08/11/22 and a readmission date of 03/15/23 with diagnoses including but not limited to type two diabetes, malignant neoplasm of prostrate, and traumatic subdural hemorrhage. Review of Resident #17's Impaired Skin Integrity Plan of Care, initiated 09/08/22, revealed the resident had a suspected deep tissue injury. An intervention was to educate resident on need to turn and reposition and ensure resident is turned and positioned. Review of Resident #17's wound Nurse Practitioner note, dated 03/20/23, revealed Resident #17 had a new suspected deep tissue injury to the right heel. The area measured 3.15 cm by 2.34 cm. Skin prep was ordered to be on the heel. Review of Resident #17's Significant Change Minimum Data Set Assessment, dated 03/23/23, revealed the resident was severely impaired for daily decison making. Review of Resident #17's Treatment Administration Record (TAR) revealed Resident #17's treatment to apply skin prep to right heel and pad and protect was not signed off as completed on 03/24/23, 04/01/23 or 04/02/23. Further review of the TAR revealed on 04/06/23, the order was changed to apply a calcium alginate border gauze in the morning for skin care. The treatment was not signed off as completed on 04/06/23 and 04/07/23. Review of Resident #17's wound documentation, dated 04/26/23, revealed Resident #17's right heel pressure ulcer measured 1.24 cm by 0.99 cm and was classified as a stage two pressure ulcer. Observation on 04/27/23 at 12:28 P.M. of Resident #17's pressure ulcer dressing change revealed Resident #17 was in a low bed with the left side against the wall and fall mats on the floor. The resident was turned on his left side with a pillow behind his back and buttocks. The resident had slipper socks on. Licensed Practical Nurse (LPN) #76 removed the dressing items from the cart and placed them on the residents bedside table. LPN #76 pulled down the residents slipper sock and removed the foam pad from his heel. There was a dark area which was approximately 1.0 cm by 1.0 cm. and the perimeter of the dark area was dry. LPN #75 stated the wound nurse pulled off the dried layer of scab over the skin that was over the heel. LPN #75 washed her hands and gloved. LPN #75 opened four by four gauze pads in order to cleanse the right heel and threw the gauze on the residents fitted mattress pad near his feet without a barrier. LPN #75 picked up the gauze off the mattress pad and held it to the residents right heel until she ran saline down the heel. She then wiped the right heel with the gauze pad that had been on the fitted mattress pad. Interview on 04/27/23 at 12:44 P.M. with LPN #75 verified when she was performing the dressing change she placed the gauze pad on the fitted mattress pad which was not a clean surface. Interview on 04/27/23 at 6:28 P.M. with the Director of Nursing verified Resident #17's treatments to the right heel had not been signed as completed 03/24/23, 04/01/23, 04/02/23, 04/06/23 and 04/07/23. Review of the facility's undated Uncomplicated Dressing Change Procedure revealed to prepare a clean hard surface work area using EPA disinfectant wipes and remove gloves and perform hand hygiene before donning gloves again. This deficiency represents non-compliance investigated under Complaint Number OH00139125.

Based on observation, record review, and interviews the facility did not ensure palatable food was served to all the residents eating meals from the kitchen. This had the potential to affect all residents in the facility, with the exception of Residents #4, #17 and #37 the facility identified as consuming nothing by mouth. The facility census was 58. Finding include: Interviews conducted intermittently on 10/31/22 between 9:18 A.M. and 3:33 P.M. with Residents #16, #22, #24, #27, #31, #35, #38, #43, #44, #51, #52 and #53 revealed multiple, pervasive complaints of cold, poor tasting food. Observation was conducted on 10/31/22 beginning at 10:30 A.M. of [NAME] #855 preparing the lunch meal which consisted of breaded fish on bun, marinated chicken thighs, seasoned green beans, potato wedges, rice pilaf and dinner rolls. [NAME] #855 pureed the fish for residents requiring pureed diets and during the pureeing process, added juice from the green beans to the pureed fish. She verified she used green bean juice to add moisture to the pureed fish. Cook #855 was observed to start lunch meal service on the tray line without taking temperatures of the foods in the steam table. She verified she did not take the temperatures of the food prior to starting tray line. When asked by the surveyor what the safe food temperature range would be at the point of service on tray line for hot foods [NAME] #855 said the food should reach 165 degrees prior to being served. [NAME] #855 took the temperature of the potato wedges which read 145 degrees Fahrenheit (F) and removed the pan from the steam table to place back in the oven. When the surveyor asked [NAME] #855 what the minimum temperature at which hot food could be held in the steamtable for service, she said she did not know. The lunch meal service came to a stop while [NAME] #855 reheated the food to reach 165 degrees F. Observation of a test tray was conducted on 10/31/22 and the test tray was placed on the last cart which left the kitchen at 1:39 P.M. At 2:03 P.M. the test tray was delivered to the Culinary Director (CD) #871 who confirmed the temperature of the green beans was 116 degrees Fahrenheit (F) and the potatoes wedges were 111 degrees F. The coffee was one forth cup full with a temperature of 70 degrees F. The surveyor tasted the potatoes and the potatoes were bland with no seasoning or butter and formed a ball more consistent with mashed potatoes than potato wedges. CD #871 said the potatoes did not look like potato wedges, nor did they appear to have any seasoning. CD #871 did not taste test the food. Interview on 11/01/22 at 7:24 A.M. with CD #871 revealed all foods should be served to the resident at a minimum temperature of 120 degrees for palatibility. CD #871 explained all cooks were trained on the proper preparation of meals and meal service, but CD #871 had no records or evidence of any training completed with the cooks. Review of the facility policy titled Food: Quality and Palatability, dated September 2017, revealed food would be palatable, attractive and served at a safe and appetizing temperature. Review of the facility recipe titled baked fish, undated, revealed liquid such as margarine or lemon juice should be added if the product needed flavor or appeared dry. [NAME] bean juice was not listed as an acceptable liquid on the recipe. Review of the facility document titled tray line checklist, undated, revealed food placed on the steam table should be 135 degrees F or hotter and temperatures should be taken, recorded and corrected if not adequate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure a Skilled Nursing Facility Advanced Beneficiary Notice Form (SNF ABN) Form CMS-10055 was provided to Resident #14 and #71 as required. This affected two residents (#14 and #71) of three residents reviewed for liability notices. The facility census was 72. Findings include: 1. Resident #14 was admitted to the facility on [DATE]. On 10/06/2019 Resident #14 was placed under skilled traditional Medicare part A services. The facility issued a Notice of Medicare Non-Coverage form (NOMNC) for a last skilled Medicare day of 12/16/2019. Review of the facility provided forms revealed a SNF ABN form was not provided at the time the NOMNC was issued. 2. Resident #71 was admitted to the facility on [DATE]. On 10/16/2019 Resident #71 was placed under skilled traditional Medicare part A services. The facility issued a Notice of Medicare Non-Coverage form (NOMNC) for a last skilled Medicare day of 11/04/2019. Review of the facility provided forms revealed a SNF ABN form was not provided at the time the NOMNC was issued. Interview with Business Office Manager (BOM) #11 on 02/11/2020 at 2:45 P.M. verified the SNF ABN form was not provided to Resident #14 and #71 when skilled services were ended by the facility.

2. Review of Resident #21's medical record revealed an admission date of 8/21/17 with diagnoses that included post traumatic stress disorder, personal history of other mental and behavioral disorders and major depressive disorder. Review of the resident's PASSAR revealed it was completed on 08/18/17 and did not indicate the resident had post traumatic stress disorder or other mental and behavior disorders. Interview on 02/11/20 at 3:30 P.M. with Director of Social Services #10 confirmed the residents PASSAR was not completed correctly, and therefore the determination stating the resident did not need services might not be accurate. 3. Review of Resident #10's medical record revealed an admission date of 03/25/2009 with admission diagnoses including psychotic disorder and schizophrenia. Review of the Pre admission Screening and Resident Review (PASARR) for Resident #10 revealed the PASARR was completed on 11/01/2007 which found no indication of serious mental illness nor mental retardation/developmental disabilities. Interview with Social Services Designee (SSD) #10 on 02/11/2020 at 3:35 P.M. verified Resident #10's PASARR did not indicate any serious mental illness and the resident was admitted to the facility with psychotic disorder and schizophrenia. Based on record review and staff interview the facility failed to ensure Preadmission Screening and Resident Review (PASSAR) were accurate to contain diagnosis of serious mental disorders. This affected three resident (#10, #21 and #29) of five residents reviewed for PASSAR. Findings include: 1. Review of Resident #29's medical record revealed an admission dated of 06/09/17. Review of the diagnoses included a 02/01/17 major depressive disorder with severe psychotic symptoms, 04/12/18 diagnosis of unspecified psychosis not due to a substance or known physiological condition and 07/01/18 generalized anxiety disorder. A PASSAR dated 04/17/13 had a determination of no indication of serious mental illness. The PASSAR was coded yes for depression and faxed to the facility 06/09/17. Record review revealed no updated PASSAR that included the diagnosis of psychosis and anxiety. Interview on 02/11/20 at 03:47 P.M. with Social Service #10 verified there was not a PASSAR completed for the resident including the diagnoses of psychosis and anxiety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure residents who were dependent on staff for personal care received adequate and timely nail care. This affected three residents (#3, #43, and #172) of five residents reviewed for actives of daily living. The facility census was 72. Findings include: 1. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, muscle weakness, and unspecified convulsion. Review of Resident #3's care plan dated 11/26/19 revealed the resident had a self care deficit related to personal care, the facility was to maintain proper hygiene and staff were to provide total assistance with care. Review of Resident #3's Minimum Data Set (MDS) 3.0 assessment, dated 1/27/20 revealed the resident required total dependence on staff for personal hygiene. Observation on 02/11/20 at 2:10 P.M. of Resident #3 revealed he had very long fingernails and he was unable to cut them himself. Interview on 02/11/20 at 2:10 P.M. Resident #3 revealed he does not like his nail to get that long and that he could not cut them independently. Interview on 02/11/20 2:14 P.M. with Registered Nurse #16 confirmed Resident #3's nails were very long and needed to be cut. 2. Review of Resident #172's medical record revealed an admission date of 1/28/20 with diagnoses including personal history of trans-ischemic attack and cerebral infarction, chronic obstructive pulmonary disease and hypertension. Review of Resident #172's MDS 3.0 assessment revealed the resident required extensive assistance from staff for personal hygiene. Observation on 02/11/20 at 1:38 P.M. revealed the resident's nails were long and dirty. The fingers on her left hand were curled into the palm of her hand leaving indentations on her skin. Interview on 02/11/20 at 1:37 P.M. with Registered Nurse #53 confirmed the resident's nails were very long and leaving indentation on the resident's left hand due to her her history of having a stroke. 3. Review of Resident #43's medical record revealed an admission dated of 10/11/19 with diagnoses including type 2 diabetes, atherosclerotic heart disease, escherichia coli, altered respiratory failure, acute kidney failure and osteomyelitis. Review of the 11/20/19 Activity of Daily Living plan of care revealed the resident had a self care deficit related to altered mental status and limited mobility. Interventions included two staff were required for personal hygiene and oral care. Review of the 01/03/20 Significant Change Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for daily decision making, required extensive assist of two staff for bed mobility and transfers, did not walk, required limited assist of one staff for eating and extensive assist of two staff for personal hygiene. Observation on 02/10/20 at 03:32 P.M. revealed the nail beds of the resident's fingers had debris under them. Observation on 02/11/20 at 1:45 P.M. with the Director of Nursing verified the resident's fingernails had not been cleaned and he required extensive assist (from staff) for personal hygiene. Observation on 02/12/20 at 08:34 A.M. revealed the staff had cleaned his fingernails. Review of the Nail and Hair Hygiene Services Policy revised 04/14/17 revealed residents would have routine nail hygiene and hair hygiene as part of the bath or shower. Nails should be trimmed immediately after bathing or alternatively, soaking nails in warm soapy water prior to trimming or filing to reduce tearing and provide ease of trim and filing.

Based on observation, record review and interview the facility failed to ensure Resident #14 received adequate and as ordered care for treatment related to a fracture. This affected one resident (#14) of one resident reviewed for injuries of unknown origin. Findings include: Review of Resident #14's medical record revealed an admission date of 09/04/19 with diagnoses including, epilepsy, unsteadiness on feet and schizophrenia. Review of a 12/26/19 hospital note revealed the resident suffered a fracture to his middle phalanx of the right digit. Review of Resident #14's December 2019 physician's order revealed an order, dated 12/31/19 that stated may buddy tape fingers if resident wont keep splint in place. Review of the resident's February 2020 Medication Administration Record revealed splint to right hand for fracture. The record also revealed may buddy tape fingers if the resident wont keep splint in place. The record revealed documentation of the devices being in place each shift from 02/01/20 to 02/12/20. Observations on 02/12/20 at 2:52 P.M., 02/13/20 at 8:44 A.M. and 02/13/20 at 10:30 A.M. revealed Resident #14 did not have a splint or buddy tape to this fingers. Interview on 02/13/20 at 10:35 A.M. with Licensed Practical Nurse #25 confirmed Resident #14 did not have a splint or buddy tape on hand or fingers. She further verified that she must have missed it because the prior shift usually applied either the splint or the buddy tape.

