**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and policy review, the facility failed to ensure residents were treated with dignity, when staff stood over residents while providing assistance with eating. This affected three (#2, #37, and #41) of three residents reviewed for feeding assistance. The facility census was 62. Findings include: Review of the medical record for Resident #2 revealed and admission date of 11/12/20, with diagnoses of Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident has a memory problem and cognitive skills were severely impaired. Resident #2 was dependent on staff assistance with all activities of daily living (ADL)s. Review of the care plan dated 12/04/23 revealed the facility will provide and serve meals as ordered and provide adaptive equipment to improve self-feeding skills. Review of the medical record for Resident #37 revealed and admission date of 07/06/20, with diagnoses of Alzheimer's disease with late onset, anorexia, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly MDS dated [DATE] revealed the resident has a memory problem, and cognitive skills were severely impaired. Resident #37 was dependent on staff assistance with all ADLs. Review of the care plan dated 07/07/20 revealed resident had a nutritional problem with intervention to provide and serve diet as ordered. Review of the medical record for Resident #41 revealed and admission date of 06/16/20, with diagnoses of anorexia, Alzheimer's disease with late onset, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Discharge Return Anticipated MDS, dated [DATE] revealed the resident had a memory problem, and cognitive skills were severely impaired. Resident #41 was dependent on staff assistance with all ADLs. Review of the care plan dated 06/22/20 revealed resident had a nutritional problem with intervention to provide and serve diet as ordered. Observation on 06/04/25 at 8:08 A.M., revealed Licensed Practical Nurse (LPN) #290 standing over Resident #37 feeding her. Observation on 06/04/25 at 8:15 A.M., revealed LPN #290 standing over Resident #41 feeding her. Observation on 06/04/25 at 8:16 A.M., revealed Certified Nursing Assistant (CNA) #204 standing over Resident #2 feeding her Interview on 06/04/25 at 8:20 A.M., with LPN #290 confirmed she was standing over Resident #37 and #41 feeding them breakfast. Interview with LPN #290 confirmed staff should sit down while feeding Resident #37 and #41. Interview on 06/04/25 at 8:20 A.M with CNA #204 confirmed she was standing over Resident #2 feeding her. Interview with CNA #204 confirmed staff should sit down while feeding residents. Review of the undated policy titled Fair Haven Meal Supervision and Assistance, revealed staff should assist with meal feeding as needed to prevent accidents. This deficiency represents the noncompliance investigated under Complaint Number OH00162995.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the medical record review, staff interviews, and policy reviews, the facility failed to address complaints of pain when reported. Additionally, the facility failed to monitor the effectiveness of routine pain medication. This affected one resident (#12) of two residents revealed for pain management. The facility census was 62. Findings include: Medical record review for Resident #12 revealed an admission on [DATE], with diagnoses including but not limited to heart failure, atrial fibrillation, hearing loss, peripheral vascular disease, insomnia, chronic kidney disease, rheumatoid arthritis, dementia, hypertension, osteoarthritis, anxiety disorder, and congestive heart failure. Review of the Annual Minimum Data Set assessment dated [DATE] for Resident #12 revealed resident was cognitively intact. Resident had no behaviors. Resident was independent with eating, dependent with toileting, supervision for bed mobility and transfers. Resident #12 received routine pain medication. Resident #12 reported pain in the last five days, frequency of pain reported almost constantly, pain frequently effecting sleep, pain rarely or not at all interfering with day to day activities and pain intensity was rated seven on a scale of one to ten. Review of the plan of care for Resident #12 dated 07/29/21 revealed resident was at risk for pain related to rheumatoid arthritis, osteoarthritis and bilateral lower extremities wounds. Interventions included anticipate need for pain relief and respond promptly to any complaint of pain, evaluate the effectiveness of pain interventions after initiation or administration, provide, monitor for effectiveness of, and document, non medication interventions for pain prior to administration of analgesics. Review of the active physician orders for Resident #12 revealed an order dated 03/13/25, for prednisone oral tablet five milligrams (mg) give one tablet by mouth one time a day for arthritis; an order dated 09/17/2024, for diclofenac gel (pain relieving gel) apply to bilateral knees topically as needed for pain three times a day; an order dated 09/17/24, for rolamine salicylate 10 percent cream apply to affected areas topically as needed for pain twice daily as needed; an order dated 09/17/24, for lidocaine four percent patch over the counter apply to right shoulder topically two times a day for arthritis pain, apply patch in am in remove patch at bedtime; an order dated 09/17/24, for tramadol 50 mg give one tablet by mouth four times a day for pain; and an order dated 09/17/2024, for Tylenol 325 milligrams, give 1 tablet by mouth four times a day for pain and give two tablet by mouth every six hours as needed for pain. Review of the pain assessment dated [DATE] at 1:00 P.M., for Resident #12 revealed resident had pain in the last five days, that pain was constant in the last five days, that pain made it hard for the resident to sleep and resident rated the pain as a seven on a scale of one to ten. Review of the progress notes for Resident #12 dated 04/11/25 was silent for any documentation for pain management. Review of the Medication Administration Record for Resident #12's month of April 2025 revealed resident was not provided with any as needed pain medications on 04/11/25. Review of the Treatment Administration Record for Resident #12's the month of April 2025 revealed resident was not provided with any as needed topical creams on 04/11/25. Interview on 06/02/25 at 10:50 A.M., with Resident #12 stated she has had arthritis for years and her hands especially just ache at times. Resident #12 reports that pain is manageable, but have had periods in the past that my hands just ache and pain medications do not help. Resident #12 reported that facility staff do not routinely ask her if she is having pain. Interview on 06/05/25 at 11:01 A.M., with Licensed Practical Nurse (LPN) #217 stated the medication administration record does not have a place to document routine pain monitoring. LPN #217 stated she will ask the patient if they are having any pain and will document the level of pain identified by the patient when an as needed (prn) medication has been administered, but can not document that without PRN administration. Interview on 06/09/25 at 10:30 A.M., LPN #426 stated the facility does not document any pain effectiveness on a routine basis, only when a PRN medication has been given. Interview on 06/09/25 at 3:45 P.M., with Director of Nursing (DON) verified at the time of the pain assessment conducted on 04/11/25 at 1:00 P.M., no as needed pain medication was administered. Additionally, the DON verified the facility does not routinely monitor for pain on a daily bases. Review of the undated policy titled Pain Management Policy, stated under number seven: facility staff will reassess resident's pain management for effectiveness and or adverse consequences. This deficiency represents the noncompliance investigated under Complaint Number OH00162889.

Based on observation, staff interview, review of the facility menu, and review of the policy, the facility failed to ensure all residents received a balanced and nutritious meal. This had the potential to affect six residents (#01, #02, #19, #31, #26, and #53) who receive a pureed diet and did not receive bread or the desert, as well as all of the residents, who did not receive the desert. Resident #28 was identified as not receiving anything by mouth and is not affected. The facility census was 62. Findings include: Observation on 06/04/25 at 10:00 A.M. revealed [NAME] #237 preparing the pureed foods. No bread was added to the beef patty, nor the roasted zucchini. Review of the menu served on 06/04/25 included beef pepper patty, mashed potatoes, roasted zucchini, choice of roll, and cherry crisp. Observation on 06/04/25 from 11:27 A.M. to 1:20 P.M., revealed [NAME] #265 served the meals and was assisted by Dietary Manager (DM) #214 preparing the trays for delivery. The meal consisted of a beef pepper patty, mashed potatoes with gravy, roasted zucchini, a dinner roll, margarine, and cherry crisp. As the meals were being plated for the residents receiving a pureed diet, no bread was added to the plate. No pureed desert was noted in any of the serving dishes. Neither DM #214, nor [NAME] #265 placed the desert, cherry crisp, onto any of the trays to be delivered to the units as well as to the residents eating in the dining room. No margarine was placed on the trays. Observation at 11:50 A.M. of the dining room revealed no margarine on any of the tables with residents seated. At 12:16 P.M., surveyor questioned Food Service Worker (FSW) #274 if any of the residents in the dining had been served the desert or had been offered margarine. FSW #274 replied no, and entered the kitchen and began dishing out the desert and grabbed a handful of margarine tubs to offer to the residents. FSW #274 verified a few of the residents had already left the dining room after finishing their meal. Interview at 1:20 P.M. with [NAME] #265 and DM #214 provided verification the desert had not been served with the room trays nor to the residents in the dining room before FSW #274 dished the desert and served it to the remaining residents. They both also stated pureed bread is not served as it is unappealing and none of the residents eat it. [NAME] #265 and DM #214 verified margarine should be on the carts, but when checked the carts did not have any on it. Review of the undated policy titled Menus, revealed menus shall provide a variety of foods and indicate standard portions. This deficiency represents non-compliance investigated under Complaint Number OH00162995.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility self-reported incident (SRI), staff and Detective #40 interviews, and policy review, the facility failed to thoroughly investigate an injury of unknown injury. This affected one (#11) out of three residents reviewed for injuries of unknown origin. The facility census was 57. Findings include: Review of medical record for Resident #11 revealed admission date of 10/24/23. Diagnoses include late onset Alzheimer's, right femoral head fracture, depression, heart failure, and dementia with mood disturbance. Resident #11 was discharged to the hospital on [DATE] and did not return to the facility. Review of Resident #11's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed she required set up for eating and was dependent for toileting hygiene, bed mobility and transfers. Review of the care plan revealed Resident #11 had impaired Activities of Daily Living (ADL's) with the goal to maintain existing ADL self-performance created on 12/07/23. Review of Resident #11's medical record revealed a fall assessment dated [DATE] which documented the resident scored an 11 indicating moderate risk for falls. Review of Resident #11's nurse's notes dated 11/21/24 at 8:38 P.M. revealed the resident was complaining of severe pain to right knee/hip/leg this shift, and holding right leg out to the side in an abnormal position. Resident #11's physician was contacted and also in the facility to assess the resident. Resident #11's physician was concerned for a possible fracture or hip displacement, and gave orders for the resident to be sent to the emergency room for evaluation and treatment of right leg pain. The family was also notified. Resident #11 was transferred to the hospital. Review of Resident #11's hospital medical record revealed on 11/21/24 the resident was seen in the emergency room and was admitted to the hospital for a right femur fracture. Review of a facility SRI dated 11/22/24 for an injury of unknown origin revealed Resident #11 returned from an appointment outside of facility. Resident #11 had the inability to bear weight noted to increase after her return to the facility and continued throughout the next day following her return. Resident #11 was assessed by the physician and was sent to the hospital for evaluation. Resident #11 found to have a fracture to right distal femur. The facility conducted an investigation and determined it to be unsubstantiated. Further review of the SRI and investigation revealed there was no evidence of interviews being conducted with Certified Nursing Assistants (CNA) #43, #44 or #49. Interview on 12/23/24 at 4:51 P.M. with Detective #40 revealed he had been contacted by Resident #11's family regarding a concern of possible abuse. Detective #40 stated the facility contacted him shortly after to report the incident allegation as well involving Resident #11 regarding the fractured femur. Detective #40 verified he had reviewed Resident #11's hospital records and the injury was consistent with a fall. Detective #40 shared the facility had cooperated with him during his investigation. Detective #40 stated he had given a voice test, which he explained was essentially a lie detector test to six staff members with no concern about the results in regarding to caring for Resident #11. Detective #40 stated he had one outstanding interview with the staff member (CNA #44) who put Resident #11 to bed the morning prior to her 11/20/24 doctor appointment. Interview on 12/23/24 at 5:05 P.M. with the Director of Nursing (DON) revealed Resident #11 had been sent to the hospital on [DATE]. The DON stated the hospital completed an x-ray had determined Resident #11 had a right femur fracture. The DON stated she initiated a SRI related to an injury of unknown origin. The DON explained family had come to the facility with allegations of abuse after Resident #11's hospitalization. The DON stated the facility called the Sheriff and Detective #40 came to the facility regarding the Resident #11's injury allegation. The DON shared and supplied the names of six staff members who had been interviewed and voluntarily given what she understood to be a lie detector test by the Sheriff Department with no concerns. The DON stated Detective #40 had one more staff member (CNA #44) to interview before closing his case. The DON confirmed the facility did not interview CNA #44 and this CNA provided care to Resident #11. Interview on 12/24/24 at 9:41 A.M. with CNA #44 revealed she had worked on 11/19/24 and had assisted Resident #11 out of bed and transferred her directly into a shower chair. CNA #44 shared Resident #11 had an appointment the following morning and needed a shower. CNA #44 stated Resident #11 was being resistant during the shower and threw herself from the shower chair and onto the floor. CNA #44 stated Resident #11 did not have any obvious injuries. CNA #44 stated Resident #11's fall on 11/19/24 was reported to Licensed Practical Nurse (LPN) #45 but she did not come to assess the resident and CNA #43 assisted with getting the resident off the shower room floor. Interview on 12/24/24 at 9:58 A.M. with CNA #43 denied assisting CNA #44 with getting Resident #11 off of the floor after a fall on 11/19/24 or any other time. CNA #43 further denied any knowledge of the incident or fall involving Resident #11. Interview on 12/24/24 at 10:26 A.M. with the DON and the Administrator revealed they were unaware of the fall of Resident #11 from 11/19/24. Interview on 12/24/24 at 12:27 P.M. with LPN #45 denied having been informed or any knowledge Resident #11 had a recent fall. A follow up interview with the DON on 12/24/24 at 2:29 P.M. revealed she had not interviewed CNA #44 regarding Resident #11's injury allegation. The DON stated Detective #40 had informed her to only interview facility staff and CNA #44 had been terminated on 12/02/24. The DON acknowledged she did not have any documentation of the Detectives request. Interview on 12/30/24 at 10:11 A.M. with CNA #49 who worked on the evening shift on 11/19/24 with CNA #43 denied knowledge Resident #11 had a fall that night or any other night. Interview on 12/30/24 at 2:10 P.M. with the DON revealed she did not interview CNA #43 or #49 because although they were on the locked unit they were not assigned to care for Resident #11. DON acknowledged she would not know without interviewing CNA #43 or #49 if they had provided care for Resident #11 on 11/19/24. Review of the facility policy titled Freedom from Abuse, Neglect and Exploitation dated 10/20 revealed the investigation would include an interview with staff members having contact with the resident during the relevant periods. This deficiency represents non-compliance investigated under Complaint Numbers OH00160651 and OH00160238.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to develop a comprehensive care plan to address the amount of assistance a resident required with activities of daily living (ADL's). This affected one (#11) out of three resident reviewed for ADL assistance. The facility census was 57. Findings include: Review of medical record for Resident #11 revealed admission date of 10/24/23. Diagnoses include late onset Alzheimer's, right femoral head fracture, depression, heart failure, and dementia with mood disturbance. Resident #11 was discharged to the hospital on [DATE] and did not return to the facility. Review of Resident #11's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed she required set up for eating and was dependent for toileting hygiene, bed mobility and transfers. Review of the care plan revealed Resident #11 had impaired Activities of Daily Living (ADL's) with the goal to maintain existing ADL self-performance created on 12/07/23. Further review of Resident #11's care plan revealed there was care plan or instructions regarding the amount of staff assistance the resident required with any ADL's. Review and interview on 12/30/24 at 12:54 P.M. with the Director of Nursing (DON) regarding the [NAME] for Resident #11 revealed there were no specifics or instructions for transfers. The DON explained if a resident required a mechanical lift or two-person assistance it would state accordingly on the [NAME]. The DON continued to explain since Resident #11 did not have a transferring section on her [NAME], she would only require one person assistance, however two may be used. Interview on 12/30/24 at 1:13 P.M. with MDS Coordinator #50 verified Resident #11's care plan did not indicate the amount of staff assistance required for ADL's including how much assistance was required with transfers. This deficiency represents non-compliance investigated under Complaint Numbers OH00160651 and OH00160238.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews and policy review, the facility failed to assess a resident and complete a post fall investigation after a resident experienced a fall. This affected one (#11) out of three residents reviewed for falls. The facility census was 57. Findings include: Review of medical record for Resident #11 revealed admission date of 10/24/23. Diagnoses include late onset Alzheimer's, right femoral head fracture, depression, heart failure, and dementia with mood disturbance. Resident #11 was discharged to the hospital on [DATE] and did not return to the facility. Review of Resident #11's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed she required set up for eating and was dependent for toileting hygiene, bed mobility and transfers. Review of the care plan revealed Resident #11 had impaired Activities of Daily Living (ADL's) with the goal to maintain existing ADL self-performance created on 12/07/23. Further review of Resident #11's care plan revealed there was care plan or instructions regarding the amount of staff assistance the resident required with any ADL's. Review of Resident #11's medical record revealed a fall assessment dated [DATE] which documented the resident scored an 11 indicating moderate risk for falls. Further record review for Resident #11 revealed there was no documentation regarding the resident experiencing a fall on 11/19/24. There were no documented falls for Resident #11 in the past six months. Interview on 12/24/24 at 9:41 A.M. with Certified Nursing Assistant (CNA) #44 revealed she had worked on 11/19/24 and had assisted Resident #11 out of bed and transferred her directly into a shower chair. CNA #44 shared Resident #11 had an appointment the following morning and needed a shower. CNA #44 stated Resident #11 was being resistant during the shower and threw herself from the shower chair and onto the floor. CNA #44 stated Resident #11 did not have any obvious injuries. CNA #44 stated Resident #11's fall on 11/19/24 was reported to Licensed Practical Nurse (LPN) #45 but she did not come to assess the resident and CNA #43 assisted with getting the resident off the shower room floor. Interview on 12/24/24 at 9:58 A.M. with CNA #43 denied assisting CNA #44 with getting Resident #11 off of the floor after a fall on 11/19/24 or any other time. CNA #43 further denied any knowledge of the incident or fall involving Resident #11. Interview on 12/24/24 at 12:27 P.M. with LPN #45 denied having been informed or any knowledge Resident #11 had a recent fall. Interview on 12/24/24 at 10:26 A.M. with the Director of Nursing (DON) revealed she had not been informed by any staff member that Resident #11 had fallen during a shower on 11/19/24. A second interview on 12/30/24 at 2:10 P.M. with the DON revealed a fall investigation had not been completed for Resident #11 for a fall on 11/19/24 and it would be the expectation of the facility, staff would report a fall. The DON confirmed a fall investigation should then be completed and the resident should be assessed following a fall. Interview on 12/30/24 at 10:11 A.M. with CNA #49 who she also worked on the evening shift on 11/19/24 with Resident #11 and denied knowledge Resident #11 had a fall that night or any other night. Review of the facility policy, Fall Prevention Policy last reviewed 12/01/21 revealed post fall nursing would assess resident and follow up as appropriate. This deficiency represents non-compliance investigated under Complaint Numbers OH00160651 and OH00160238.