**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility reported incident review, and interview, the facility failed to complete a thorough investigation for an allegation of physical abuse. This affected one resident (#75) of three residents reviewed for allegations of abuse. The facility census was 36. Findings included: Closed record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including respiratory failure, chronic obstructive pulmonary disease, chronic systolic congestive heart failure, dysphagia, anemia, panic disorder, and gastro-esophageal reflux disease. Review of minimum data set assessment collected on 04/04/23 revealed Resident #75 had mild- impaired cognition and did not have behaviors related to refusing care. Review of transfer and discharge records revealed Resident #75 transferred to the hospital on [DATE]. Review of a facility reported incident completed on 04/03/23 revealed Resident #75's representative spoke with the administrator regarding an allegation of staff forcing her to take a shower. The facility did start an immediate report to appropriate agencies regarding the alleged incident, but the facility did not provide evidence of interviews with Resident #75, like residents, or staff members and the investigation did not include evidence of a skin check or resident assessment being completed. Interview on 11/07/23 at 2:05 P.M. with the Administrator confirmed there were no other records regarding the investigation to review. Review of a policy titled Abuse, Mistreatment, Neglect, Injuries of Unknown Source revealed the facility should interview the resident, the accused, and all witnesses including anyone who worked directly with the resident, came into contact with the resident, or heard or saw the incident occur. After each interview, the interviewee should be allowed to review the statement collected and sign to prove the documentation is an accurate reflection of their view. Policy also stated the facility should review the resident records. This deficiency is cited as an incidental finding to Complaint Number OH00143598.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure nutritional interventions were provided to residents in a timely manner. This affected one resident (#74) of three residents reviewed for nutrition services. The facility census was 36. Findings included: Record review revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including dementia, heart failure, chronic kidney disease stage 3, anemia, gastro-esophageal reflux disease, and atrial fibrillation. Review of a minimum data set (MDS) assessment collected on 11/02/22 revealed Resident #74 had mildly impaired cognition, no behaviors, required set up or clean up assistance with meals, and was receiving a therapeutic diet. Review of orders revealed Resident #74 had an order for a no added salt diet on 10/27/22 and had received an order for Ensure Plus twice a day on 11/22/22. Review of medication administration record (MAR) for November and December 2022 revealed Resident #74 did not receive first administration of Ensure Plus until 12/01/22. Interview on 11/07/23 at 2:02 P.M. with the Director of Nursing (DON) revealed the dietician had made a recommendation for Ensure Plus on 11/22/22, however the physician was out of town and the order was not signed until 12/01/22. The DON stated the facility did have a nurse practitioner to cover for emergent services while the physician was unavailable but she would not sign certain orders such as nutrition recommendations. The DON stated she did not feel this was sufficient and she did not believe the facility had a policy related to physician services. This deficiency represents non-compliance investigated under Complaint Number OH00143598.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the State Ombudsman was notified of a transfer to the hospital involving Resident #16. This affected one resident (#16) of one resident reviewed for hospitalization. Findings Include: Record review for Resident #16 revealed an admission date of 07/09/22 with diagnoses including chronic obstructive pulmonary disease, history of falling, urinary tract infection, atrial fibrillation, hypertension, dizziness and giddiness, chronic gout, tobacco use, pulmonary edema, anemia, type two diabetes mellitus, hypothyroidism, long term use of anticoagulants, low back pain, overactive bladder, hyperlipidemia, major depressive disorder, anxiety disorder, insomnia and post-laminectomy syndrome. Review of the 10/12/22 quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident was cognitively intact, required limited assistance from staff for dressing and supervision (from staff) for bed mobility, transfers, walking in room, eating, toilet use, and personal hygiene. The assessment revealed the resident used a walker and wheelchair to aid in mobility, was occasionally incontinent of bladder and always continent of bowel. Review of a progress note, dated 10/16/22 at 5:40 P.M. revealed the resident was summoning staff to room. The resident was laying in bed rigid, yelling out and complaining of severe intermittent pain to mid abdominal region and also had complaints of pain to the upper chest. The physician was notified and new orders were received to send the resident to the emergency room for evaluation. Review of the medical record revealed no documented evidence the State Ombudsman was notified of the resident being transferred/admitted to the hospital on [DATE]. Interview with the Administrator on 11/16/22 at 1:40 P.M. revealed the facility was unable to provide written evidence the