Based on observation, record review and interview the facility failed to ensure a splinting device was provided as planned for Resident #29 who had a left wrist/hand/finger contracture. This affected one resident (#29) of three residents reviewed for positioning. Findings include: Review of Resident #29's medical record revealed an admission date of 06/09/17 with diagnoses including major depressive disorder with severe psychotic symptoms, hemiplegia affecting left non dominant side and polyneuropathy. Review of a 08/30/17 Occupational Therapy Discharge note revealed a Left Wrist, Hand, Finger Orthosis (WHFO) was to be used for the resident at night in bed. Review of the 01/01/20 annual Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for daily decision making, had verbal behaviors one to three days a week, was totally dependent on two staff for bed mobility, required extensive assist from two staff for transfers, and extensive assistance from two staff for personal hygiene. The MDS assessment revealed the resident had upper and lower extremity impairment on one side. Review of the current physician's orders revealed an order (initiated 08/02/18) for the resident to wear a left wrist, hand, finger orthosis (WHFO) every evening and night shift. Observation on 02/10/20 at 3:59 P.M. revealed the resident's left hand and fingers were contracted. Interview with the resident at the time of the observation revealed the hand splint was lost and no one could find it. However, review of the treatment administration record revealed staff were documenting the splint was being signed off each evening and night shift as being applied. On 02/11/20 at 01:20 P.M. upon request staff were unable to located the resident's splint. Interview on 02/11/20 at 4:46 P.M. with State Tested Nursing Assistant #51 (STNA) revealed she had not seen the resident's splint for a long time, at least a month. She revealed she had it when she was in another bed but not this one. She stated she had not put the splint on for the evening shift for a long time. Interview on 02/11/20 at 4:58 P.M. with Licensed Practical Nurse #35 (LPN) revealed she did not even realize she was signing off the splint was on when it had not been (on the treatment administration record). Interview on 02/11/20 at 05:16 P.M. with the Director of Nursing (DON) verified the staff were marking the splint was on every evening and night when it was not. The DON said she found a splint in a basket in the linen closet with no name on it.

Based on observation, record review and interview the facility failed to ensure nebulizer treatments were maintained under sanitary conditions and oxygen humidification was provided for Resident #43. This affected one resident (#43) of four residents reviewed for respiratory care. Findings include: Review of Resident #43's medical record revealed an admission date of 10/11/19 with diagnoses including type 2 diabetes, atherosclerotic heart disease, escherichia coli, altered respiratory failure, acute kidney failure and osteomyelitis. Review of the 12/09/19 oxygen therapy plan of care revealed the resident required oxygen related to congestive heart failure, ineffective gas exchange and respiratory illness. Review of the physician's orders revealed an order dated 12/10/19 for DuoNeb Solution 0.5-2.5 milligrams/in 3 milliliter (MG/ML) (Ipratropium-Albuterol) one International Unit Dose (IUD) inhale orally via nebulizer every four hours related to acute respiratory failure with hypoxia and 12/17/19 order for oxygen at three liters per minute (LPM) continuous every shift. Review of the 01/03/20 significant change Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for daily decision making, required extensive assist of two staff for bed mobility and transfers, did not walk, required limited assist of one staff for eating and extensive assist of two staff for personal hygiene and was on oxygen. Observation on 02/10/20 at 03:32 P.M. revealed the Nebulizer mask was on the resident's overbed table face side down. The mask was undated and was not contained in a bag or hooked to the nebulizer machine. The humidifier bottle was on the oxygen condenser but was not connected. The humidifier bottle was undated. Observation on 02/11/20 at 1:45 P.M. with the Director of Nursing verified the nebulizer mask remained on the resident's bedside table face down. The mask was not contained in a bag for sanitation and was undated. The humidification bottle was not hooked into the oxygen tubing. The humidification bottle was undated.