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to administer medications per physician order. This affected one (Resident #63) of three residents reviewed for medication administration. The facility census was 67. Findings include: Review of the medical record for Resident #63 revealed an admission date of 07/16/24 with diagnoses including congestive heart failure, dementia, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 was cognitively intact. Review of Resident #63's Medication Administration Record (MAR) for September 2024 revealed cyancobalamin 1,000 (Vitamin B12) microgram (mcg) per milliliter (ml) give one ml on the 26th of every month was not given due to medication being available. Levothyroxine (treats thyroid) 25 mcg was not signed off as administered on 09/17/24 and 09/27/24. The MAR for October 2024 revealed Levothyroxine 25 mcg was not signed off as administered on 10/01/24 and 10/02/24. Interview on 10/09/24 at 4:06 P.M. with the Director of Nursing (DON) verified the cyancobalamin was not signed off as administered on 09/26/24 to Resident #63 and the nursing note stated the medication was not available. The DON verified the Levothyroxine was not signed off as administered on 09/17/24, 09/27/24, 10/01/24, and 10/02/24. The DON verified the facility could not validate the medications were administered to Resident #63 as they were not documented as given. Subsequent interview on 10/09/24 at 4:37 P.M. with the DON stated the cyancobalamin was administered on day shift on 09/29/24 per the nursing report sheet. The DON verified there was no physician order to hold the medication until medication arrived or an order to give the medication when it was available from the pharmacy. The DON verified Resident #63's medical record did not include cyancobalamin was administered to Resident #63 on 09/29/24. This deficiency represents non-compliance investigated under Complaint Number OH00158208.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and resident, family, and staff interview, the facility failed to ensure they had a qualified professional activities director and activities were provided to the residents as scheduled. This affected two residents (#45 and #63) of four residents reviewed for activities. This had the potential to affect all residents except for the 18 residents identified by the facility who usually decline to attend activities. The facility census was 67. Findings include: 1. Review of the medical record for Resident #45 revealed an admission date of 04/08/24 with diagnoses including dementia, Alzheimer's disease, major depressive disorder, and altered mental status. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had moderate cognitive impairment. Review of the care plan dated 10/10/24 revealed the resident needed assistance/escort for activity functions, preferred activities included reading the bible, church, family and friends, bingo, special events, outings with family and friends, walking, and playing cards on her computer. Staff to remind resident that she may leave activities at any time and that it was not required to stay for the entire activity. Interview on 10/09/24 at 1:36 P.M. with Resident #45 stated she would like to go to activities when she knows they were doing them. Resident #45 stated she likes bingo. Family Member #390 in the room at the time of the interview and stated she felt like the resident needed to be asked and reminded of the activities that were planned. Family Member #390 stated the resident does not always understand the first time she was asked about an activity and may not want to go, but feels she would enjoy the activity. Family Member #390 stated the facility needed an activities director and they should have more crafts. 2. Review of the medical record for Resident #63 revealed an admission date of 07/16/24 with diagnoses including rheumatoid arthritis, dementia, and anxiety. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of the care plan dated 10/11/24 revealed the resident needed assistance/escort to activity functions. Preferred activities were working on puzzle books, talking with family, watching television, socializing with staff, reading, and listening to christian music. Interview on 10/09/24 at 11:19 A.M. with Resident #63 stated the facility does not have enough good activities anymore. Resident #63 stated they have not had an activities director for about a year. Resident #63 stated the last two they had hired did not work out and did not stay. Resident #63 stated the activities assistant was going around today selling items from the cart to help raise money for activities. Observation on 10/09/24 during the initial tour from 8:17 A.M. to 9:16 A.M. of the activity calendar revealed the following activities: 10:30 A.M. fall van ride, seated exercise for those not going on the van ride, 1:30 P.M. fall van ride, 2:30 P.M. brain games. Market Cart Monday through Friday 10:30 A.M. to 11:30 A.M. and 2:30 P.M. to 3:30 P.M. Observation on 10/09/24 from 10:30 A.M. to 10:40 A.M. revealed no seated exercises was performed. Interview on 10/09/24 at 12:39 A.M. with Activities Assistant (AA) #200 verified there was no seated exercises activity for the residents at 10:30 A.M. AA #200 explained she was unable to conduct the exercise activity as planned at 10:30 A.M. due to gathering residents for the fall van ride. AA #200 verified she was the only one in activities at this time. AA #200 verified she works five days a week. AA #200 stated she has on average of 15-20 residents attending activities depending on what the activity was. Interview on 10/09/24 at 1:02 P.M. with the Administrator revealed the facility has tried to hire an activities director with no success. Administrator stated they had hired for the position twice but they did not stay. Administrator stated the office staff help with the activities when the activities assistant is off. This deficiency represents non-compliance investigated under Complaint Number OH00158208.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, medical record reviews, and policy review, the facility failed to ensure medications were administered as ordered resulting in two medication errors out of 33 opportunities or six percent (%) medication error rate. This affected two (#2 and #17) out of the three residents observed for medication administration. The facility census was 66. Findings included: 1. Review of the medical record for Resident #17 revealed an admission date of 06/06/15 with medical diagnoses of cerebral infarction with left hemiparesis, chronic pain syndrome, diabetes mellitus, and depression. Review of the medical record for Resident #17 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #17 was cognitively intact and required substantial staff assistance with toilet hygiene, bathing, and bed mobility. Review of the medical record for Resident #17 revealed a physician order dated 07/24/18 for lisinopril 20 milligram (mg) one tablet by mouth daily for blood pressure. Observation with interview on 02/05/24 at 9:10 A.M. of Licensed Practical Nurse (LPN) #117 administering medications to Resident #17 revealed the Lisinopril 20 mg one tablet was not administered as ordered. LPN #117 confirmed the Lisinopril was not in the medication cart and was not administered to Resident #17 was ordered. 2. Review of the medical record for Resident #2 revealed an admission date of 04/16/21 with medical diagnoses of cerebral infarction with right hemiparesis, dementia, depression, and anxiety. Review of the medical record for Resident #2 revealed a quarterly MDS, dated [DATE], which indicated Resident #2 had moderate cognitive impairment and required substantial staff assistance with bathing, bed mobility, and transfers, and was independent with eating. Review of the medical record for Resident #2 revealed a physician order dated 01/07/23 for Nuedexta (administered for neurological conditions) 20-10 mg one capsule by mouth two times per day. Observation with interview on 02/05/24 at 9:22 A.M. of LPN #117 administering medications to Resident #2 revealed the Nuedexta 20-10 mg capsule was not administered as ordered. LPN #117 confirmed the Nuedexta was not in the medication cart and the medication was not administered to Resident #2 as ordered. Interview on 02/05/24 at 1:05 P.M. with Director of Nursing (DON) stated all medications are to be reordered from the pharmacy when there is a week supply left so that the facility has medications in stock to administer to all residents. Review of the facility policy titled, Medication Administration, stated medications must be administered in accordance with the written orders of the attending physician. This deficiency represents non-compliance investigated under Complaint Number OH00150230.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interviews, and policy review, the facility failed to follow infection control guidelines when performing incontinence care. This affected one (#53) out of three residents reviewed for incontinence care. The facility census was 66. Findings included: Review of the medical record for Resident #53 revealed an admission date of 12/02/16 with medical diagnoses of Alzheimer's disease, macular degeneration, peripheral vascular disease, and anxiety. Review of the medical record for Resident #53 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #53 had severe cognitive impairment and was dependent for toilet hygiene, bed mobility, transfers, eating, and bathing. The MDS indicated Resident #53 was always incontinent of bladder and bowel. Observation on 02/06/24 at 12:51 P.M. revealed Registered Nursing (RN) #108 and Stated Tested Nursing Assistant (STNA) #106 completed incontinence care for Resident #53. The observation revealed STNA #106 cleansed Resident #53 peri area with cleansing wipes and then proceeded to cleanse Resident #53's buttocks. As STNA #106 was cleaning Resident #53 stool was noted on the cleansing wipes. STNA #106 properly disposed of soiled cleansing wipes and soiled depends. STNA #106 proceeded to apply barrier cream to Resident #53's buttocks and then applied a clean depends. The observation revealed STNA #106 did not remove her gloves or perform hand hygiene after she performed incontinence care for Resident #53 or prior to the application of the barrier cream and clean depends. Interview on 02/06/24 at 1:26 P.M. with STNA #106 confirmed she did not perform hand hygiene or change gloves after completing incontinence care for Resident #53 and prior to application of barrier cream and clean depends. Interview on 02/06/24 at 2:32 P.M. with Infection Control Nurse #157 confirmed during incontinence care, staff are to remove soiled gloves, wash hands, and then apply clean gloves prior to application of barrier creams and clean depends. Review of the policy titled, Infection Control, dated 03/19/21, stated the facility believed good, basic hygiene was the most powerful weapon against infection, particularly with respect to hand washing. The policy stated all staff members should wash their hands after handling any body fluids or soiled items. This deficiency represents non-compliance investigated under Complaint Number OH00150806.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, staff interview, and policy review, the facility failed to administer medications as ordered. This affected four (#2, #3, #17, and #25) out of the four residents reviewed for medication administered as ordered. The facility census was 66. Findings included: 1. Review of the medical record for Resident #2 revealed an admission date of 04/16/21 with medical diagnoses of cerebral infarction with right hemiparesis, dementia, depression, and anxiety. Review of the medical record for Resident #2 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #2 had moderate cognitive impairment and required substantial staff assistance with bathing, bed mobility, and transfers, and was independent with eating. Review of the medical record for Resident #s revealed physician orders dated 03/07/22 for ferrous sulfate 325 milligram (mg) one tablet by mouth two times per day, 12/03/19 for Dilantin 100 mg one capsule by mouth three times per day, 10/30/19 for fish oil 1200 mg one capsule by mouth three times per day, 09/12/21 for atorvastatin 10 mg one tablet by mouth daily, 10/30/19 for Zoloft 50 mg take one and one half tablet daily, 10/30/19 for protonix 40 mg on tablet by mouth daily, and 01/07/23 for Nuedexta 20-10 mg one capsule by mouth two times per day. Review of the medical record for Resident #2 revealed the Medication Administration Records (MAR) for January 2024 which did not contain documentation to support the following medications were administered: ferrous sulfate 325 milligram (mg) one tablet by mouth on 01/08/24 and 01/22/24, Dilantin 100 mg one tablet by mouth on 01/08/24, 01/21/24, and 01/22/24, fish oil 1200 mg one tablet by mouth on 01/22/24, atorvastatin 10 mg one tablet by mouth on 01/08/24, Zoloft 50 mg one tablet by mouth on 01/08/24, and protonix 40 mg one tablet by mouth on 01/08/24. Further review of the medical record for Resident #2 revealed the February 2023 MAR which did not contain documentation to support Resident #2's Nuedexta 20-20 mg one capsule by mouth on 02/05/24. 2. Review of the medical record for Resident #3 revealed an admission date of 11/03/22 with medical diagnoses of chronic obstructive pulmonary disease (COPD), psychotic disorder with delusions, dementia, anxiety, and gastric esophageal reflux disease (GERD). Review of the medical record for Resident #3 revealed a quarterly MDS, dated [DATE], which indicated Resident #3 had severely impaired cognition and was independent with toileting, bed mobility, transfers and required supervision with bathing. Review of the medical record for Resident #3 revealed physician orders dated 10/24/23 for Buspar 10 mg one tablet by mouth three times per day, 11/03/22 for Advair disc 500/50 use one puff daily, 01/10/24 for Namenda 10 mg one tablet by mouth every evening, and Zoloft 125 mg one tablet by mouth every evening. Review of the medical record for Resident #3 revealed the January 2024 MAR did not contain documentation to support the following medications were administered as ordered: Namenda 10 mg tablet by mouth on 01/17/24 and 01/30/24, Zoloft 125 mg one tablet by mouth on 01/17/24, Advair disc one puff on 01/17/24, and Buspar 10 mg one tablet by mouth on 01/08/24. 3. Review of the medical record for Resident #17 revealed an admission date of 06/06/15 with medical diagnoses of cerebral infarction with left hemiparesis, chronic pain syndrome, diabetes mellitus, and depression. Review of the medical record for Resident #17 revealed a quarterly MDS, dated [DATE], which indicated Resident #17 was cognitively intact and required substantial staff assistance with toilet hygiene, bathing, and bed mobility. Review of the medical record for Resident #17 revealed physician orders dated 06/06/15 for metoprolol 25 mg by mouth one tablet two times per day, 09/04/18 for simvastatin 20 mg one tablet by mouth daily, 06/06/15 Novolog insulin to be administered per sliding scale instructions of blood sugar levels of 0-139 none, 140-189 one unit, 190-239 three units, 240-289 five units, 290-339 seven units, 340-389 nine units, readings less than 70 or greater than 389 facility to call physician for orders. Review of the medical record for Resident #17 revealed the January 2024 MAR which did not contain documentation to support the following medications were administered as ordered: metoprolol 25 mg one tablet by mouth on 01/04/24, simvastatin 20 mg one tablet by mouth on 01/14/24, and Novolog insulin per sliding scale on 01/20/24, 01/17/24, and 01/18/24. 4. Review of the medical record for Resident #25 revealed an admission date of 01/25/24 with medical diagnoses of right femur fracture, diabetes mellitus, hypertension, hypothyroidism, and depression. Review of the medical record for Resident #25 revealed an admission nursing screener completed 01/25/24 which indicated Resident #25 was alert and oriented to person, place, and time and required extensive staff assistance with bed mobility, transfers, and toileting. Review of the medical record for Resident #25 revealed physician orders dated 01/25/24 for glipizide 10 mg one tablet by mouth two times per day, Levemir eight units inject subcutaneous (SQ) daily, Actos 30 mg one tablet by mouth daily, ranolazine 500 mg one tablet by mouth two times per day, senna 8.6 mg two tablets by mouth daily, Synthroid 125 micrograms one tablet by mouth daily, and acetaminophen 325 mg two tablets by mouth four times per day. Review of the medical record for Resident #25 revealed the January 2024 MAR did not contain documentation to support the following medications were administered as ordered: glipizide 10 mg on tablet by mouth on 01/31/24, Levemir inject eight units SQ daily on 01/30/24, Actos 30 mg one tablet by mouth on 01/30/24, ranolazine 500 mg one tablet by mouth on 01/30/24, senna 8.6 mg two tablets by mouth on 01/30/24, Synthroid 125 micrograms one tablet by mouth on 01/31/24, and acetaminophen 325 mg two tablets by mouth on 01/30/24. Interview on 02/05/24 at 3:10 P.M. with Director of Nursing (DON) confirmed the medical records for Residents #2, #3, #17, and #25 did not contain documentation to support the residents received their medications as ordered in January and February 2024. Review of the facility policy titled Medication Administration stated all medications must be administered in accordance with the written orders of the attending physician. This deficiency represents non-compliance investigated under Complaint Number OH00150230.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, observation, and review of facility recipes, the facility failed to make pureed food to the correct texture and failed to follow a recipe to make the pureed food. This had the potential to affect six (#5, #15, #20, #24, #38, and #53) residents who have orders for pureed food. Facility census was 75. Finding include: Observation and interview on 10/18/22 at 11:00 A.M. revealed Dietary Staff #73 placed an unmeasured amount of grilled chicken in a blender to make pureed chicken, then seven,four ounce scoops of gravy were added. The food was blended and the remainder of the pot of gravy was poured into the mixture (unmeasured). Dietary staff revealed they put in typically seven to eight chicken breasts to make the required seven pureed meals. The mixture appeared to be thin and smoothie like consistency. Observation and interview on 10/18/22 at 11:07 A.M. revealed Dietary Staff #73 placed four, four ounce scoops of mixed vegetables in the blender, blended the vegetables and placed the mixture on the warming table. No butter or thickener was added during the observation. Observation and interview on 10/18/22 at 11:15 A.M. with Dietary Staff #73 placed seven servings of ice cream, canned peaches and a fruit syrup into the blender. When mixed the consistency was about a thin milkshake consistency. When asked if the consistency was accurate for pureed texture dietary staff did not comment, but then pumped about three pumps of liquid thickener into the pan and mixed with a spoon. Interview on 10/18/22 at 11:18 with Dietary Staff #73 and Kitchen Manager #42 revealed the facility had recipes for the pureed food in binders in the back of the kitchen. Kitchen Manager #42 revealed they were waiting to get a final copy of recipes from the menu on 10/18/22 but revealed it was on her computer just not in the binder. Dietary Staff #73 confirmed recipe was not used in making pureed foods on 10/18/22. Interview on 10/20/22 at 5:51 P.M. with Dietician #99 revealed staff from her company review the menus and recipes. Dietician #99 confirmed staff should follow the recipes provided to ensure nutritive value and proper texture. The facility confirmed the identified concern had the potential to affect six (#5, #15, #20, #24, #38, and #53) residents who have orders for pureed food. The recipe for chicken breast ranch crunchy baked called for the baked crunchy ranch chicken breast to be made according to recipe then pureed along with a chicken stock base and hot water mixture as well as thicker for texture. The recipe for vegetable blend prince charles called for four ounces per serving to be blended with butter and thickener for consistency. The recipe for peach [NAME] (ice cream, peaches, and fruit syrup) called to remove portions to be pureed and puree separately then add to the dish. Apple juice was to be added as a thinning agent. Menu spreadsheet for lunch meal on 10/18/22 revealed resident's with orders for pureed foods should have received a four ounce servings for vegetables. Facility had no policy regarding the making of therapeutic texture meals.