State Ombudsman was notified of Resident #16's hospital transfer/admission on [DATE]. The Administrator revealed the facility had not been notifying the State Ombudsman of resident transfers and discharges for the previous four months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #18's Pre-admission Screening and Resident Review (PASARR) documents were accurate related to the resident's condition and diagnoses. This affected one resident (#18) of one resident reviewed for PASARR. Findings Include: Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including hypertensive heart and chronic kidney disease, heart failure, atrial fibrillation, end stage renal disease, type II diabetes, orthostatic hypotension, atherosclerotic heart disease, major depressive disorder, dysphagia, chronic respiratory failure, delusional disorder, peripheral vascular disease, generalized anxiety disorder, hyperlipidemia, iron deficiency, gout, and insomnia. Review of Resident #18 PASARR document, dated 12/16/19 revealed under Section D, it indicated the resident had no mental health diagnoses. However, review of the resident's diagnoses list, the resident had the following diagnoses that should have been indicated on the PASARR document: major depressive disorder (dated 11/21/19). Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/10/22 revealed the resident was cognitively intact. On 11/17/22 at 10:09 A.M. interview with Licensed Practical Nurse (LPN) #135 revealed the facility would complete a PASARR/update a PASARR document after 20 days of an initial stay after a resident's admission from the hospital or a resident had left to go to the hospital, and was not back in the facility for 72 hours. LPN #135 revealed the facility did not have a mechanism/procedure to inform her of updated/added mental health diagnoses while resident was in the facility. She confirmed Resident #18 had mental health diagnoses that were not included in the PASARR documentation submitted for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a new Pre-admission Screening and Resident Review (PASARR) was competed for Resident #18 following changes to the resident's mental health diagnoses. This affected one resident (#18) of one resident reviewed for PASARR. Findings Include: Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including hypertensive heart and chronic kidney disease, heart failure, atrial fibrillation, end stage renal disease, type II diabetes, orthostatic hypotension, atherosclerotic heart disease, major depressive disorder, dysphagia, chronic respiratory failure, delusional disorder, peripheral vascular disease, generalized anxiety disorder, hyperlipidemia, iron deficiency, gout, and insomnia. Review of Resident #18 PASARR document, dated 12/16/19 revealed under Section D, it indicated the resident had no mental health diagnoses. However, review of the resident's diagnoses list, the resident had the following diagnoses that should have been indicated/updated on the PASARR document: major depressive disorder (dated 11/21/19), delusional disorders (dated 12/02/20) and generalized anxiety disorder (added 06/09/20). Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/10/22 revealed the resident was cognitively intact. On 11/17/22 at 10:09 A.M. interview with Licensed Practical Nurse (LPN) #135 revealed the facility would complete a PASARR/update a PASARR document after 20 days of an initial stay after a resident's admission from the hospital or a resident had left to go to the hospital, and was not back in the facility for 72 hours. LPN #135 revealed the facility did not have a mechanism/procedure to inform her of updated/added mental health diagnoses while resident was in the facility. She confirmed Resident #18 had mental health diagnoses that were not included in the PASARR documentation submitted for review.

Based on observation, facility policy and procedure review and interview the facility failed to properly store, date (label), and prepare food to protect against contamination and/or spoilage. This had the potential to affect all 37 residents residing in the facility. Findings Include: 1. On 11/14/22 at 8:45 A.M. and 9:20 A.M. observation in the kitchen revealed three sealed/unopened packages of ham in a large plastic container in the walk in refrigerator. Two packages were thawed and cool to the refrigerator's temperature. One package still had frost/ice on the outside and was frozen to touch. Neither package had a date as to when it was delivered or when it was removed from the freezer to thaw for service. Also, there was one package of a block of cheese that was in a sealed plastic bag, due to the cheese being opened but not fully used. There was no date on the bag of the cheese as to when it was opened. Finally, there was a large metal pan of vegetable soup with no top and no date on the pan, inside the walk in freezer. Interview with Dietary Staff #201 on 11/14/22 at 8:50 A.M. confirmed the ham packages that were in the walk in refrigerator, were originally in the freezer. She confirmed staff typically take frozen items out of the freezer, and allow them to thaw in the refrigerator for three days, and then use them. She confirmed she does not know the exact date when the packages of ham were taken out, but confirmed that one package was still frozen and two were not. She stated she cooked the vegetable soup that morning, and put it in the freezer to cool, because it would be served for the residents to eat in a few days. She indicated there was no lid on the pan of vegetable soup, so it would cool/freeze faster. Interview with