Every finding on record at Austintown Healthcare Center

Based on record review, interview, observation and facility policy review, the facility failed to ensure Resident #3 had a fitted sheet placed on his bed. This affected one resident (#3) of six residents reviewed for clean, comfortable, homelike environment. The facility census was 87.Findings include:Review of Resident #3 's medical record revealed an admission date of 04/09/22 with diagnoses of fluid overload, localized edema, acute posthemorrhagic anemia, gastrointestinal hemorrhage, acute respiratory failure with hypoxia, epilepsy, not intractable, with status epilepticus, type II diabetes mellitus with diabetic chronic kidney disease, chronic kidney disease, morbid (severe) obesity due to excess calorie, bipolar disorder, current episode mixed, adjustment disorder with mixed disturbance of emotions and conduct, chronic venous hypertension (idiopathic) with inflammation of bilateral lower extremity, mild cognitive impairment of uncertain or unknown etiology, diabetic neuropathy, intermittent explosive disorder, personal history of COVID-19, hyperlipidemia, lack of expected normal physiological development in childhood, cognitive communication deficit, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic sinusitis, atrial fibrillation, long term (current) use of insulin, gout, difficulty in walking, muscle weakness (generalized), and need for assistance with personal care.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was alert and oriented and cognitively intact. Resident #3 had impairment on both sides of upper and lower extremities in functional limitation of range of motion and was at risk for skin breakdowns.Observation on 03/23/26 at 11:13 A.M. revealed Resident #3 had no fitted sheet on his bed.Interview on 03/23/26 at 11:14 A.M. with Resident #3 revealed he rarely had a fitted sheet on his bed, the facility doesn't have fitted sheets to fit this size bed (bariatric bed). Interview on 03/23/26 at 11:13 A.M. with Housekeeping Director #250 confirmed no fitted sheet was on Resident #3 bed, and the facility does have issues getting fitted sheets to fit the bariatric bed. The facility usually uses flat sheets.Interview on 03/23/26 at 11:17 A.M. with Assistant Director of Nursing (ADON) #294 confirmed Resident #3 did not have a fitted sheet on his bed, and Resident #3 was lying on the bare mattress.Review of the undated, Resident Rights policy the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents.This deficiency represents non-compliance identified under Complaint Number 2655564.

Based on record review, interview and facility policy review, the facility failed to report Resident #101's allegations of staff-to-abuse to the State agency. This finding affected one (Resident #101) of three residents reviewed for abuse. This facility census was 87.Findings include:Review of Resident #101's medical record revealed the resident was admitted on [DATE] and discharged on 02/18/26 with diagnoses including wedge compression fracture of the T7-T8 vertebra, repeated falls and bipolar disorder.Review of Resident #101's Witness Statement dated 12/22/25 revealed Curricular Practical Training Registered Nurse (CPT RN) #277 went into the resident's room to administer the morning medications, and the resident was seen trying to sit up by himself in bed. He asked the nurse to help him sit up, the nurse tried to help him sit up, and the resident became combative and abusive. The nurse told him she was sorry and they had only tried to pull him up as he asked for help.Review of Resident #101's Witness Statement dated 12/22/25 authored by Certified Nursing Assistant (CNA) #296 revealed the staff member observed the resident and nurse during medication pass and the resident was lying down. The resident asked for assistance, and the nurse assisted by holding wrists and assisting him to sit up. The resident became agitated and she stopped. The resident can be very combative and argumentative. The resident did not like the nurse and the new staff.Review of Resident #101's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Interview on 03/23/26 at 10:07 A.M. with the Director of Nursing (DON) revealed Resident #101 had problems with the Nigerian nursing staff and one staff member specifically (CPT RN Intern #277). Interview on 03/23/26 at 11:00 A.M. with the Administrator revealed Resident #101 did not report abuse. The Administrator indicated CPT RN Intern #277 pulled his hands to help him up and he felt it hurt his back. The Administrator confirmed the facility did not file an abuse Self-Reported Incident (SRI) with the State agency.Telephone interview on 03/23/26 at 11:54 A.M. with CPT RN Intern #277 indicated she walked into Resident #101's room to administer the resident's medications, and the resident was lying on his back. CPT RN Intern #277 felt the resident would choke on the medications and asked the resident to sit up. She stated the resident put his hands out and the nurse placed her hands in his and let him use her to move his body around to sit up. She denied pulling the resident by his hands at any point. CPT RN Intern #277 indicated the resident had reported she hurt him and she denied the allegation.Telephone interview on 03/24/26 at 10:17 A.M. with Ombudsman #298 revealed she called the Administrator on 12/29/25 and reported that Resident #101 had alleged physical abuse against one of the nursing staff. Ombudsman #298 indicated the Administrator did not file an SRI on behalf of Resident #101.Review of the undated Ohio Abuse, Neglect and Misappropriation policy revealed alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported no later than two hours after an allegation involving abuse and/or serious bodily injury. For alleged violations of neglect, exploitation, misappropriation of resident property, or mistreatment that do not result in serious bodily injury, the facility must report the allegation no later than 24 hours. The self-report will be made by the administration to the State Survey Agency and other local authorities including but not limited to, the local police if appropriate.This deficiency represents non-compliance investigated under Complaint Number 2696067.