Based on observations, staff interview and policy review, the facility failed to safety store food items in the refrigerator, freezer, and dry storage areas. This had the potential to affect 74 out of 75 residents residing in the facility, the facility identified one (#52) resident who receives no food from the kitchen. Facility census was 75. Findings include: Observation on 10/17/22 at 11:20 A.M. to 11:40 A.M. revealed the following concerns in the walk in refrigerator: - shredded lettuce left open to air with no date - shredded white cheese left open to air with no date - both containers of cranberry juice were had expired 10/13/22 - unknown pureed food in a styrofoam bowl with no label and no date - butter sticks were left open to air and undated - lunch meat turkey was open to air and undated - hotdog's were left open to air and undated - chunk of meat (appeared like ham) was not labeled or dated Observations in the walk in freezer revealed the following concerns: - pie missing slice and two whole pies were undated - breadsticks undated - slices of bread and rolls undated - chicken nuggets open to air and undated - unknown meat was not labeled and was undated Observations in the dry storage area revealed the following concerns: - salsa had been opened and placed back in dry storage (bottle had instructions to refrigerate after opening). The salsa had gone bad and expanded the bottle so much it would not sit straight on the shelf. - nine bottles of lemon juice expired on 08/27/22 - three dented cans of sliced apples, mandarin oranges, and sweet potatoes Interview on 10/17/22 at 11:45 A.M. with Kitchen Manager #42 confirmed all food storage findings in the refrigerator, freezer, and dry storage areas. The facility confirmed this had the potential to affect 74 out of 75 residents residing in the facility, there was one (#52) resident who receives no food from the kitchen. Follow up observation on 10/18/22 at 11:20 A.M. revealed many of the findings were still in place. Observations in the walk in refrigerator revealed the following concerns: - chunk of meat (appeared like ham) was not labeled or dated Observations in the walk in freezer revealed the following concerns: - pie missing slice and two whole pies were undated - breadsticks undated - slices of bread and rolls undated - chicken nuggets open to air and undated - unknown meat was not labeled and was undated Review of facility policy titled Food Storage, undated, revealed the facility failed to implement the policy in regards to the allegation. The policy revealed food storage areas should be maintained in a clean, safe, and sanitary manner. An amendment was added 08/03/15 stating the dietary manager or designee would check refrigerators weekly for expired food or food close to expiration date and would be done for six months. The policy does not give guidance on dating, labeling, and sealing food after opening, or on the handling of expired food after 02/2016.

Based on observations and staff interview, the facility failed to maintain covered and clean trash receptacles in the kitchen. This had the potential to affect 74 out of 75 residents residing in the facility, the facility identified one (#52) resident who receives no food from the kitchen. Facility census was 75. Findings include Observation on 10/17/22 at 11:20 A.M. to 11:40 A.M. revealed the kitchen had one blue recycling bin that was overflowing with items piled on top of the lid. Their was a large gray round trash bin with a trash bag that had fallen off the rim down into the trash can with no lid or covering. Four black kitchen trash cans were observed to have no lids or coverings. Interview on 10/17/22 at 11:45 A.M. with Kitchen Manager #42 confirmed trash cans did not have lids. Kitchen manager #42 revealed the lids were thrown out before she started and she was told they were unsanitary. The facility confirmed this had the potential to affect 74 out of 75 residents residing in the facility, the facility identified one (#52) resident who receives no food from the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to provide written notification of transfer or discharge to the resident and the resident's representative. This affected two (#90 and #65) out of three residents reviewed for hospitalization. The facility census was 96. Findings include: 1. Review of the medical record for Resident #90 revealed he was admitted to the facility on [DATE]. His diagnoses included left hip fracture dated 09/15/19, Parkinson's disease, cataracts bilaterally, glaucoma, atrial fibrillation, prostate cancer, hypotension and cardiac pacemaker. Review of the discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #90 was discharged , return anticipated on 09/11/19. The Entry MDS dated [DATE] revealed Resident #90 returned to the facility on [DATE]. Review of the medical record revealed no evidence Resident #90 was provided information in writing of the reason for his transfer to the emergency room and subsequent admission to the hospital on [DATE]. Interview with Licensed Social Worker (LSW) #306 on 11/20/19 at 11:47 A.M. stated the nursing staff were responsible to provide the written notice of transfer to the hospital to the resident at the time of the transfer. LSW #306 verified there was no evidence of notification of transfer or discharge provided to Resident #90. 2. Resident #65 was admitted to he facility on 11/22/16. She was readmitted to the facility on [DATE] with diagnoses including displaced fracture of left hip, anemia, peripheral vascular disease, anxiety disorder, Alzheimer's disease , dementia with behavior disturbances, major depressive disorder,and chronic kidney disease. Review of Resident #65's annual minimum data set (MDS) assessment dated [DATE] revealed the resident scored a three on the Brief Interview for Mental Status indicating she had severe cognitive impairment. Review of the medical record revealed Resident #65 was admitted to the hospital on [DATE] through 08/01/19 following a fall resulting in a fractured hip. There was no evidence in the medical record the resident's representative was given a written summary of the reason for transfer/discharge to the hospital. On 11/20/19 at 5:45 P.M. interview with the Director of Nursing and Administrator verified the nurses are to give a written summary of the reason for discharge and bed hold to the family and document this in the medical record . They verified there is no documentation stating a written reason for hospitalization was given to Resident #65 representative. Review of the facility policy titled, Tranferring Resident to Another Facility Policy and Procedure, dated 10/2018 revealed the communication document was a tool for sharing information during transfers. Per the policy the facility will provide a copy of the transfer notice to the receiving facility, the resident or the resident's family representative, and a copy of the transfer notice will be added in the resident's chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to provide written notification of the bed hold policy to the resident or resident representative at the time of discharge to the hospital. This affected two (#90 and #65) out of three residents reviewed for hospitalization. The facility census was 96. Findings include: 1. Review of the medical record for Resident #90 revealed he was admitted to the facility on [DATE]. His diagnoses included left hip fracture dated 09/15/19, Parkinson's disease, cataracts bilaterally, glaucoma, atrial fibrillation, prostate cancer, hypotension and cardiac pacemaker. Review of the discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #90 was discharged , return anticipated on 09/11/19. The Entry MDS dated [DATE] revealed Resident #90 returned to the facility on [DATE]. Review of the medical record revealed no evidence Resident #90 and/or his representative were provided information in writing of bed-hold policy at the time of his transfer to the emergency room and subsequent admission to the hospital on [DATE]. Interview with Licensed Social Worker (LSW) #306 on 11/20/19 at 11:47 A.M. stated the nursing staff were responsible to provide the written notice of transfer to the hospital to the resident at the time of the transfer. The notice included the bed hold policy. LSW #306 verified there was no evidence Resident #90 and/or his representative were provided information in writing of bed-hold policy at the time of his transfer to the emergency room and subsequent admission to the hospital on [DATE]. 2. Resident #65 was admitted to he facility on 11/22/16. She was readmitted to the facility on [DATE] with diagnoses including displaced fracture of left hip, anemia, peripheral vascular disease, anxiety disorder, Alzheimer's disease, dementia with behavior disturbances, major depressive disorder,and chronic kidney disease. Review of Resident #65's annual MDS assessment dated [DATE] revealed the resident scored a three on the Brief Interview for Mental Status indicating she had severe cognitive impairment. Review of the medical record revealed Resident #65 was admitted to the hospital on [DATE] through 08/01/19 following a fall resulting in a fractured hip. There was no evidence in the medical record the resident's representative was given a notice of the faciliy's bed hold policy. On 11/20/19 at 5:45 P.M. interview with the Director of Nursing and Administrator verified the nurses are to give a written summary of the reason for discharge and bed hold to the family and document this in the medical record. They verified there is no documentation stating a bed hold policy was given to Resident #65 representative. Review of the facility policy titled, Transferring Resident to Another Facility Policy and Procedure, dated 10/2018 revealed the communication document was a tool for sharing information during transfers. Per the policy the facility will provide a copy of the transfer notice to the resident or the resident's family representative and place a copy of the transfer notice in the resident's chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed implement a a dietary recommendation and physician order to increase a dietary supplement for a resident with a history of a significant weigh loss. This affected one (#91) out of two residents reviewed for significant weight loss/nutrition. The facility census was 96. Findings include: Resident #91 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, contracture of the left knee and bilateral hands, and peripheral vascular disease. Review of the annual minimum data set (MDS) assessment dated [DATE] documented the resident had short and long term memory loss. She exhibited rejection of care four to six days of the assessment period. She required extensive assistance of one person for eating. She had no swallowing or chewing difficulties. Her weight at the time of the assessment was 124 pounds with no weight loss. Review of an annual MDS assessment dated [DATE] revealed the resident required total assistance for all activities including eating. Her weight at the time of the assessment was 98 pounds with significant weight loss The nutrition care area assessment (CAA) stated the resident was at nutrition risk and stated to see the nutritional assessment dated [DATE]. Review of the plan of care , updated 10/30/19, documented the resident had a nutritional problem or due to Alzheimer's disease, edema and poor intakes. The interventions included providing supplements as ordered and monitoring the acceptance of the supplements. Review of the weights recorded in the medical record revealed on 07/09/19 the resident weighed 103 pounds. On 08/01/19 the resident weighed 100 pounds; on 09/01/19 the resident weighed 97 pounds; on 10/01/19 the resident weighed 98 pounds; on 10/26/19 the resident weighed 98 pounds; on 11/02/19 the resident weighed 88 pounds and on 11/17/19 the resident weighed 88 pounds. Review of the Consultant Dietician Recommendations, dated 10/30/19, documented to increase Resource supplement to eight ounces (240 milliliters (ml)) three times a day from the current amount of four ounces (120 ml) three times a day. The dietary note stated her current weight was 98 pounds. On 11/07/19 a physician order was received to follow the dieticians recommendations and increase the Resource supplement to eight ounces three times a day between meals due to poor intakes and weight loss. Review of the November 2019 medication administration record revealed the resident was receiving Resource 2.0 dietary supplement four ounces (120 ml) three times a day from 11/01/19 through the morning of 11/21/19. Interview with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) # 339 on 11/21/19 at 10:30 A.M. verified there was a physician order dated 11/07/19 instructing staff to increase the Resource supplement to eight ounces three times a day. They verified the order had not been put on the November 2019 medication record and the resident had continued to receive four ounces of the supplement three times a day between 11/07/19 through the current time on 11/21/19. .