Based on observation, record review and interview the facility failed to ensure Resident #26 received routine dental care. This affected one resident (#26) of two residents reviewed for dental care. Findings include: Review of Resident #26's revealed an admission date of 06/13/17 with diagnoses including anxiety disorder, hypertension, weakness, bipolar disorder, post traumatic stress disorder and hyperlipidemia. The resident signed the dental consent 06/13/17 he wanted he wanted to receive dental services. A new dental provider form was signed 09/16/19 for a new company. Review of the annual 03/22/19 Minimum Data Set (MDS) 3.0 assessment revealed the resident had obvious or likely cavity or broken natural teeth. Review of the 12/13/19 quarterly MDS 3.0 assessment revealed the resident was independent for daily decision making and required supervision set up for personal hygiene. Observation on 02/11/20 at 08:35 A.M. revealed Resident #26 was in bed. Observation of the resident's mouth revealed the resident had white built up around the gum line. Interview on 02/11/20 at 08:57 A.M. with Resident #26 revealed he had not seen a dentist since he was admitted to the facility. Review of the medical record revealed no evidence of a dental consult since the 06/13/17 admission. Interview on 02/12/20 at 04:12 P.M. with Social Services (SS) #10 revealed the expectation was for residents to see the dentist annually. SS #10 verified the resident signed a consent on admission for dental care. The resident signed a consent with the new dental company 09/16/19 and had not received dental service from either company since the 2017 admission. SS #10 verified the facility had not followed up as to why the resident had not been seen the dentist since the admission in 2017.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the infection control log/antibiotic stewardship program and interview the facility failed to implement a comprehensive antibiotic stewardship program. This affected three residents (#14, #57, and #222) of three residents reviewed for infections and had the potential to affect all 72 residents residing in the building. Findings include: 1. Review of Resident #14's medical record revealed an admission date of 09/04/19 with diagnoses including epilepsy, unsteadiness on feet and schizophrenia. Review of the infection surveillance log revealed that while at the hospital on [DATE] the resident was started on an antibiotic, Bactrim for a urinary tract infection (UTI). The section on the log indicating what organism the culture grew was left blank on the form. Review of the December 2019 Medication Administration Record (MAR) revealed Bactrim DS 800-160 milligrams (mg) was given every 12 hours for 10 days for a UTI. Interview on 02/13/20 at 1:09 P.M. with Registered Nurse (RN) #13 confirmed the facility did not obtain the culture from the hospital, and therefore did not monitor for antibiotic stewardship. 2. Review of Resident #57's medical record revealed an admission date of 11/02/18 with diagnoses that included acute kidney failure, hypertension and benign prostatic hyperpiesia without lower urinary tract symptoms. Review of the infection control log revealed on 12/01/19 the resident was started on the antibiotic, Levaquin for an upper respiratory tract infection. Review of the facility Infection Surveillance Criteria Report revealed the resident did not meet criteria to start on an antibiotic. Review of the resident's December 2019 MAR reveled he received Levaquin 750 mg daily for an upper respiratory infection. Interview on 02/13/20 at 1:09 P.M. with Registered Nurse (RN) #13 confirmed the resident did not meet criteria to be started on an antibiotic, and therefore the facility did not follow antibiotic stewardship. 3. Review of Resident #222's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, type two diabetes and hypertension. Review of the facility Infection Control Log revealed the resident was started on an antibiotic, Cipro on 12/1/19 for a UTI. It further revealed the urine culture came back and did not show (bacterial) growth. Review of the facility Infection Surveillance Report revealed the resident did not meet criteria for starting an antibiotic. Review of the 11/30/19 urine culture revealed there was no (bacterial) growth at 48 hours indicating the resident was negative for a UTI Review of the resident's December 2019 MAR revealed from 12/01/19 to 12/10/19 the resident received Cipro 500 mg twice daily for a UTI. Review of the December 2019 nurse's notes revealed the physician was never made aware the culture came back indicating no growth at 48 hours. Interview on 02/13/20 at 1:09 P.M. with Registered Nurse (RN) #13 confirmed the resident did not meet criteria to be started on an antibiotic, the facility failed to notify the physician of the negative urine culture and therefore the facility did not follow antibiotic stewardship. Review of the facility policy titled Infection Monitoring, dated 01/05/18 revealed the facility would monitor antibiotic orders for indications for ordering and any associated clinical lab monitoring. Review of the facility policy titled Antibiotic Stewardship Overview, dated 05/01/17 revealed the facility would provide surveillance, tracking, trending and reporting to the leadership team to optimize the use of antibiotics in the facility.