Based on record review and interview, the facility failed to ensure laboratory tests were obtained per physician's order for one (#15) of five residents reviewed for unnecessary medications. ADON #1 identified 41 residents who resided in the facility. Findings: Res #15 had diagnoses which included cerebral infarction, polyneuropathy, and diabetes mellitus. A physician's order, dated 12/04/21, documented to obtain a lipid profile yearly in June. There were no results of the lipid profile for June 2024 found in Res #15's medical record. On 07/23/24 at 8:35 a.m., the corporate nurse consultant was asked to provide the results of the June 2024 lipid profile. On 07/23/24 at 8:45 a.m., the corporate nurse consultant stated the lipid profile lab had not been obtained per order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure MDS assessments were accurately entered for three (#3, #14 and #30) of four sampled residents reviewed for MDS accuracy. ADON #1 identified 41 residents resided in the facility. Findings: 1. Res #3's annual MDS, dated [DATE], documented the resident had a restraint. On 07/21/24 at 10:03 a.m., Res #3 was observed in their bed. A circular half rail was observed on the right side of the bed. The resident stated they had the rail for positioning, and it was their preference to have the rail. A record review documented the required consents and assessments were completed for the rail. On 07/23/24 11:39 a.m., the MDS coordinator stated there were no residents in the facility with restraints. They stated they coded the MDS incorrectly. 2. Res #14's annual MDS, dated [DATE], documented the resident had a wound infection. On 07/21/24 at 8:58 a.m., Res #14 stated they had not had any infections in months and did not have any wound infections they could remember. A record review documented Res #14 did not have a wound infection during the review period for the annual MDS. On 07/23/24 11:39 a.m., the MDS coordinator stated the infection was coded incorrectly. 3. Res #30's quarterly MDS, dated [DATE], documented the resident had a restraint. On 07/21/24 at 10:38 a.m., the resident was observed in their room in their wheelchair. Half side rails were observed at the head of the bed on both sides of the resident's bed. The resident stated they liked the rails and used them to pull themselves up in bed. A record review documented the required consents and assessments were completed for the rail. On 07/23/24 11:39 a.m., the MDS coordinator stated there were no residents in the facility with restraints. They stated they coded the MDS incorrectly.

Based on record review and interview, the facility failed to ensure resident assessments accurately reflected the residents' status for two (#8 and #48) of thirteen sampled residents whose assessments were reviewed. The facility failed to accurately code antipsychotic medications for resident #8 and discharge status for resident #48. The Resident Census and Conditions of Residents form documented 45 residents resided in the facility. Findings: 1. Res #8 had diagnoses which included anxiety, depressive disorder, and schizoaffective disorder. An annual assessment, dated 04/01/23, documented the resident received an antipsychotic medication seven of seven days of the look back period. A review of the resident's medication documented the resident had not received an antipsychotic medication during the assessment period. On 06/29/23 at 1:27 p.m., the MDS coordinator #1 reported the MDS was filled out incorrectly. 2. Res #48 had diagnoses which included acute kidney failure, diabetes, and hypertension. A discharge assessment, dated 05/05/23, documented the resident was discharged to an acute hospital. A review of the resident's discharge summary documented the resident was discharged home with the services of home health. On 06/29/23 at 1:30 p.m., the MDS coordinator #1 reported the MDS was inaccurately filled out and that the resident had discharged home.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to refer a resident with a new serious mental illness diagnosis to OHCA for a level II evaluation for two (#3 and #5) of three residents sampled for PASRR level II evaluations. The Resident Census and Conditions of Residents form documented 45 residents resided in the facility. Findings: 1. Res #3 was admitted with diagnoses of osteoporosis, hypertension, and cauda equine syndrome. On 09/10/18 the resident was diagnosed with paranoid personality disorder. On 02/14/19 the resident was diagnosed with schizoaffective disorder, bipolar type. There was no documentation the OHCA had been notified of the resident's new diagnosis to see if a level II PASRR was required. 2. Res #5 was admitted to the facility on [DATE] with diagnoses of quadriplegia, abnormal involuntary movements, aphasia, and chronic kidney disease. A PASRR level I, dated 07/07/06, documented the resident had no serious mental illness. The medical record documented, on 01/25/18, the resident was diagnosed with unspecified psychosis and specified mental disorders. There was no documentation the OHCA had been notified of the resident's new diagnosis to see if a level II PASRR was required. On 06/30/23 at 9:45 a.m., the administrator was asked if OHCA had been notified to see if the resident required a level II PASARR. The administrator stated, I don't know. On 06/30/23 at 9:53 a.m., Corporate Nurse #1 reported OHCA should have been notified.