Based on observation and staff interview, the facility failed to ensure meals were served under sanitary handling conditions for Resident #122. This affected one (#122) randomly observed resident receiving a hall tray on the Sycamore hall. The facility census was 96. Findings include: Observation on 11/18/19 from 11:52 A.M. to 12:16 P.M. of hall trays being served on the sycamore hall revealed -no issues identified until the last room tray for infection control. Observation on 11/18/19 at 12:12 P.M. of Resident Assistant (RA) #394 passing hall trays on the sycamore hall revealed the RA #394 touched Resident #122's shoulder to awaken the resident. RA #394 assisted Resident #122 by cutting up her food. It was observed RA #394 had a rope type dangling bracelet on her left wrist. It was observed the bracelet was dangling and went into the residents beverage several times as she was cutting up the food. Interview on 11/18/19 at 12:16 P.M. with RA #394 verified after touching her bracelet, the bracelet was wet and had gone into Resident #122's beverage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #70 revealed she was admitted to the facility on [DATE] with diagnoses of congestive heart failure, chronic kidney disease, anemia, general anxiety disorder, chronic obstructive pulmonary disease, iron deficiency anemia, arthritis, and hypothyroidism. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #70 was cognitively intact, required partial moderate assistance to substantial maximal assistance for activities of daily living. The MDS further revealed the Resident #70 required supervision to ambulate 10-50 feet and was dependent for ambulation of 150 feet. Review of nursing notes from 11/06/19 to 11/19/19 revealed no documentation of any incidents for the Resident #70 indicating a bruise on the residents cheekbone. Observation on 11/19/19 at 10:27 A.M. revealed Resident #70 was reclined in her recliner in her room. Further observation revealed the Resident #70 had a black and blue bruise under her left eye around the cheek bone area. Interview on 11/19/19 at 10:29 A.M. with the Resident #70 revealed the resident did not know she had a bruise on her cheekbone and did not know how she could have gotten one. The Resident #70 revealed she had not fallen. Further review of the Resident #70's medical record from 11/06/19 to 11/19/19 revealed no identification, investigation, implementations of policy for bruises of unknown origin. Interview on 11/19/19 at 10:34 A.M. with the Licensed Practical Nurse (LPN) #341 revealed the resident had not fallen and the LPN #341 was not aware of the Resident #70 having a bruise on her left cheekbone. Interview on 11/19/19 at 10:41 A.M. with the RN #313 revealed the Resident #70 had not previously had a bruises on her left cheekbone and if the Resident #70 had a bruise it would be a new bruise. Interview on 11/19/19 at 10:46 A.M. with the RN #313 revealed she had just observed the Resident #70's bruise on the left cheek and it looked to the RN that Resident #70 had a bruise starting on the right cheekbone as well. RN #313 revealed Resident #70 was prescribed Aspirin 81 milligrams daily and her opinion was the bruising could be from oxygen nasal cannula tubing. RN #313 revealed the facility would contact the medical director for orders. Interview on 11/19/19 at 4:13 P.M. with LPN #341 revealed she had assessed Resident #70 for facial bruising and the resident didn't know how it happened. LPN #341 revealed she hadn't had time to notify the medical director (MD) or the family as of yet. LPN #341 revealed she had not had time to investigate the facial bruising pertaining to questioning other nursing staff as to how or when it may have occurred. LPN #341 revealed the administrator, DON and RN #313 supervisor would find out about the bruising after the MD gives a telephone order regarding the bruising. LPN #341 revealed a carbon copy of the telephone orders are picked up every morning by the RN #313 supervisor and those orders are discussed at the morning meeting. LPN #341 revealed the staff does not have to notify the administrator or DON directly for injuries of unknown origin (IUO). Interview on 11/19/19 at 4:23 P.M. with the State Tested Nursing Assistant (STNA) #357 revealed she had worked at the facility since January 2019. STNA #357 revealed she had been working on 11/19/19 since six o'clock in the morning and she had been assigned to the Resident #70. STNA #357 revealed she observed a bruise on the left cheek of the Resident #70 when she provided her morning care. STNA #357 revealed she had not been given any information about the facial bruising at shift change and she did not notify the nurse of the bruise found on the left cheekbone of the Resident #70. STNA #357 revealed nothing had happened during the morning care that could have caused it and she had not idea how or when it may have happened. STNA #357 revealed she had not worked with the Resident #70 the previous day. Interview on 11/19/19 at 4:51 PM with the DON revealed anytime an IUO is identified an investigation and appropriate reporting should be done immediately. The DON revealed no IUO had been identified since the Ohio Department of Health had entered the faciliy on 11/18/19 and no one had reported any bruising. Interview on 11/20/19 at 7:54 A.M. with the DON verified the staff had been trained on the policy and procedure for injury of unknown origin. The DON revealed the STNA's are to report to the nurse, the nurse will report to the RN supervisor and the RN supervisor will report to the Administrator. The DON revealed if she is here they can report to her but an injury of unknown origin has to be reported to the administrator. The DON further revealed an investigation should be done and the incident of unknown origin should be reported to the ODH. Interview on 11/20/19 at 8:48 A.M. with the Resident #70 revealed the nursing staff had questioned her about the bruising on her face and she was told by the nursing staff the bruising was probably from her nasal cannula tubing. Interview on 11/20/19 at 8:53 A.M. interview with the Medical Doctor (MD) #99 revealed he had not been contacted about the care for Resident #70. Once the ODH surveyor explained finding bruising on the left cheekbone of Resident #70 the MD revealed he remembered being called. MD #99 revealed he would assess Resident #70 and then discuss his findings. Interview on 11/20/19 at 8:59 A.M. with MD #99 revealed the Resident #70 presented with left cheekbone bruise that was not painful, not swollen, no fracture, and very superficial. MD #99 revealed the resident is on aspirin and he did not believe it was abuse. Observation on 11/20/19 at 09:20 A.M. of Resident #70 sitting in the beauty shop in the facility. Observation of Resident #70 with nasal cannula tubing on and the bruise on the left cheekbone did not follow the line of the nasal tubing. Interview on 11/20/19 at 11:28 A.M. with LPN #341 revealed a risk assessment was completed on the Resident #70 after she notified the physician at 6:15 P.M. LPN #341 confirmed she had been aware of the Resident #70's left cheekbone bruise for almost eight hours before notifying the MD. LPN #341 further verified no investigation, or reporting to the administrator had been completed for the Resident #70's IUO. Further review of the Risk assessment dated [DATE] revealed no investigation of how Resident #70 could have obtained the facial bruising. Review of SRI's to the ODH revealed the facility did not report the IUO for Resident #70 reported by ODH surveyor to LPN #341 and RN #313 on 11/19/19. Based on medical record review, review of facility self reported incidents (SRI's), review of facility incident reports, observations, staff, resident and physician interview and review of the facility policy, the facility failed implement their abuse policy to ensure injuries of unknown origin were immediately reported to the to administrator/designee and to the state agency as required and to ensure injuries of unknown origin were thoroughly investigated. This affected four (#38, #66, #67 and #70) out of four residents reviewed for abuse. The facility census was 96. Findings include: 1. Review of the medical record for Resident #38 revealed she was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, right eye blindness, hypertension, cardiac arrhythmia, anemia, hypothyroidism, chronic kidney disease and mental disorders due to known physiological condition. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was cognitively impaired. Review of the nurse progress note dated 10/05/19 at 2:43 A.M. revealed a skin tear three centimeters (cm) long was observed on Resident #38's left knee. The area was open and unable to approximate and with scant bleeding. The wound was surrounded by bruising measuring three cm by five cm. The wound was cleansed and treated. Resident #38 did not know how it happened. Review of the Facility Incident Report dated 10/05/19 revealed on 10/05/19 Resident #38 was discovered to have an Injury of Unknown Origin (IUO) identified as a skin tear three cm long surrounded by bruising measuring three cm by five cm observed on her left knee. Resident #38 was unable to identify the cause of the skin tear. The incident report contained no investigation into the cause of the skin tear. No people or agencies were notified of the IUO. Review of the a second nurse progress note dated 10/31/19 at 9:30 P.M. revealed Resident #38 was discovered to have another IUO. During bedtime care the State Tested Nurse Aid (STNA) called the nurse to Resident #38's room. Resident #38 was noted to have a very large purple bruise to her left inner thigh. The nurse asked Resident #38 about said bruise. Resident #38 didn't know where or how the bruise occurred. Resident #38 stated I have a bruise! Where is it? I don't remember hitting my leg on anything. The bruise was 15 cm by 10 cm on Resident #38's left inner thigh and purple in color. Resident #38 had no incidents reported and does transfer or toilet herself. Review of the Facility Incident Report dated 10/31/19 revealed on 10/31/19 Resident #38 was discovered to have a very large bruise on her left inner thigh, purple in color, measuring 15 cm x 10 cm. Resident #38 was unable to identify the cause of the bruise. The incident report contained no investigation into the cause of the bruise. No people or agencies were notified of the IUO. Review of the facilities SRI's submitted to the Ohio Department of Health (ODH) revealed the facility did not report the two IUO for Resident #38 dated 10/05/19 or dated 10/31/19. Interview on 11/19/19 at 4:02 P.M. with Registered Nurse (RN) #320 verified Resident #38 had a bruise on her left upper inner thigh and verified the cause was unknown. Interview with RN Supervisor #322 on 11/20/19 at 9:13 A.M. verified she was a member of management. She verified Resident #38 had a bruise at her left thigh noted 10/31/19 and a skin tear noted 10/05/19 and there was no identified cause for either injury. RN #322 stated Resident #38's bruise could easily have resulted from her self-propelling in her wheelchair and denied any need to conduct an investigation into the IUO. RN #322 stated it was only necessary to investigate an IUO when she though it was suspicious. RN #322 stated she was not present at the time Resident #38's bruise and skin tear were discovered, but she would not report the IUO to the DON or the Administrator. Interview on 11/18/19 at 4:50 P.M. with the Director of Nursing (DON) verified the nursing staff completed the Facility Incident Reports at the time of the two incidents involving Resident #38 on 10/05/19 and 10/31/19 and stated that was all they were required to do. DON verified the facility did not ensure Resident #38 was free from abuse and there was no investigation conducted by the facility to determine the cause of the bruise or the skin tear. DON verified the facility did not implement the abuse policy to prevent abuse, investigate abuse, to immediately report abuse to the State Survey Agency and to protect Resident #38 in regard to two instances of IUO. 3. Resident #66 was admitted the facility on 06/07/19 with diagnoses including intracerebral hemorrhage, dementia, peripheral vascular disease, chronic obstructive pulmonary disease, seizure disorder and osteoarthritis. Review of the November 2019 monthly physician orders revealed the resident is not receiving any anti coagulant medications. Review of quarterly MDS dated [DATE] stated the resident has short and long term memory loss with behaviors or rejection of care. Review of the plan of care, updated 10/16/19, revealed no mention of behaviors or rejection of care . Review of the nursing progress note dated 11/19/19 at 11:38 AM stated during a shower it was noted Resident # 66 had a bruise to her right breast. The area was purple. The resident denied any pain when touched. The physician was notified. Review of the nursing progress note dated 09/23/19 stated the origin of the bruise to her right breast was of unknown origin. Interview on 11/19/19 02:57 P.M. with STNA #358 stated the resident can be combative hitting staff during care at times. She stated if you walk away and re-approach her later she is fine. Interview with the DON on 11/19/19 at 3:00 P.M. verified the bruise to Resident #66 right breast was an injury of unknown origin and had not been investigated, reported to the Administrator, or the state agency. 4. Resident #67 was admitted to the facility 09/03/14 with diagnoses including major depressive disorder, anxiety disorder, macular degeneration, diabetes with diabetic neuropathy, hypertension, and unspecified urinary incontinence. Review of the quarterly MDS dated [DATE] revealed the resident scored a 12 on the Brief Interview for Mental Status' indicating moderate cognitive impairment. The resident is assessed as not having any behaviors or rejection of care. The resident has not received any anticoagulants. Review of the plan of care, updated 10/16/19, documented when the resident becomes agitated intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff is to walk calmly away and approach later. Review of the nursing progress notes dated 09/14/2019 at 4:26 A.M. documented Resident #67 was combative during bedtime care earlier this shift. During incontinent care, staff noted a bruise to right posterior arm. The purple bruise measuring approximately 11.0 centimeters (cm.) in length by 8.0 cm in width. Resident #67 was not able to recall how the bruise occurred. She denied any pain. She was able to move her fingers and bend her wrist freely. Review of the nursing progress note, dated 09/15/2019, at 4:57 P.M. documented during morning (AM.) care Resident #67 had a fading quarter sized bruise to left side jaw and a fading purple bruise with slight yellowing around the edges approximately 7.0 cm. in diameter. Interview with the DON on 11/19/19 at 3:00 P.M. verified the bruises to Resident #67 right arm and left jaw was an injury of unknown origin and had not been investigated, reported to the Administrator, or the state agency. On 11/20/19 at 9:45 A.M. interview with LPN #333 stated anytime there is a bruise of unknown origin it is to be immediately investigated by interviewing staff who have recently worked with the resident, the resident, and other residents to help determine the cause of the injury. She verified the bruising of unknown injury on Resident #66 right breast and Resident #67 left jaw absolutely should have been investigated. per facility policy. Review of the facility policy titled Resident Care Policy Freedom from Abuse, Neglect, and Exploitation, dated 03/17, documented under Identification, that all staff are responsible to monitor residents and will know how to identify potential signs and symptoms of abuse. Symptoms that will be monitored includes suspicious or unexplained bruising. Under the heading, Reporting and Response documented abuse allegations including injuries of unknown origin are reported per federal and state law. The policy indicated injuries of unknown origin must be investigated immediately to rule out abuse. Injuries include, but not limited to bruising on the inner thigh, chest, face, breast, bruises of unusual size, and multiple bruises in an area not typically [NAME] to trauma.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #70 revealed she was admitted to the facility on [DATE] with diagnoses of congestive heart failure, chronic kidney disease, anemia, general anxiety disorder, chronic obstructive pulmonary disease, iron deficiency anemia, arthritis, and hypothyroidism. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #70 was cognitively intact, required partial moderate assistance to substantial maximal assistance for activities of daily living. The MDS further revealed the Resident #70 required supervision to ambulate 10-50 feet and was dependent for ambulation of 150 feet. Review of nursing notes from 11/06/19 to 11/19/19 revealed no documentation of any incidents for the Resident #70 indicating a bruise on the residents cheekbone. Observation on 11/19/19 at 10:27 A.M. revealed Resident #70 was reclined in her recliner in her room. Further observation revealed the Resident #70 had a black and blue bruise under her left eye around the cheek bone area. Interview on 11/19/19 at 10:29 A.M. with the Resident #70 revealed the resident did not know she had a bruise on her cheekbone and did not know how she could have gotten one. The Resident #70 revealed she had not fallen. Further review of the Resident #70's medical record from 11/06/19 to 11/19/19 revealed no identification, investigation, implementations of policy for bruises of unknown origin. Interview on 11/19/19 at 10:34 A.M. with the Licensed Practical Nurse (LPN) #341 revealed the resident had not fallen and the LPN #341 was not aware of the Resident #70 having a bruise on her left cheekbone. Interview on 11/19/19 at 10:41 A.M. with the RN #313 revealed the Resident #70 had not previously had a bruises on her left cheekbone and if the Resident #70 had a bruise it would be a new bruise. Interview on 11/19/19 at 10:46 A.M. with the RN #313 revealed she had just observed the Resident #70's bruise on the left cheek and it looked to the RN that Resident #70 had a bruise starting on the right cheekbone as well. RN #313 revealed Resident #70 was prescribed Aspirin 81 milligrams daily and her opinion was the bruising could be from oxygen nasal cannula tubing. RN #313 revealed the facility would contact the medical director for orders. Interview on 11/19/19 at 4:13 P.M. with LPN #341 revealed she had assessed Resident #70 for facial bruising and the resident didn't know how it happened. LPN #341 revealed she hadn't had time to notify the medical director (MD) or the family as of yet. LPN #341 revealed she had not had time to investigate the facial bruising pertaining to questioning other nursing staff as to how or when it may have occurred. LPN #341 revealed the administrator, DON and RN #313 supervisor would find out about the bruising after the MD gives a telephone order regarding the bruising. LPN #341 revealed a carbon copy of the telephone orders are picked up every morning by the RN #313 supervisor and those orders are discussed at the morning meeting. LPN #341 revealed the staff does not have to notify the administrator or DON directly for injuries of unknown origin (IUO). Interview on 11/19/19 at 4:23 P.M. with the State Tested Nursing Assistant (STNA) #357 revealed she had worked at the facility since January 2019. STNA #357 revealed she had been working on 11/19/19 since six o'clock in the morning and she had been assigned to the Resident #70. STNA #357 revealed she observed a bruise on the left cheek of the Resident #70 when she provided her morning care. STNA #357 