Director of Food Services #123 on 11/14/22 at 9:20 A.M. confirmed there was no date on the three packages of ham, block of cheese in the plastic bag, and vegetable soup that was in the freezer. She also confirmed there should be dates on all three items; when the vegetable soup was placed in the freezer, when the ham was removed from the freezer to the refrigerator, and when the cheese was first opened. She also confirmed the pan of vegetable soup should have had a lid on it. Review of facility Refrigerated Storage policy, dated January 2016 revealed perishable foods shall be stored in a manner that optimizes food safety and quality. All pre-dished items shall be covered to prevent off-flavoring, drying, or cross contamination while refrigerated. Food container covers shall be impervious and non-absorbent. Refrigerated items shall bear a label indicating product name and date (month, day, year) product was received, used or first opened. Review of Frozen Storage policy, dated January 2016 revealed all frozen products shall be labeled indicating product name and date of delivery (month, day, and year). Review of facility Thawing policy, dated January 2016 revealed all frozen foods shall be thawed in a manner that optimizes food safety and quality. The dietary manager or designee shall indicate products to be removed from the freezer for thawing. Food shall be thawed under refrigeration that maintains the food temperature at 41 degrees Fahrenheit or below. Food items shall be placed in a pan to collect any juices and shall be placed on the lowest refrigerated unit shelf to prevent cross contamination. Pan shall be checked frequently to prevent overflow. Food items shall be placed in separate pans for thawing (do not thaw chicken with beef or ham.) 2. On 11/16/22 at 10:17 A.M., 10:21 A.M., and 10:25 A.M. Dietary Staff (DS) #201 was observed with a disposable glove on her right hand. DS #201 was observed to place pieces of pork into the blender with her gloved hand. After putting the pork in, she touched the blender, dirty counter top, metal pans, cloth towel, utensil, and blender lid. Then, she put more pork into another blender to make ground textured meat. She used the same gloved hand (did not change glove), to put more of the meal into the blender. After blending the meat to the proper texture, she opened the lid and put the same gloved hand on the inside of the blender to hold the blade intact while dumping the meat into a metal pan. After putting the metal pan of ground meat on the steam table, she took the pork gravy pan to the steam table to put it on the tray line as well. Prior to doing that, she wiped the sides of the gravy pan with the same gloved hand four times, and put the wiped gravy back into the gravy pan. Interview with Dietary Staff #201 on 11/16/22 at 10:26 A.M. confirmed she did not change her gloves throughout the entire preparation and storage process listed above. DS #201 revealed she does not change her gloves while she is working with the same food type (all pork products). Review of facility Disposable Gloves policy, dated October 2020 revealed disposable gloves shall be used for only one task and shall be discarded when damaged or soiled or when interruptions occur in operation. Gloved hands were considered a food contact surface that could become contaminated or soiled. Disposable gloves need to be changed between tasks and as often as hands need to be washed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and test tray, the facility failed to provide residents with palatable food. This affected seven residents (Residents #37, #18, #36, #2, #93, #20 and #197) and had the potential to affect all residents residing in the facility at this time. The facility also failed to follow the recipe for pureed meat. This had the potential to affect two residents (Residents #15 and #29) identified by the facility as receiving pureed diets. The facility census was 54. Findings include: 1. Review of the facility's menu for the week of 01/20/20 through 01/24/19 revealed lunch for 01/23/20 was cod nuggets, Spanish rice, Key [NAME] blend vegetables, cornbread and cherry pie. A test tray was completed on 01/23/20 at 11:50 A.M. by surveyors #32654, #36303, and #41271 which revealed the cod nuggets and Spanish rice were not palatable due to the rice being mushy and the cod having a rubbery texture. Observation 01/23/20 between 11:30 A.M. and 12:45 P.M. of residents eating lunch revealed Residents #37, #18, #36, #2, #93, #20 and #197, had eaten between 25 percent (%) to 50% of their meals. Interview on 01/23/20 between 11:50 A.M. and 12:45 P.M. with Residents #37, #18, #36, #2, #93, #20 and #197 revealed the food did not taste good, and the cod nuggets were over cooked and too difficult to chew. Interview on 01/23/20 with Dietary #14 confirmed the residents did not consume much of their lunch. 2. Observation on 01/22/20 at 11:00 A.M. of [NAME] #29 preparing pureed ham for lunch revealed she used one ounce of water to mix in with the pureed ham to ensure the correct texture. Review of the facility's recipe for pureeing meat revealed one ounce of broth was to be used with pork, beef and chicken to ensure correct texture while still preserving the flavor of the meat. Interview on 01/22/20 at 11:02 A.M. with [NAME] #29 confirmed the use of water with the ham to ensure the correct texture. Interview on 01/22/20 at 11:30 A.M. with Dietary #14 confirmed [NAME] #29 should have used broth to mix with the ham instead of the water. The facility identified two residents (Residents #15 and #29) as receiving pureed diets.