Based on observation and interview, the facility failed to properly store food and keep the kitchen and equipment clean and in good repair. The DM identified 45 residents received services from the kitchen. Findings: On 06/27/23 at 11:27 a.m., an initial tour of the kitchen was conducted. The following observations were made: a. there was a very dirty saturated blanket on the floor beside the ice machine with puddles of water surrounding it in the dry storage room. b. there were particles of food on the shelves inside both freezers in the kitchen area. c. there were white dish towels that were observed to be wet and had orange juice spills on them under the shelving in both refrigerators in the kitchen. d. there was a dirty saturated blanket with shoe prints on it in front of the two refrigerators in the kitchen. On 06/28/23 at 8:43 a.m., a follow up tour of the kitchen was conducted. The following observations were made: a. there was an accumulation of dust and hair on all of the shelves underneath the kitchen counters. There were trays with plastic drinking cups and pans stored on the shelves. b. there was an accumulation of lint on the outside of the window A/C unit in the kitchen area. On 06/27/23 at 11:30 a.m., the DM was asked why there were wet blankets on the floor in front of the ice machine in the dry storage area and in front of the refrigerators in the kitchen. The DM stated it was because of the condensation from the refrigerators and ice machine. The DM stated the towels were changed out every Thursday and needed to be changed out today. On 06/28/23 at 9:14 a.m., the shelves underneath the counters in the kitchen area were wiped with a clean white paper towel. The paper towels were covered with dust, debris, and hair. The paper towels were shown to the DM manager and the director of nutritional services. The director of nutritional services stated but it is not by the food. On 06/28/23 at 9:16 a.m., the DM and the director of nutritional services was asked how often they cleaned the refrigerators, freezers, and shelving below the kitchen counters. The DM stated every two weeks.

Based on observation, interview, and record review, the facility failed to ensure privacy and confidentiality for six (#4, 15, 34, 43, 147, and #247) of six sampled residents reviewed for abuse. The facility failed to ensure a staff member did not take photos of residents and send them electronically to the staff member's family. The Census and Conditions of Residents report documented 44 residents resided at the facility. Findings: Pictures of Residents (Res) #4, 15, 34, 43, and #147; and two videos of Res #247 had been submitted to OSDH by an anonymous person. CNA #1 was also observed to be included in the pictures and the videos. 1. Res #4 was pictured in her wheelchair, fully clothed, in the hallway. Half of CNA #1's face could be seen in the picture. Res#4 was unable to be interviewed due to cognitive impairment. 2. Res #15 was pictured in bed with her body covered by a blanket. Res #15 was unable to be interviewed due to cognitive impairment. 3. Res #34 was pictured sitting on the front porch of the facility with resident #147. CNA #1 was also included in the picture. On 01/04/22 at 4:10 p.m., the resident was observed sitting on his bed. The resident stated no staff had taken pictures of him. He stated he had not been abused or mistreated. 4. Res #43 was pictured from the hallway, seated on the side of her bed, fully clothed. On 01/04/22 at 8:58 a.m., the resident was observed seated on the side on her bed. She stated no one had taken any pictures of her. She stated she was not scared of anyone and had not been abused or mistreated. 5. Res #147 was pictured in his bed with body covered by a blanket and also on the facility porch with Res #34. CNA #1 was also included in the picture. The electronic record documented Res #147 had discharged from the facility on 08/10/21. 6. Res #247 was included in two videos fully clothed, lying on the lobby couch. CNA #1 was included in the videos. The electronic record documented Res #247 had discharged from the facility on 05/28/21. On 01/04/22 at 1:40 p.m. the DON and administrator viewed the pictures and identified the residents in the pictures. They verified the staff member in the pictures as CNA #1 who was hired on 05/05/21. They stated they were not aware the pictures had been taken. The DON stated consents have to be filled out and signed before resident pictures could be taken. The DON and administrator stated the pictures should not have been taken. The administrator stated the employee would be suspended pending an investigation. On 01/04/22 at 3:20 p.m., CNA #1 was shown the pictures of the residents. He stated he had taken the pictures and video. He stated he took the pictures right after being hired. He stated he took the pictures and had sent them to his wife to show her some of the residents he took care of. He stated he knew he should not have done that and had not taken any pictures since that time in May 2021.