revealed she had not been given any information about the facial bruising at shift change and she did not notify the nurse of the bruise found on the left cheekbone of the Resident #70. STNA #357 revealed nothing had happened during the morning care that could have caused it and she had not idea how or when it may have happened. STNA #357 revealed she had not worked with the Resident #70 the previous day. Interview on 11/19/19 at 4:51 PM with the DON revealed anytime an IUO is identified an investigation and appropriate reporting should be done immediately. The DON revealed no IUO had been identified since the Ohio Department of Health had entered the faciliy on 11/18/19 and no one had reported any bruising. Interview on 11/20/19 at 7:54 A.M. with the DON verified the staff had been trained on the policy and procedure for injury of unknown origin. The DON revealed the STNA's are to report to the nurse, the nurse will report to the RN supervisor and the RN supervisor will report to the Administrator. The DON revealed if she is here they can report to her but an injury of unknown origin has to be reported to the administrator. The DON further revealed an investigation should be done and the incident of unknown origin should be reported to the ODH. Interview on 11/20/19 at 8:48 A.M. with the Resident #70 revealed the nursing staff had questioned her about the bruising on her face and she was told by the nursing staff the bruising was probably from her nasal cannula tubing. Interview on 11/20/19 at 8:53 A.M. interview with the Medical Doctor (MD) #99 revealed he had not been contacted about the care for Resident #70. Once the ODH surveyor explained finding bruising on the left cheekbone of Resident #70 the MD revealed he remembered being called. MD #99 revealed he would assess Resident #70 and then discuss his findings. Interview on 11/20/19 at 8:59 A.M. with MD #99 revealed the Resident #70 presented with left cheekbone bruise that was not painful, not swollen, no fracture, and very superficial. MD #99 revealed the resident is on aspirin and he did not believe it was abuse. Observation on 11/20/19 at 09:20 A.M. of Resident #70 sitting in the beauty shop in the facility. Observation of Resident #70 with nasal cannula tubing on and the bruise on the left cheekbone did not follow the line of the nasal tubing. Interview on 11/20/19 at 11:28 A.M. with LPN #341 revealed a risk assessment was completed on the Resident #70 after she notified the physician at 6:15 P.M. LPN #341 confirmed she had been aware of the Resident #70's left cheekbone bruise for almost eight hours before notifying the MD. LPN #341 further verified no investigation, or reporting to the administrator had been completed for the Resident #70's IUO. Further review of the Risk assessment dated [DATE] revealed no investigation of how Resident #70 could have obtained the facial bruising. Review of SRI's to the ODH revealed the facility did not report the IUO for Resident #70 reported by ODH surveyor to LPN #341 and RN #313 on 11/19/19. Based on medical record review, review of facility self reported incidents (SRI's), review of facility incident reports, observations, staff, resident and physician interview and review of the facility policy, the facility failed to immediately report injuries of unknown origin to administrator/designee and to the state agency as required. This affected four (#38, #66, #67 and #70) out of four residents reviewed for abuse. The facility census was 96. Findings include: 1. Review of the medical record for Resident #38 revealed she was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, right eye blindness, hypertension, cardiac arrhythmia, anemia, hypothyroidism, chronic kidney disease and mental disorders due to known physiological condition. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was cognitively impaired. Review of the nurse progress note dated 10/05/19 at 2:43 A.M. revealed a skin tear three centimeters (cm) long was observed on Resident #38's left knee. The area was open and unable to approximate and with scant bleeding. The wound was surrounded by bruising measuring three cm by five cm. The wound was cleansed and treated. Resident #38 did not know how it happened. Review of the Facility Incident Report dated 10/05/19 revealed on 10/05/19 Resident #38 was discovered to have an Injury of Unknown Origin (IUO) identified as a skin tear three cm long surrounded by bruising measuring three cm by five cm observed on her left knee. Resident #38 was unable to identify the cause of the skin tear. The incident report contained no investigation into the cause of the skin tear. No people or agencies were notified of the IUO. Review of the a second nurse progress note dated 10/31/19 at 9:30 P.M. revealed Resident #38 was discovered to have another IUO. During bedtime care the State Tested Nurse Aid (STNA) called the nurse to Resident #38's room. Resident #38 was noted to have a very large purple bruise to her left inner thigh. The nurse asked Resident #38 about said bruise. Resident #38 didn't know where or how the bruise occurred. Resident #38 stated I have a bruise! Where is it? I don't remember hitting my leg on anything. The bruise was 15 cm by 10 cm on Resident #38's left inner thigh and purple in color. Resident #38 had no incidents reported and does transfer or toilet herself. Review of the Facility Incident Report dated 10/31/19 revealed on 10/31/19 Resident #38 was discovered to have a very large bruise on her left inner thigh, purple in color, measuring 15 cm x 10 cm. Resident #38 was unable to identify the cause of the bruise. The incident report contained no investigation into the cause of the bruise. No people or agencies were notified of the IUO. Review of the facilities SRI's submitted to the Ohio Department of Health (ODH) revealed the facility did not report the two IUO for Resident #38 dated 10/05/19 or dated 10/31/19. Interview on 11/19/19 at 4:02 P.M. with Registered Nurse (RN) #320 verified Resident #38 had a bruise on her left upper inner thigh and verified the cause was unknown. Interview with RN Supervisor #322 on 11/20/19 at 9:13 A.M. verified she was a member of management. She verified Resident #38 had a bruise at her left thigh noted 10/31/19 and a skin tear noted 10/05/19 and there was no identified cause for either injury. RN #322 stated Resident #38's bruise could easily have resulted from her self-propelling in her wheelchair and denied any need to conduct an investigation into the IUO. RN #322 stated it was only necessary to investigate an IUO when she though it was suspicious. RN #322 stated she was not present at the time Resident #38's bruise and skin tear were discovered, but she would not report the IUO to the DON or the Administrator. Interview on 11/18/19 at 4:50 P.M. with the Director of Nursing (DON) verified the nursing staff completed the Facility Incident Reports at the time of the two incidents involving Resident #38 on 10/05/19 and 10/31/19 and stated that was all they were required to do. DON verified the facility did not ensure Resident #38 was free from abuse and there was no investigation conducted by the facility to determine the cause of the bruise or the skin tear. DON verified the facility did not implement the abuse policy to prevent abuse, investigate abuse, to immediately report abuse to the State Survey Agency and to protect Resident #38 in regard to two instances of IUO. 3. Resident #66 was admitted the facility on 06/07/19 with diagnoses including intracerebral hemorrhage, dementia, peripheral vascular disease, chronic obstructive pulmonary disease, seizure disorder and osteoarthritis. Review of the November 2019 monthly physician orders revealed the resident is not receiving any anti coagulant medications. Review of quarterly MDS dated [DATE] stated the resident has short and long term memory loss with behaviors or rejection of care. Review of the plan of care, updated 10/16/19, revealed no mention of behaviors or rejection of care . Review of the nursing progress note dated 11/19/19 at 11:38 AM stated during a shower it was noted Resident # 66 had a bruise to her right breast. The area was purple. The resident denied any pain when touched. The physician was notified. Review of the nursing progress note dated 09/23/19 stated the origin of the bruise to her right breast was of unknown origin. Interview on 11/19/19 02:57 P.M. with STNA #358 stated the resident can be combative hitting staff during care at times. She stated if you walk away and re-approach her later she is fine. Interview with the DON on 11/19/19 at 3:00 P.M. verified the bruise to Resident #66 right breast was an injury of unknown origin and had not been investigated, reported to the Administrator, or the state agency. 4. Resident #67 was admitted to the facility 09/03/14 with diagnoses including major depressive disorder, anxiety disorder, macular degeneration, diabetes with diabetic neuropathy, hypertension, and unspecified urinary incontinence. Review of the quarterly MDS dated [DATE] revealed the resident scored a 12 on the Brief Interview for Mental Status' indicating moderate cognitive impairment. The resident is assessed as not having any behaviors or rejection of care. The resident has not received any anticoagulants. Review of the plan of care, updated 10/16/19, documented when the resident becomes agitated intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff is to walk calmly away and approach later. Review of the nursing progress notes dated 09/14/2019 at 4:26 A.M. documented Resident #67 was combative during bedtime care earlier this shift. During incontinent care, staff noted a bruise to right posterior arm. The purple bruise measuring approximately 11.0 centimeters (cm.) in length by 8.0 cm in width. Resident #67 was not able to recall how the bruise occurred. She denied any pain. She was able to move her fingers and bend her wrist freely. Review of the nursing progress note, dated 09/15/2019, at 4:57 P.M. documented during morning (AM.) care Resident #67 had a fading quarter sized bruise to left side jaw and a fading purple bruise with slight yellowing around the edges approximately 7.0 cm. in diameter. Interview with the DON on 11/19/19 at 3:00 P.M. verified the bruises to Resident #67 right arm and left jaw was an injury of unknown origin and had not been investigated, reported to the Administrator, or the state agency. On 11/20/19 at 9:45 A.M. interview with LPN #333 stated anytime there is a bruise of unknown origin it is to be immediately investigated by interviewing staff who have recently worked with the resident, the resident, and other residents to help determine the cause of the injury. She verified the bruising of unknown injury on Resident #66 right breast and Resident #67 left jaw absolutely should have been investigated. per facility policy. Review of the facility policy titled Resident Care Policy Freedom from Abuse, Neglect, and Exploitation, dated 03/17, documented under Identification, that all staff are responsible to monitor residents and will know how to identify potential signs and symptoms of abuse. Symptoms that will be monitored includes suspicious or unexplained bruising. Under the heading, Reporting and Response documented abuse allegations including injuries of unknown origin are reported per federal and state law. The policy indicated injuries of unknown origin must be investigated immediately to rule out abuse. Injuries include, but not limited to bruising on the inner thigh, chest, face, breast, bruises of unusual size, and multiple bruises in an area not typically [NAME] to trauma.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #70 revealed she was admitted to the facility on [DATE] with diagnoses of congestive heart failure, chronic kidney disease, anemia, general anxiety disorder, chronic obstructive pulmonary disease, iron deficiency anemia, arthritis, and hypothyroidism. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #70 was cognitively intact, required partial moderate assistance to substantial maximal assistance for activities of daily living. The MDS further revealed the Resident #70 required supervision to ambulate 10-50 feet and was dependent for ambulation of 150 feet. Review of nursing notes from 11/06/19 to 11/19/19 revealed no documentation of any incidents for the Resident #70 indicating a bruise on the residents cheekbone. Observation on 11/19/19 at 10:27 A.M. revealed Resident #70 was reclined in her recliner in her room. Further observation revealed the Resident #70 had a black and blue bruise under her left eye around the cheek bone area. Interview on 11/19/19 at 10:29 A.M. with the Resident #70 revealed the resident did not know she had a bruise on her cheekbone and did not know how she could have gotten one. The Resident #70 revealed she had not fallen. Further review of the Resident #70's medical record from 11/06/19 to 11/19/19 revealed no identification, investigation, implementations of policy for bruises of unknown origin. Interview on 11/19/19 at 10:34 A.M. with the Licensed Practical Nurse (LPN) #341 revealed the resident had not fallen and the LPN #341 was not aware of the Resident #70 having a bruise on her left cheekbone. Interview on 11/19/19 at 10:41 A.M. with the RN #313 revealed the Resident #70 had not previously had a bruises on her left cheekbone and if the Resident #70 had a bruise it would be a new bruise. Interview on 11/19/19 at 10:46 A.M. with the RN #313 revealed she had just observed the Resident #70's bruise on the left cheek and it looked to the RN that Resident #70 had a bruise starting on the right cheekbone as well. RN #313 revealed Resident #70 was prescribed Aspirin 81 milligrams daily and her opinion was the bruising could be from oxygen nasal cannula tubing. RN #313 revealed the facility would contact the medical director for orders. Interview on 11/19/19 at 4:13 P.M. with LPN #341 revealed she had assessed Resident #70 for facial bruising and the resident didn't know how it happened. LPN #341 revealed she hadn't had time to notify the medical director (MD) or the family as of yet. LPN #341 revealed she had not had time to investigate the facial bruising pertaining to questioning other nursing staff as to how or when it may have occurred. LPN #341 revealed the administrator, DON and RN #313 supervisor would find out about the bruising after the MD gives a telephone order regarding the bruising. LPN #341 revealed a carbon copy of the telephone orders are picked up every morning by the RN #313 supervisor and those orders are discussed at the morning meeting. LPN #341 revealed the staff does not have to notify the administrator or DON directly for injuries of unknown origin (IUO). Interview on 11/19/19 at 4:23 P.M. with the State Tested Nursing Assistant (STNA) #357 revealed she had worked at the facility since January 2019. STNA #357 revealed she had been working on 11/19/19 since six o'clock in the morning and she had been assigned to the Resident #70. STNA #357 revealed she observed a bruise on the left cheek of the Resident #70 when she provided her morning care. STNA #357 revealed she had not been given any information about the facial bruising at shift change and she did not notify the nurse of the bruise found on the left cheekbone of the Resident #70. STNA #357 revealed nothing had happened during the morning care that could have caused it and she had not idea how or when it may have happened. STNA #357 revealed she had not worked with the Resident #70 the previous day. Interview on 11/19/19 at 4:51 PM with the DON revealed anytime an IUO is identified an investigation and appropriate reporting should be done immediately. The DON revealed no IUO had been identified since the Ohio Department of Health had entered the faciliy on 11/18/19 and no one had reported any bruising. Interview on 11/20/19 at 7:54 A.M. with the DON verified the staff had been trained on the policy and procedure for injury of unknown origin. The DON revealed the STNA's are to report to the nurse, the nurse will report to the RN supervisor and the RN supervisor will report to the Administrator. The DON revealed if she is here they can report to her but an injury of unknown origin has to be reported to the administrator. The DON further revealed an investigation should be done and the incident of unknown origin should be reported to the ODH. Interview on 11/20/19 at 8:48 A.M. with the Resident #70 revealed the nursing staff had questioned her about the bruising on her face and she was told by the nursing staff the bruising was probably from her nasal cannula tubing. Interview on 11/20/19 at 8:53 A.M. interview with the Medical Doctor (MD) #99 revealed he had not been contacted about the care for Resident #70. Once the ODH surveyor explained finding bruising on the left cheekbone of Resident #70 the MD revealed he remembered being called. MD #99 revealed he would assess Resident #70 and then discuss his findings. Interview on 11/20/19 at 8:59 A.M. with MD #99 revealed the Resident #70 presented with left cheekbone bruise that was not painful, not swollen, no fracture, and very superficial. MD #99 revealed the resident is on aspirin and he did not believe it was abuse. Observation on 11/20/19 at 09:20 A.M. of Resident #70 sitting in the beauty shop in the facility. Observation of Resident #70 with nasal cannula tubing on and the bruise on the left cheekbone did not follow the line of the nasal tubing. Interview on 11/20/19 at 11:28 A.M. with LPN #341 revealed a risk assessment was completed on the Resident #70 after she notified the physician at 6:15 P.M. LPN #341 confirmed she had been aware of the Resident #70's left cheekbone bruise for almost eight hours before notifying the MD. LPN #341 further verified no investigation, or reporting to the administrator had been completed for the Resident #70's IUO. Further review of the Risk assessment dated [DATE] revealed no investigation of how Resident #70 could have obtained the facial bruising. Review of SRI's to the ODH revealed the facility did not report the IUO for Resident #70 reported by ODH surveyor to LPN #341 and RN #313 on 11/19/19. Based on medical record review, review of facility self reported incidents (SRI's), review of facility incident reports, observations, staff, resident and physician interview and review of the facility policy, the facility failed to thoroughly investigate injuries of unknown origin. This affected four (#38, #66, #67 and #70) out of four residents reviewed for abuse. The facility census was 96. Findings include: 1. Review of the medical record for Resident #38 revealed she was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, right eye blindness, hypertension, cardiac arrhythmia, anemia, hypothyroidism, chronic kidney disease and mental disorders due to known physiological condition. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was cognitively impaired. Review of the nurse progress note dated 10/05/19 at 2:43 A.M. revealed a skin tear three centimeters (cm) long was observed on Resident #38's left knee. The area was open and unable to approximate and with scant bleeding. The wound was surrounded by bruising measuring three cm by five cm. The wound was cleansed and treated. Resident #38 did not know how it happened. Review of the Facility Incident Report dated 10/05/19 revealed on 10/05/19 Resident #38 was discovered to have an Injury of Unknown Origin (IUO) identified as a skin tear three cm long surrounded by bruising measuring three cm by five cm observed on her left knee. Resident #38 was unable to identify the cause of the skin tear. The incident report contained no investigation into the cause of the skin tear. No people or agencies were notified of the IUO. Review of the a second nurse progress note dated 10/31/19 at 9:30 P.M. revealed Resident #38 was discovered to have another IUO. During bedtime care the State Tested Nurse Aid (STNA) called the nurse to Resident #38's room. Resident #38 was noted to have a very large purple bruise to her left inner thigh. The nurse asked Resident #38 about said bruise. Resident #38 didn't know where or how the bruise occurred. Resident #38 stated I have a bruise! Where is it? I don't remember hitting my leg on anything. The bruise was 15 cm by 10 cm on Resident #38's left inner thigh and purple in color. Resident #38 had no incidents reported and does transfer or toilet herself. Review of the Facility Incident Report dated 10/31/19 revealed on 10/31/19 Resident #38 was discovered to have a very large bruise on her left inner thigh, purple in color, measuring 15 cm x 10 cm. Resident #38 was unable to identify the cause of the bruise. The incident report contained no investigation into the cause of the bruise. No people or agencies were notified of the IUO. Review of the facilities SRI's submitted to the Ohio Department of Health (ODH) revealed the facility did not report the two IUO for Resident #38 dated 10/05/19 or dated 10/31/19. Interview on 11/19/19 at 4:02 P.M. with Registered Nurse (RN) #320 verified Resident #38 had a bruise on her left upper inner thigh and verified the cause was unknown. Interview with RN Supervisor #322 on 11/20/19 at 9:13 A.M. verified she was a member of management. She verified Resident #38 had a bruise at her left thigh noted 10/31/19 and a skin tear noted 10/05/19 and there was no identified cause for either injury. RN #322 stated Resident #38's bruise could easily have resulted from her self-propelling in her wheelchair and denied any need to conduct an investigation into the IUO. RN #322 stated it was only necessary to investigate an IUO when she though it was suspicious. RN #322 stated she was not present at the time Resident #38's bruise and skin tear were discovered, but she would not report the IUO to the DON or the Administrator. Interview on 11/18/19 at 4:50 P.M. with the Director of Nursing (DON) verified the nursing staff completed the Facility Incident Reports at the time of the two incidents involving Resident #38 on 10/05/19 and 10/31/19 and stated that was all they were required to do. DON verified the facility did not ensure Resident #38 was free from abuse and there was no investigation conducted by the facility to determine the cause of the bruise or the skin tear. DON verified the facility did not implement the abuse policy to prevent abuse, investigate abuse, to immediately report abuse to the State Survey Agency and to protect Resident #38 in regard to two instances of IUO. 3. Resident #66 was admitted the facility on 06/07/19 with diagnoses including intracerebral hemorrhage, dementia, peripheral vascular disease, chronic obstructive pulmonary disease, seizure disorder and osteoarthritis. Review of the November 2019 monthly physician orders revealed the resident is not receiving any anti coagulant medications. Review of quarterly MDS dated [DATE] stated the resident has short and long term memory loss with behaviors or rejection of care. Review of the plan of care, updated 10/16/19, revealed no mention of behaviors or rejection of care . Review of the nursing progress note dated 11/19/19 at 11:38 AM stated during a shower it was noted Resident # 66 had a bruise to her right breast. The area was purple. The resident denied any pain when touched. The physician was notified. Review of the nursing progress note dated 09/23/19 stated the origin of the bruise to her right breast was of unknown origin. Interview on 11/19/19 02:57 P.M. with STNA #358 stated the resident can be combative hitting staff during care at times. She stated if you walk away and re-approach her later she is fine. Interview with the DON on 11/19/19 at 3:00 P.M. verified the bruise to Resident #66 right breast was an injury of unknown origin and had not been investigated, reported to the Administrator, or the state agency. 4. Resident #67 was admitted to the facility 09/03/14 with diagnoses including major depressive disorder, anxiety disorder, macular degeneration, diabetes with diabetic neuropathy, hypertension, and unspecified urinary incontinence. Review of the quarterly MDS dated [DATE] revealed the resident scored a 12 on the Brief Interview for Mental Status' indicating moderate cognitive impairment. The resident is assessed as not having any behaviors or rejection of care. The resident has not received any anticoagulants. Review of the plan of care, updated 10/16/19, documented when the resident becomes agitated intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff is to walk calmly away and approach later. Review of the nursing progress notes dated 09/14/2019 at 4:26 A.M. documented Resident #67 was combative during bedtime care earlier this shift. During incontinent care, staff noted a bruise to right posterior arm. The purple bruise measuring approximately 11.0 centimeters (cm.) in length by 8.0 cm in width. Resident #67 was not able to recall how the bruise occurred. She denied any pain. She was able to move her fingers and bend her wrist freely. Review of the nursing progress note, dated 09/15/2019, at 4:57 P.M. documented during morning (AM.) care Resident #67 had a fading quarter sized bruise to left side jaw and a fading purple bruise with slight yellowing around the edges approximately 7.0 cm. in diameter. Interview with the DON on 11/19/19 at 3:00 P.M. verified the bruises to Resident #67 right arm and left jaw was an injury of unknown origin and had not been investigated, reported to the Administrator, or the state agency. On 11/20/19 at 9:45 A.M. interview with LPN #333 stated anytime there is a bruise of unknown origin it is to be immediately investigated by interviewing staff who have recently worked with the resident, the resident, and other residents to help determine the cause of the injury. She verified the bruising of unknown injury on Resident #66 right breast and Resident #67 left jaw absolutely should have been investigated. per facility policy. Review of the facility policy titled Resident Care Policy Freedom from Abuse, Neglect, and Exploitation, dated 03/17, documented under Identification, that all staff are responsible to monitor residents and will know how to identify potential signs and symptoms of abuse. Symptoms that will be monitored includes suspicious or unexplained bruising. Under the heading, Reporting and Response documented abuse allegations including injuries of unknown origin are reported per federal and state law. The policy indicated injuries of unknown origin must be investigated immediately to rule out abuse. Injuries include, but not limited to bruising on the inner thigh, chest, face, breast, bruises of unusual size, and multiple bruises in an area not typically [NAME] to trauma.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record for Resident #80 revealed he was admitted to the facility on [DATE] with diagnoses including end stage renal disease, chronic kidney disease, hypertension, type two diabetes mellitus and metabolic encephalopathy. Review of the Resident #80's quarterly MDS/Medicare five day assessment dated [DATE] revealed the resident had impaired cognition. The MDS assessment revealed the Resident #80 required assistance for activities of daily living. The Resident #80 received extensive assist of two plus persons for mobility, used a manual wheelchair and walker. Review of a nursing note dated 10/25/19 revealed the Resident #80 was found on the floor in front of his stationary chair and the opinion of the nurse was that the Resident #80 tried to self transfer without assistance. The nursing note revealed the medical director (MD) and family were notified and neurological checks were implemented. Review of a nursing notes dated 10/25/19 to 10/27/19 revealed neurological checks were done from for an unwitnessed fall on 10/25/19. Review of a nursing note dated 10/26/2019 revealed a skilled progress note that therapy had lowered the Resident #80 to the floor and family was notified and neurological checks continued from 10/25/19. Review of a nursing note dated 10/26/2019 at 10:45 A.M. an incident note was documented of the Resident #80 was heard falling to floor by environmental services. The nursing note documented Resident #80 revealed to the nurse he was trying to reposition himself in his chair and slid out of the chair. The note revealed no injuries were note and the nurse would continue to monitor the resident. Review of the Incident Reports dated 10/25/19 and 10/26/19 revealed Resident #80 had two unwitnessed falls in his room and one witnessed fall where he was lowered to the floor. No injuries were noted however after the last unwitnessed fall the MD sent the Resident #80 to the ER for assessment. The family and physician were notified of all three falls. However, there were no investigations of the cause of the falls and no implementations to prevent the resident from falling were identified. Interview on 11/20/19 at 09:53 A.M. with Registered Nurse (RN) #313 revealed she was aware of the fall that occurred on 10/25/19. RN #313 revealed she did not work that weekend but she was the nurse that sent the Resident #80 to the emergency room (ER) on the following Monday after the Resident #80 returned from dialysis and was not feeling well. RN #313 revealed she would not have known the resident had fallen other than the emergency medical technician's (EMT)'s had revealed to her they were the same EMT's that transported the Resident #80 over the weekend after he had fallen. Interview on 11/20/19 at 10:16 A.M. with the Resident # 80 revealed he did not remember how or when he had last fallen. Resident #80 thought he may have fallen three times in the past year but he doesn't remember any of the details surrounding the falls. Review of the facility policy titled Fall Assessment Policy updated on 11/21/17 revealed it was the policy to assess all residents for falls at the time of admission and at the time of completion of any MDS and upon any falls or near falls thereafter. With each fall event, documentation shall include Fall Risk Management, a progress note and physician, family and DON notification. For unwitnessed fall events the resident's and/or visitor's statement of what happened and initiate neuro checks. With each fall event, update the resident's care plan with a new intervention to prevent future fall or injuries due to falls. The facility policy was silent to any requirement to investigate the cause of resident falls. This deficiency represents ongoing non-compliance from the survey dated 10/16/19. Based on medical record review, review of facility incident reports, staff and resident interview and policy review, the facility failed to thoroughly investigate incidents of falls. This affected four (#80, #65, #38 and #90) out of seven residents reviewed for falls. The facility census was 96. Findings include: 1. Review of the medical record for Resident #38 revealed she was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, right eye blindness, hypertension, cardiac arrhythmia, anemia, hypothyroidism, chronic kidney disease and mental disorders due to known physiological condition. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was cognitively impaired. Resident #38 had one fall with an injury since her last MDS assessment. Review of the Plan of Care (POC) revealed Resident #38 was at risk for falls due to unaware of safety needs, deconditioning and vision and hearing problems. Interventions included to anticipate and meet needs, be sure the call light is within reach and encourage to use for assistance as needed, encourage toileting every two hours during the night, ensure resident is wearing appropriate footwear when ambulating or mobilizing in her wheelchair, explain procedures before transferring resident, remind resident and reinforce safety awareness, lock brakes on the wheelchair before transferring, sit on the edge of the bed for a few minutes before transferring/standing, provide a safe environment with even floors free from spills and/or clutter, adequate, glare-free light, a working and reachable call light, the bed in low position at night, side rails as ordered, handrails on walls, personal items within reach. The POC was revised on 09/21/19 with a new intervention to review information on past falls and attempt to determine the cause of falls. Record possible root causes. Alter or remove any potential causes if possible. Review of the quarterly Fall Risk assessment dated [DATE] revealed a score of 11 indicating she was at a moderate risk for falls. Review of the nurse progress notes revealed on 09/21/19 at 7:31 P.M. Resident #38 was observed sitting on the floor in the her bathroom in her room in front of the toilet with her back up against the wall. Resident #38 stated she fell and hit her head. Resident #38 was assessed and had a small abrasion noted on her left knee. Review of the medical record revealed there was no Fall Risk Assessment completed after her fall dated 09/21/19. Review of the facility incident report dated 09/21/19 revealed Resident #38 had an unwitnessed fall on 09/21/19 at 7:30 P.M. in her bathroom which resulted in a small abrasion to her left knee. The incident report did not include any investigation of the fall. There was no information indicating the cause of the fall or if prior POC interventions were in place to prevent her fall. Interview with Director of Nursing (DON) on 11/20/19 at 7:43 A.M. she verified there was no evidence of an investigation in regards to Resident #38's fall dated 09/21/19 in the medical record. The DON verified the facility incident report was completed by the nursing staff and it was the only documentation completed in regards to Resident #38's fall. The DON verified the fall should have been investigated to determine the cause of the fall. Additionally, the DON verified the POC included a new intervention post fall dated 09/21/19 to review information on past falls and attempt to determine the cause of falls, record possible root causes and alter or remove any potential causes if possible. The DON verified the new intervention was never initiated in regards to investigating the cause of Resident #38's fall dated 09/21/19. 2. Review of the medical record for Resident #90 revealed he was admitted to the facility on [DATE]. His diagnoses included left hip fracture dated 09/15/19, Parkinson's disease, cataracts bilaterally, glaucoma, atrial fibrillation, prostate cancer, hypotension and cardiac pacemaker. Review of the discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #90 was discharged , return anticipated on 09/11/19. The Entry MDS dated [DATE] revealed Resident #90 returned to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #90 was cognitively intact. There were no falls identified. Review of the POC revealed Resident #90 was at risk for falls due to hypotension, Parkinson's, psychotropic med use and incontinence. Interventions included to anticipate and meet needs, be sure call light is within reach and encourage resident to use for assistance as needed, lock the wheelchair before bending over or repositioning, provide a safe environment with even floors free from spills and/or clutter, adequate, glare-free light, a working and reachable call light, the bed in low position at night, side rails as ordered, handrails on walls, personal items within reach and remind resident to ask for help. the POC was revised on 09/11/19 to remind him to ask assistance related to his room change and new surroundings. Review of the Incident Report dated 09/11/19 revealed Resident #90 had an unwitnessed fall in his bathroom which resulted in a left hip fracture and other abrasions. The family and physician were notified. There were no investigation of the cause of the fall. It did not indicate if Resident #90 was using his wheelchair, if it was locked, it there was clutter, if there was adequate light or if the call light was available to Resident #90 to call for assistance per his POC. Review of the nurse progress noted dated 09/11/19 at 12:15 A.M. revealed Resident #90 was heard yelling. The nurse went down hall and nurse entered his room. Resident #90 was laying on the floor in front of toilet in his bathroom. Resident #90 stated he was taking himself to the bathroom and turned to sit down and missed the toilet. Resident #90 was assessed. He had multiple abrasions to left lower outer leg, abrasion to left upper back, redness to upper back and slight redness at his left hip. Further review of the medical record revealed X-rays of Resident #90's left hip were positive for left hip fracture and Resident #90 was discharged to the hospital on [DATE]. His left hip was surgically repaired and Resident #90 returned to the facility on [DATE]. Review of the Fall Risk assessment dated [DATE] revealed Resident #90 was at moderate risk for falls. There were no more recent fall assessment completed after his fall dated 09/11/19. Review of the facility incident report dated 09/11/19 revealed Resident #90 had an unwitnessed fall on 09/11/19 at 12:15 A.M. in his bathroom which resulted in abrasions to left lower outer leg, abrasion to left upper back, redness to upper back and redness at his left hip. No injuries were observed post fall. The incident report did not include any investigation of the fall. There was no information indicating the cause of the fall or if prior POC interventions were in place to prevent Resident #90's fall. Interview with Resident #90 on 11/20/19 at 3:18 P.M. verified he took himself to the bathroom and he was putting himself onto the toilet when he fell on [DATE]. He verified he did not request help prior to going to use the bathroom. Resident #90 verified he had a left hip fracture from his fall on 09/11/19. Interview with DON on 11/20/19 at 11:15 A.M. verified there was no evidence of an investigation in regard to Resident #90's fall dated 09/11/19 in the medical record. The DON verified the facility incident report was the only documentation completed in regards to Resident #90's fall. The DON verified the fall should have been investigated to determine the cause of the fall. The DON verified there was no fall assessment completed after his fall dated 09/11/19. 3. Resident #65 was admitted to the facility on [DATE] with a readmission to the facility on [DATE] with diagnoses including displaced fracture of left hip, anemia, peripheral vascular disease, anxiety disorder, Alzheimer's disease, dementia with behavior disturbances, major depressive disorder,and chronic kidney disease. Review of Resident #65's annual assessment dated [DATE] revealed the resident scored a three on the 'Brief Interview for Mental Status (BIMS) indicating she had severe cognitive impairment and exhibited no behaviors. She required supervision of one person physical assistance for bed mobility and toileting. She required extensive assistance of one person for personal hygiene and dressing. She was occasionally incontinent of urine and always continent of bowel. She received an antidepressant all 7 days of the assessment period. used a walker for ambulation. Review of the Care Area Assessment (CAA) stated the resident was at risk for falls based on loss of balance during transitions in position. Will process to the plan of care. Review of the plan of care with a revision date of 07/25/19 documented the resident was at risk for falls due to confusion, gait/balance problems, and history of falls . The interventions included to anticipate and meet the resident's needs, call light within reach, ensure resident is wearing appropriate footwear, and provide a safe environment with even floors, free from spills and/or clutter. Review of the nursing progress note, dated 07/28/2019 at 12:37 P.M. documented staff heard a muffled yelling coming from the bathroom. Resident #65 was found laying on her stomach with hands under head. The resident stated she had fallen. The resident was uncooperative with range of motion and obtaining vital signs. She stated she could not move. She was confused and continues to state she could not move and needed to see a doctor. She stated her leg gave out on her and now she could not move. An x-ray was obtained and it was determined the resident had a left hip fracture. She was sent to the emergency room for evaluation and treatment. Review of the Fall Incident, dated 07/28/19, stated the incident was unwitnessed and described the incident as it was written in the nursing progress notes. The incident stated there were no injuries at the time of the fall. Predisposing environmental, factors was listed as clutter and ambulating without assistance. There were no staff interviews as to circumstances prior to the fall or how the resident may have fallen, or the type of footwear the resident had on. There was no fall investigation regarding the unwitnessed fall. Review of the nursing progress note dated 10/27/19 at 12:50 P.M. documented a pressure alarm was sounding in the dining room. Resident #65 was found lying on her right side on the floor with her left arm on her hip crying out, Don't touch me. Her left leg was extended and her left foot pointing slightly inward. Her wheelchair was behind her with the brakes unlocked. Review of the Fall Incident dated 10/27/19, documented the incident was unwitnessed. Predisposing environmental, factors was listed as crowding and noise. Other predisposing factors were listed were the wheelchair brakes were unlocked. There were no staff interviews as to circumstances prior to the fall or how the resident may have fallen, or the type of footwear the resident had on. There was no fall investigation regarding the unwitnessed fall. Interview with the DON on 11/19/19 at 4:30 P.M. stated her expectation was for an investigation into all unwitnessed falls. She verified the only information she had regarding Resident #65 unwitnessed falls was the incident report. She verified there was no fall investigations regarding the falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #87 revealed she was admitted to the facility on [DATE] with diagnoses including major depressive disorder with recurrent and severe psychotic features, peripheral vascular disease, anxiety disorder, chronic venous hypertension, and enterocolitis. Review of the Resident #87's quarterly MDS assessment dated [DATE] revealed the resident had impaired cognition. The MDS assessment revealed the Resident #87 received anti-psychotic, anti-anxiety, antidepressant, and anticoagulant medications routinely. Review of Monthly Consultant Pharmacist Reports from October 2019 to September 2019 revealed the pharmacist identified significant irregularities of use of potassium supplementation due to potent diuretic and normal dietary intake. The reports further revealed other medications with significant irregularities where anti-psychotics of ability five milligrams (mg) to two mg taken daily and an antidepressant reduction of seratraline 200 mg daily to be reduced to 150 mg. Further review revealed the facility had no documentation of pharmacy recommendations for the Resident #87 for October 2019. Review of a Medication Therapy Review dated 09/20/19 written by the former Director of Nursing (DON) revealed a registered nurse (RN) recommendation, but no pharmacist or physician signatures. The review revealed the current aripirrazole two mg to be taken by mouth at bedtime for depression was recommended to be reduced from aripirrazole two mg to aripirrazole one mg by mouth at bedtime. The medication therapy review had a notation revealing the family did not want to give consent and noted no change to be made dated 09/20/19. Interview on 11/21/19 at 10:28 A.M. with the DON revealed the Medication Therapy Review dated 09/20/19 was the actual pharmacy recommendations for the facility even though there were no pharmacist or physician signatures. The DON revealed the Pharmacist (R.Ph) #299 was present when the former DON wrote and signed the pharmacy recommendations at the monthly facility meetings. Review of all facility documentation related to pharmacy medication reviews and recommendations revealed the facility could not provide documentation that any physician had reviewed all the pharmacists recommendations since the last annual survey. Review of physician progress notes from 04/12/19 through 08/17/19 for the Resident #87 revealed no discussion of pharmacy reviews or recommendations. Interview on 11/21/19 at 11:40 A.M. with R.Ph #299 regarding pharmacy reviews and recommendations for the Resident #87 revealed the pharmacist had the expectation the medical director, or other physicians caring for the facility residents would be communicated his monthly drug recommendation. R.Ph #299 confirmed the pharmacy sends the recommendations to the facility and the facility would be responsible for the physicians being notified. R.Ph #299 could not provide any documentation or communication to the residents physicians regarding pharmacy reviews or recommendations. R.Ph #299 revealed he attends a quarterly meeting in addition to the pharmacy monthly reviews but confirmed there is no documentation of the recommendations being reviewed by a physician or the physicians response. 4. Record review of Resident #64's medical chart revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #64 include artificial knee replacement, dementia, psychosis, pain, peripheral vascular disease, weakness and depression. Review of Resident #64's MDS quarterly assessment dated [DATE] revealed the resident had impaired cognition. Per the assessment the resident received anti-psychotic and anti-depressant medications during the review period. Review of medications for Resident #64 revealed the resident was prescribed Aripiprazole one mg orally every other day for psychosis and Lexapro five mg orally daily for depression. Review of Resident #64's care plans dated 09/11/15 revealed a focus for psychotropic medication use for Aripiprazole and Lexapro related to anxiety and depression. Interventions for the focus include consult with pharmacy and physician to consider dosage reduction per reduction policy. Review of the Resident #64's consultant pharmacy's monthly drug regimen reviews dated from 12/30/18 to 10/30/2019 revealed the pharmacist made no recommendations or noted any irregularities for Resident #64 in the monthly reviews. Review of Resident #64's medication therapy review documents dated 05/29/19 revealed Resident #64's current order for escitalopram (Lexapro) 10 mg orally daily for depression, was to be changed to escitalopram five mg orally daily. No staff signature for reviewer name, signature, or date was completed on the form. For the form's follow up it was documented the medication was to be changed to escitalopram five mg orally daily. The physician signed the form on 05/29/19. No documentation from the pharmacist was noted on the form. Further review of Resident #64's medical chart revealed there was no documentation of the pharmacist communicating the irregularities and recommendations to the attending physician, medical director, or the DON in the resident's medical chart. Interview on 11/21/19 at 11:40 A.M. with the R.Ph #299 verified the recommendations for each medication change for Resident #64 were not noted in the individual's medical charts on a monthly basis. Per R.Ph #299, irregularities and medication recommendations are addressed in the quarterly Quality Assurance, (QA), meetings at the facility and the irregularities are reported to the physician during those meeting. Per R.Ph #299, the nurses at the meetings are writing the recommendations and getting the physician's responses to the recommendations on a quarterly basis. R.Ph #299 verified his signature was not noted on the medication therapy review forms in Resident #64 medical charts noting the irregularities. Per R.Ph #299, the medication therapy reviews are completed monthly however the recommendation for medication changes are different from the medication review regimen documents in the resident's chart because he only makes his recommendations to the physicians during the quarterly meetings. 5. Record review of Resident #68's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #68 include delirium, Alzheimer's disease, falls, anxiety, dementia with behaviors, hallucinations, urinary tract infection, and behavioral syndromes with physiological and disturbances. Review of the Resident #68's comprehensive MDS assessment dated [DATE] revealed the resident had impaired cognition. Per the assessment the resident received anti-anxiety, anti-depressants, and anti-psychotics during the review period. Review of Resident #68's medications revealed the resident was prescribed fluoxetine 20 milligrams, (mg) daily for depression, Ativan 0.5 mg twice a day for anxiety, and Seroquel 25 mg on tablet in morning and 12.5 mg tablet in the evening for dementia. Review of Resident #68 care plans dated 09/06/19 revealed a focus for psychotropic medications. Interventions for the focus include consult with pharmacy and physician to consider dosage reduction per reduction policy. Review of the Resident #68's consultant pharmacy's monthly drug regimen reviews dated from 12/30/18 to 10/30/2019 revealed the pharmacist made no recommendations or noted any irregularities for Resident #68 in the monthly reviews. Review of Resident #68's medication therapy review documents dated 05/29/19 revealed Resident #68's current order for Ativan was 0.25 mg orally twice a day, per the recommendation the order would be changed to Ativan 0.25 mg orally daily for anxiety. No staff signature for reviewer name, signature, or date was completed on the form. For the form's follow up it was documented due to the family's refusal there will be no change to the medication. The physician signed the form on 05/29/19. No documentation from the pharmacist was noted on the form. Review of Resident #68's medication therapy review form dated 09/19/19 revealed the current order was Fluoxetine 20 mg orally daily. Per the recommendation the medication would be changed to Fluoxetine 10 mg daily for depression. The form reviewer was signed by the DON of the facility, no date was noted for the reviewer's signature. Per the follow up section of the form the recommendation was crossed out with 'family refusal no change to be made'. The form was signed by a Licensed Practical Nurse and the physician, dated 09/19/19. No documentation from the pharmacist was noted on the form. There was no rationale from the attending physician for the refusal of the recommendations dated 05/29/19 and 09/19/19 noted in the resident's medical record. Interview on 11/21/19 at 11:40 A.M. with R.Ph #299 verified the recommendations for each medication change for Resident #68 were not noted in the individual's medical charts on a monthly basis. R.Ph #299 verified his signature was not noted on the medication therapy review forms in Resident #68 medical charts noting the irregularities. Review of the facility policy titled, 'Tapering Medications and Gradual Drug Dose Reduction' dated 09/19 revealed per the policy the staff and practitioner will review for continued relevance of each resident's medications. Resident's who use antipathetic drugs must receive gradual dose reductions unless clinically contraindicated. Based on medical record review, pharmacist and staff interview and facility policy review, the facility failed to ensure the licensed pharmacist reported medication irregularities to the attending physician, medical director and the Director of Nursing. This affected five (#31, #64, #65, #68 and #87) out of five residents reviewed for unnecessary medications. The facility census was 96. Findings include: 1. Review of the medical record for Resident #31 revealed she was admitted to the facility on [DATE] with diagnoses including chest pain, diabetes, cataract, spinal stenosis, nail dystrophy, depression, anxiety, obsessive-compulsive disorder, left bundle branch block, hemiplegia, cardiomyopathy, congestive heart failure and hypertension. Review of the Plan of Care for Resident #31 revealed a focus of psychotropic medication use which included Prozac and Xanax related to depression and anxiety. The goal was Resident #31 will receive the lowest effective dose of psychoactive medication to manage her symptoms. The interventions included to consult with pharmacy and physician to consider dosage reduction quarterly per reduction policy and as needed. Review of the Drug Regimen Review for 12 months from November 2018 to October 2019 revealed the consulting pharmacist did review Resident #31's medication each month. The pharmacist documented no new recommendations 11 of 12 months during the previous year. For the July, 2019 review there was a note that stated family refused Gradual Dose Reduction (GDR) dated 07/31/19 and initialed by the consulting pharmacist. The details of the GDR recommendation were not documented on the Drug Regimen Review form. Review of the Medication Therapy Review form for Resident #31 revealed the resident was currently taking Alprazolam 0.25 milligrams (mg) by mouth three times daily. The recommendation was to decrease Alprazolam to twice daily. The form was signed by the former Director of Nursing (DON) and dated 09/20/19. Below the DON signature the note Family refusal was written, date 09/20/19 at 1:20 P.M. and initialed by a Licensed Practical Nurse (LPN). Below the LPN note the note No changes to be made was written and signed by the physician and dated 09/20/19. Further review of Resident #31's medical record revealed no pharmacy recommendations completed by the consulting pharmacist for the last 12 months. There were no irregularities noted by the pharmacist and documented on a separate, written report provided to the attending physician and the facility's medical director and director of nursing which included the resident's name, the relevant drug, and the irregularity the pharmacist identified. Interview with the facility consulting Pharmacist (R.Ph) #299 on 11/21/19 at 11:43 A.M. verified he did not provide separate, written reports for each resident which contained noted irregularities to the attending physician and the facility's medical director and DON which included the resident's name, the relevant drug, and the irregularity the pharmacist identified. In regard to making recommendations R.Ph #299 stated he meets quarterly with the DON and other nursing staff during which time they reviewed individual resident medication irregularities and recommendations and facility staff completed recommendations for individual residents during the quarterly meetings. R.Ph #299 verified he did not complete or sign the recommendations and there were no monthly recommendations. 2. Resident #65 was admitted to the facility on [DATE] with readmission date on 08/01/19 with diagnoses including displaced fracture of left hip, anemia, peripheral vascular disease, anxiety disorder, Alzheimer's disease , dementia with behavior disturbances, major depressive disorder,and chronic kidney disease. Review of the November 2019 monthly physician orders revealed the resident is receiving Buspar (anti anxiety medication) 10 milligrams (mg) twice a day for anxiety. The start date for Buspar was 02/25/17. The resident was receiving Ativan 0.5 mg (anti anxiety medication) twice a day with a start date of 04/30/17. Review of a significant change in status MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of one indicating she has severe cognitive impairment. She had no behaviors during the assessment period. She received an antidepressant and anti anxiety medication all seven days of the assessment period. Review of the Care Area Assessment for psychotropic medications stated the resident takes Buspar (anti anxiety), and Ativan (anti anxiety) to treat depression and anxiety. She is at risk for adverse effects such as falls and changes in mood. Will proceed to plan of care. Review of the plan of care, dated 08/01/16, with update of 08/08/19, revealed psychotropic medication (Buspar, Ativan) is prescribed for anxiety and depression. The goal is for the resident will receive the lowest effective dose of psychoactive medication to manage symptoms. The interventions included to consult with pharmacy and physician to consider dosage reduction quarterly per reduction policy and as needed and discuss the ongoing need for the use of the medication with the physician and family. Review of the Psychotropic Drug Therapy History monthly report dated 11/06/19 through 08/08/19 revealed Resident #65's Buspar and Ativan dosage was reviewed with no recommendations to gradually reduce the dosage of the medications. There were no recommendations from the pharmacist to the physician to attempt to decrease the dose of the two anti anxiety medications in the past year. On 11/20/19 at 3:00 P.M. the Director of Nursing verified there were no pharmacy recommendations to the physician found in Resident #65 medical record.

Based on observations and staff and resident interviews, the facility failed to serve food at a palatable temperatures. This has the potential to affect all 96 residents residing in the facility who are receiving food from the kitchen. The facility census was 96. Findings include: On 11/18/19 at 10:47 A.M. Resident #296 states the food is poor quality, always cold, and the taste is not good. She stated the problem is they don't have a microwaves on this side of the building. Observation of the plating of lunch on 11/20/19 at 11:35 A.M. revealed Dietary Assistant #415 plated food then placed the plate on a tray. Fourteen trays were placed on an open cart for the Sycamore (skilled) Unit. At 11:50 A.M. Chef #406 took the cart from the kitchen to the Sycamore Unit . The cart arrived on the unit at 11:52 A.M. At 11:58 A.M. Resident Assistant (RA) #394 began passing the trays to the residents in their rooms on the unit. At 12:00 P.M. State Tested Nursing Assistant (STNA) #366 began delivering trays from the open cart. At 12:07 P.M. the last tray was delivered to a resident's room. A test tray, that was requested that was left on the cart and the tray was provided to the surveyor. At 12:08 P.M. the temperature of the turkey per the facility's digital thermometer was 139 degrees Fahrenheit, the mashed potatoes temperature was 120 degree Fahrenheit, and the roasted mixed vegetable was 105 degrees Fahrenheit. State Tested Nursing Assistant (STNA) #366 verified the temperatures of the test tray. When tasting the turkey, mashed potatoes, and vegetables the food was not warm enough to be palatable. STNA #366 verified there was no microwave on the Sycamore Unit. She stated to warm food up the staff had to take the food across the facility to the Buckeye unit to heat it. The facility confirmed this had the potential to affect all 96 residents residing in the facility. On 11/18/19 at 12:23 P.M. interview with Resident #1 stated the food is never hot. It is luke warm at best and was usually cold. She stated her mashed potatoes was were cold for lunch today. On 11/20/19 at 2:15 P.M. during the Resident Council meeting with five (#31, #51, #4, #92, #53) Residents revealed the food could be warmer. All five (#31, #51, #4, #92, #53) Residents revealed they all eat in the Meadows dining room and have asked for their food to be warmed up before; however, there is no microwave to warm food available in their area. Resident #51 stated he just eats his food cold or how ever they serve it because it happens all the time.