Based on observation, interview and record review, the facility failed to provide timely incontinent care and bathing for two (#8 and #36) of three sampled residents reviewed for ADL care. The Census and Conditions of Residents report documented 39 residents required assistance with bathing and 28 residents required assistance with toileting. Findings: 1. Resident (Res) #8's annual assessment, dated 10/15/21, documented she was cognitively intact and required total assistance with toileting. On 01/04/22 at 4:14 p.m., the surveyor entered the hall and Res #8's call light was observed on. At 4:19 p.m., CMA #1 entered Res #8's room. The CMA asked the resident what she needed. The resident stated she needed to be changed. The CMA stated she would get help and be back. The CMA then turned the call light off and left the room. At that time hall meal trays were not being passed. At 4:35 p.m., CNA #3 was observed on the hallway and CNA #2 was observed to take Res #8's meal tray to her. At 4:37 p.m., Res #8 stated she usually doesn't have to wait longer longer than 30 minutes and the day shift was the worst at being timely. She stated the staff often turned the call light off and would leave the room without giving care. At 4:45 p.m., the surveyor left the hallway to charge her computer. At 5:13 p.m., CNA #3 was observed coming out of Res #8's room with a trash bag full of linens. The aide was asked how long she had been in the room. She stated less then 10 minutes. She was asked how she knew Res #8 needed care. She stated the resident's call light had just come on so she had went in to change her. She was asked if anyone had told her the call light had been on earlier before the hall trays went out and she said, No. She stated she did not know the light had been turned off earlier. At 05:17 p.m., CMA #1 was asked who she told about the resident needing incontinent care. She stated she told CNA #2. On 01/06/22 at 12:18 p.m., the DON stated the staff should not turn off the call light if leaving the room without care being given. 2. Res #36's quarterly assessment, dated 12/03/21, documented the resident was cognitively intact, required extensive to total assistance with ADLs, and the bathing activity had not occurred. The ADL bathing report, dated December 2021, documented the resident was scheduled for a bath every Tuesday, Thursday, and Saturday. The report documented the resident did not receive a bath eight times out of 13 opportunities. On 01/11/22 at 11:49 a.m., Res #36 stated her shower days were Tuesday, Thursday, and Saturday. She stated she did not always get her shower as scheduled. On 01/11/22 at 2:15 p.m., the DON was interview related to the resident not getting her baths as scheduled. She stated it was probably because the aides were not documenting every time they had given a bath.

Based on record review and interview, the facility failed to guarantee the person designated to serve as the DM was certified no later than on year after hire and/or maintained certification. The DON identified 42 residents received services from the kitchen. Findings: An employee list, dated 01/04/22, documented the DM was hired 06/03/16. There was no documentation the DM was certified as a dietary manager. On 01/04/22 at 8:25 a.m., the DM was asked if he was certified as a DM. He stated the RD had been trying to set up classes to renew his certification.

Based on observation and interview, the facility failed to maintain the kitchen clean and in good repair. The DON identified 42 residents received services from the kitchen. Findings: On 01/04/22 at 8:25 a.m., a tour of the kitchen of was conducted. The following observations were made: a. End caps were missing off of plastic sleeves on lights, b. Water was leaking from the gasket area on the faucet located on the three compartment sink, c. The wood around the air conditioner wall unit was bare and not finished, d. There was visible daylight around the window, e. The floor was peeling upward and/or missing around, and/or under equipment, e. There was brown water marks on the ceiling tiles, f. There was an accumulation of black residue the floor under equipment and along the base boards, g. There was paint peeling off of the wall behind the ice machine, and h. There was a gap and daylight was visible under the back door in the kitchen next to the three compartment sink. On 01/05/22 at 10: 50 a.m., the DM was asked what the policy was for maintenance and cleaning issues. He stated they reported maintenance issues to the maintenance department for repairs and they cleaned as they went. He was shown the above observations.