Based on review of facility records, staff interview and facility policy review the facility failed to establish and maintain an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections which included a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, and visitors. This had the potential to affect 96 residents of 96 residents residing in the facility. Facility census was 96. Findings include: Review of the facility IPCP with Director of Nursing (DON) on 11/21/19 at 10:38 A.M. revealed the facility IPCP had not been completed since since 08/24/19. DON verified the last entry on the facility Infection Control Log was dated 08/24/19. DON verified no had completed the IPCP since the previous DON resigned on 09/30/19. The prior DON's last day was 09/25/19. DON stated she thought she would eventually assume the responsibility. DON stated the only infection information currently being collected was a running list of residents being treated with antibiotics. There was no tracking/trending in place and no antibiotic (ATB) stewardship in place. DON verified the facility did not implement a system for ongoing surveillance of communicable diseases or infections which included routine, ongoing, and systematic collection, analysis and interpretation of identify infections (facility-acquired and community-acquired) which included, at a minimum, the infection site, type of infection, pathogen (if available), signs and symptoms, and resident location, including summary and analysis of the information. The facility had no one designated infection preventionist and no established antibiotic stewardship program. This facility confirmed this had the potential to affect all 96 residents residing in the facility. Review of the facility policy titled Infection Control Surveillance revised 02/23/18 revealed the facility will have an Infection Surveillance Program that investigates, controls and prevents infections in the facility. Surveillance encompasses monitoring of staff practices and compliance with infection control policies and procedures as well as monitoring the residents or infections Surveillance data is part of the facility's ongoing performance improvement process and data is analyzed to make improvements in care and practice. The Infection Control Preventionist (ICP) occupies the key position in the IPCP. The ICP provides surveillance data and carries out or promotes many of the prevention and control measures that are adopted as a result of the surveillance activities. The ICP reviews findings relevant to infection control issues. Current surveillance data will be maintained which follows carefully defined events to be surveyed and applies the accepted definitions of infections systematically in the data collection process. Staff members will notify the ICP when they suspect a resident has an infection. Newly admitted residents' records will be reviewed by the ICP to determine if any pre-existing infections are present and that staff is knowledgeable regarding the proper procedures required to care for the resident. The ICP will review these reports daily for information concerning any resident exhibiting signs and symptoms of infection. The ICP will review microbiology and serology reports. A facility Summary of Cultures will be requested from the laboratory. The ICP collects data for the IPCP log. All infections whether nosocomial or acquired outside the facility are to be included. The ICP determines presence of an infection using criteria in the facility's Definitions of Infections Policy. The ICP tabulates data and prepares a summary report at least monthly, calculates incidence rates per 1000 resident days and compares current incidence rates to previous rates. The ICP and the Infection Control Nurse present reports to the Infection Control Committee. The Infection Control Committee will conduct an in-depth review of the problems revealed by the data collects. The Infection Control Committee reports a summary of the findings, actions and results to the QA or Performance Improvement Committee. The Infection Control Nurse reports all communicable diseases, as required, to state and local agencies.

Based on review of facility records, staff interview and facility policy review, the facility failed to develop and implement an Antibiotic Stewardship Program (ASP) to promote facility-wide monitoring for the appropriate use of antibiotics. This had the potential to affect 96 residents of 96 residents residing in the facility. Facility census was 96. Findings include: Review of the facility IPCP with Director of Nursing (DON) on 11/21/19 at 10:38 A.M. revealed the facility Infection Prevention Control Program (IPCP) had not been completed since since 08/24/19. The IPCP included the ASP. DON verified the last entry on the facility Infection Control Log was dated 08/24/19. DON verified no one had completed the IPCP since the previous DON resigned on 09/30/19. The prior DON's last day was 09/25/19. DON stated she thought she would eventually assume the responsibility. DON stated the only infection information currently being collected was a running list of residents being treated with antibiotics which was not thoroughly completed and had not been reviewed by anyone since the departure of the previous DON. There was no tracking/trending in place and no ASP in place. DON verified the facility did not implement a system for ongoing surveillance of communicable diseases or infections which included routine, ongoing, and systematic collection, analysis and interpretation of identify infections (facility-acquired and community-acquired) which included, at a minimum, the infection site, type of infection, pathogen (if available), signs and symptoms, and resident location, including summary and analysis of the information. DON verified the facility had no one designated as the identified Infection Preventionist and no established antibiotic stewardship program. DON verified the facility policy did not include the requirements necessary to ensure antibiotics were prescribed for the correct indication, dose, and duration to treat the resident and to improve resident outcomes while also attempting to reduce the development of antibiotic-resistant organisms for all current, new and readmitted residents. The policy did not require a designated individual to be responsibility for the ASP. The policy did not identify how the medical director, consulting pharmacist, nursing and administrative leadership participated in the ASP. The policy had no system for reports related to monitoring antibiotic usage and resistance data. The policy was silent regarding antibiotic use tracking which included resident signs or symptoms of an infection; laboratory tests ordered and the results and prescription information including the indication for use. DON verified the facility was not applying an infection assessment tool such as the McGeer Criteria when prescribing antibiotics. The facility confirmed this had the potential to affect all 96 residents residing in the facility. Review of the facility policy titled Antibiotic Stewardship revised July 2016 revealed antibiotics will be prescribed and administered to residents under the guidance of the Antibiotic Stewardship Program. The purpose was to monitor the use of antibiotics of the residents. Staff will be educated in antibiotic stewardship and how the inappropriate use of antibiotics affects the resident and overall community. Prescriber's will provide complete antibiotic orders including the drug name, dose, frequency of administration, duration of treatment, route of administration and indication for use. Upon admission the admitting nurse will review the medical information for current antibiotic/anti-infective orders. Discharge or transfer medical records must include all the above drug and dosing elements. When a nurse calls a physician to communicate a suspected infection the following information will be included: signs and symptoms; onset; hydration status; current medications; allergies; infection type; current Warfarin order and last international normalized ratio (INR) results (as applicable); last creatinine clearance or serum creatinine if available and time of the last antibiotic dose. The physician will assess the resident within 72 of prescribing antibiotics by phone. The consultant pharmacist should be advised of all new antibiotic orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to issue written notice of the reason for transfer to the hospital to the resident and/or resident representative and failed to notify the Ombudsman of a transfer. This affected two (#86 and #66) of two residents reviewed for hospitalizations. The facility census was 82. Findings include: 1. Review of Resident #86's closed medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), diabetes mellitus, adjustment disorder with mixed anxiety and depressed mood, chronic respiratory failure with hypoxia, heart failure, hyperlipidemia, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed a the resident had moderate cognitive impairment. Review of the physician's order dated [DATE] at 7:45 P.M. revealed an order to send the resident to the emergency room for evaluation and treatment related to respiratory distress. Review of the nursing progress note dated [DATE] at 8:40 P.M. revealed the resident was sent to the hospital for evaluation and treatment related to respiratory failure. The progress notes further revealed the resident's wife was notified via telephone of the transfer to the hospital. There was no evidence the facility provided a written notice of the transfer/discharge to the hospital to the resident/resident representative. There was no evidence the Ombudsman was notified of Resident #86's transfer to the hospital. Further review of the closed medical record revealed the resident returned did not return to the facility because he expired while in the hospital. 2. Review of Resident #66's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease (PVD), emphysema, hypertension, and cardiac arrhythmia. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had moderate cognitive impairment. Review of the physician's order dated [DATE] at 5:19 A.M. revealed an order to send the resident to the emergency room for evaluation and treatment related to low oxygen saturation. Review of the nursing progress note dated [DATE] at 5:46 A.M. revealed the resident was transferred to the hospital for evaluation and treatment due to shortness of breath (SOB). There was no evidence the facility provided a written notice of the transfer/discharge to the hospital to the resident/resident representative. There was no evidence the Ombudsman was notified of Resident #66's discharge to the hospital on [DATE]. Further review of the progress notes revealed the resident returned to the facility on [DATE] at 3:20 P.M. Interview on [DATE] at 4:38 P.M., the Director of Nursing (DON) confirmed the facility did not issue a written notice of the transfer or discharge to the hospital to the resident/resident representative related to Resident #86 and Resident #66's discharge to the hospital. The DON further confirmed the facility does not routinely provide this documentation to the resident/resident representative when a resident is transferred or discharge to the hospital and the facility does not notify the Ombudsman of hospital transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to issue written notice of the bed hold policy to a resident/resident's representative upon discharge to the hospital for two (#66 and #86) of two residents reviewed for hospitalizations. The facility census was 82. Findings include: 1. Review of Resident #66's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease (PVD), emphysema, hypertension, and cardiac arrhythmia. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident had moderate cognitive impairment. Review of the physician's order dated [DATE] at 5:19 A.M. revealed an order to send the resident to the emergency room for evaluation and treatment related to low oxygen saturation. Review of the nursing progress note dated [DATE] at 5:46 A.M. revealed the resident was transferred to the hospital for evaluation and treatment due to shortness of breath (SOB). Review of the record revealed no evidence the facility provided a written notice of bed hold policy to the resident/resident representative related to Resident #66's discharge to the hospital on [DATE]. Further review of the progress notes revealed the resident returned to the facility on [DATE] at 3:20 P.M. 2. Review of Resident #86's closed medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), diabetes mellitus, adjustment disorder with mixed anxiety and depressed mood, chronic respiratory failure with hypoxia, heart failure, hyperlipidemia, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed a the resident had moderate cognitive impairment. Review of the physician's order dated [DATE] at 7:45 P.M. revealed an order to send the resident to the emergency room for evaluation and treatment related to respiratory distress. Review of the nursing progress note dated [DATE] at 8:40 P.M. revealed the resident was sent to the hospital for evaluation and treatment related to respiratory failure. The progress notes further revealed the resident's wife was notified via telephone of the transfer to the hospital. Review of the record revealed no evidence the facility provided a written notice of bed hold policy to the resident/resident representative related to Resident #86's transfer to the hospital. Further review of the closed medical record revealed the resident returned did not return to the facility because he expired while in the hospital. Interview on [DATE] at 4:38 P.M., the Director of Nursing (DON) confirmed the facility did not issue a written notice of bed hold policy to the resident/resident representative related to Resident #66's discharge to the hospital on [DATE] and Resident #86's transfer to the hospital. The DON further confirmed the facility does not routinely provide this documentation to the resident/resident representative when a resident is transferred or discharge to the hospital, the bed hold policy is only reviewed on admission to the facility. Review of the facility policy titled Bed Hold Policy, dated 2017, revealed the facility was to formally notify each resident or designated responsible party of an outside transfer to another facility such as a hospital or therapeutic leave where the bed hold policy would take effect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview; the facility failed to accurately complete Minimum Data Set (MDS) assessments for three (#9, #18, and #41) of 20 resident MDS assessments reviewed. The facility census was 82. Findings include: 1. Review of the medical record for Resident #41 revealed the resident was admitted to the facility on [DATE]. Diagnoses included psychosis, anxiety disorder, major depressive disorder, hypertension, and dementia without behavioral disturbances. Review of the state Preadmission Screening and Resident Review (PASRR) Level II Determination and Summary Report, dated 05/19/17, revealed it was determined Resident #41 had a serious mental illness and was appropriate for a nursing facility. There were no special services recommended. Review of the annual MDS assessment, dated 06/27/18, section A1500 revealed no documentation Resident #41 was considered by the state Level II PASRR process to have serious mental illness. Interview on 09/27/18 at 1:12 P.M., Registered Nurse (RN) #350 verified Resident #41's annual MDS assessment dated [DATE], section A1500 was not properly coded. 2. Review of the medical record for Resident #18 revealed the resident was admitted to the the facility on 03/07/18. Diagnoses included Alzheimer's disease, dementia with behavioral disturbances, polyarthritis, pneumonia, osteoarthritis, congestive heart failure, insomnia, fluid overload, thrombocytopenia, and anxiety. Review of Resident #18's quarterly MDS assessment, dated 07/03/18, revealed the resident was assessed as receiving antibiotic medication on seven days during the seven day reference period. Review of Resident #18's medication administration record (MAR) dated 06/18 and 07/18, revealed no documentation the resident received antibiotic medication on 06/27/18, 06/28/18, 06/29/18, 06/30/18, 07/01/18, 07/02/18, or 07/03/18. Interview on 09/27/18 at 11:58 A.M., RN #350 revealed Resident #18 did not receive antibiotic medication on 06/27/18, 06/28/18, 06/29/18, 06/30/18, 07/01/18, 07/02/18, or 07/03/18. RN #350 verified the quarterly MDS assessment dated [DATE] for Resident #18 was not accurate. 3. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, diabetes mellitus, hypertension, and atherosclerotic heart disease. Review of the MDS assessment, dated 09/10/18, revealed the resident had received an antidepressant five of seven days during the look-back period. Review of the most recent physician's orders for September 1, 2018 through September 30, 2018 revealed Resident #9 had orders for Lexapro (antidepressant) 10 mg daily, which was increased to 20 mg daily on 09/04/18. Review of the medication administration record (MAR) for September 2018 revealed the resident received Lexapro six of seven days of the look-back period, the medication was held 09/06/18. Interview on 09/26/18 at 12:28 P.M., RN #350 revealed the seven day look-back period was 09/04/18 through 09/10/18. She further revealed she did not see the dose for Lexapro had changed and confirmed Resident #9 had been coded as receiving an antidepressant on five days, but had actually received it on six days.

Based on observation, staff interview, and facility policy review, the facility failed to ensure proper storage of medications on the medication carts. This had the potential to affect 26 Resident (#2, #3, #6, #8, #9, #14, #15, #16, #23, #25, #27, #33, #37, #38, #47, #50, #51, #52, #58, #59, #69, #77, #85, #86, #87, and #137) who reside on the Buckeye Hallway. The facility census was 82. Findings include: Observation on 09/25/18 at 11:45 A.M. of medication administration on the Buckeye Hallway revealed Registered Nurse (RN) #200 left a vial of insulin on top of the medication cart and walked into a resident room, out of sight of the medication cart. Interview on 09/25/18 at 11:47 A.M., RN #200 provided verification of the vial of insulin having been left on top of the medication cart and unattended. Review of the undated facility policy titled Storage of Medicationsrevealed drugs are to be stored in locked compartments when not in use or attended. The facility identified 26 Resident's (#2, #3, #6, #8, #9, #14, #15, #16, #23, #25, #27, #33, #37, #38, #47, #50, #51, #52, #58, #59, #69, #77, #85, #86, #87, and #137) who reside on the Buckeye Hallway.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and review of the facility policy, the facility failed to ensure insulin vials were cleaned prior to inserting sterile needles to draw the insulin for administration. This effected one resident (#16) of two residents observed for insulin administration. In addition the facility failed to ensure the glucose monitor was disinfected between each resident use. The facility identified 16 residents (#6, #7, #9, #13, #15, #16, #21, #22, #29, #32, #39, #46, #68, #69, #73 and #86) who receive insulin and 17 residents (#6, #7, #9, #13, #15, #16, #21, #22, #29, #32, #36, #39, #46, #68, #69, #73 and #86) who receive blood sugar monitoring. The facility census was 82. Findings include: Observation on 09/25/18 at 11:48 A.M. of Registered Nurse (RN) #200 administering insulin to Resident #16 revealed she removed the opened vial of Humulin Regular insulin from the box and inserted a syringe into the rubber stopper. She withdrew the 16 units of insulin, replaced the cap on the syringe and replaced the insulin into the box. She had not cleansed the stopper with alcohol prior to inserting the syringe. Interview on 09/25/18 at 11:50 A.M. with RN #200 provided verification of not cleansing the rubber stopper prior to inserting the syringe. Observation on 09/25/18 at 11:55 A.M. of blood sugar monitoring performed by RN #200 revealed after using the glucose monitor to check Resident #16's blood sugar. RN #200 did not cleanse the glucose monitor prior to being observed to obtain Resident #86's blood sugar. Interview on 09/25/18 at 11:55 A.M., RN #200 verified she did not disinfect the monitor after obtaining Resident #16's blood sugar and before obtaining Resident #86's blood sugar. RN #200 then used an alcohol swab to cleanse the meter. When this surveyor questioned the use of alcohol, RN #200 asked the Unit Manager what to use to disinfect the monitor. Unit Manager responded with bleach wipes and instructed RN #200 where to locate the wipes. Review of the undated facility policy titled Fair Haven [NAME] County Home Insulin Injection Instructions for Sub Q revealed to wipe the top of the bottle with alcohol swab prior to inserting the needle into the rubber stopper. Review of the facility policy titled Cleaning and Disinfection Procedures revealed to disinfect the monitor using a one to 10 quaternary to bleach ratio wipe. The facility identified 16 residents (#6, #7, #9, #13, #15, #16, #21, #22, #29, #32, #39, #46, #68, #69, #73 and #86) who receive insulin and 17 residents (#6, #7, #9, #13, #15, #16, #21, #22, #29, #32, #36, #39, #46, #68, #69, #73 and #86) who receive blood sugar monitoring.