Based on record review, interview and facility policy review, the facility failed to ensure Residents #20 and #22's showers were completed as scheduled. This finding affected two (Residents #20 and #22) of ten residents who were dependent on staff for activities of daily living (ADL). The facility census was 87.Findings include:1. Review of Resident #20's medical record revealed the resident was admitted on [DATE], discharged to the hospital on [DATE] and returned on 03/12/26 with diagnoses including atherosclerotic heart disease, vascular dementia and cognitive communication deficit.Review of Resident #20's ADL care plan revealed an intervention dated 01/30/26 stating the resident required substantial/maximal assistance with showering/bathing.Review of Resident #20's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment and required substantial/maximal assistance with showering/bathing.Review of shower schedule confirmed Resident #20's showers were scheduled Tuesday, Thursday and Saturday on dayshift from 7:00 A.M. to 3:00 P.M.Review of shower sheets from 02/24/26 to 03/24/26 revealed no documented evidence that Resident #20 received showers on 02/24/26, 02/26/26, 02/28/26 and 03/14/26. Further review revealed the resident was set up to wash in the bathroom sink on 03/17/26, 03/19/26 and 03/21/26.Interview on 03/23/26 at 9:49 A.M. with Resident #20 revealed the resident was not receiving showers as scheduled.Interview on 03/24/26 at 1:00 P.M. with Registered Nurse (RN) Regional #300 confirmed the above findings.2. Review of Resident #22's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, low back pain and essential hypertension.Review of Resident #22's ADL care plan revealed an intervention dated 03/09/26 indicating the resident required substantial/maximal assistance with showering/bathing.Review of the shower schedule revealed Resident #22 was scheduled for showers Tuesday, Thursday and Saturday on dayshift from 7:00 A.M. to 3:00 P.M.Review of Resident #22's shower sheets revealed no documented evidence showers were completed on 02/24/26, 02/26/26, 02/28/26, 03/03/26 and 03/05/26. Further review, the resident received bed baths on 03/07/26, 03/10/26, 03/12/26 and showers on 03/17/26, 03/19/26 and 03/21/26.Interview on 03/23/26 at 10:34 A.M. with Resident #22 revealed showers were not completed as scheduled.Interview on 03/24/26 at 1:00 P.M. with RN Regional #300 confirmed the above findings.Review of the undated Routine Resident Care policy revealed it was the policy of the facility to promote resident centered care by attending to the total medical, nursing, physical, emotional, mental, social, and spiritual needs and honor resident lifestyle preferences while in the care of the facility.

Based on record review, observation, interview and facility policy review, the facility failed to ensure Residents #4 and #90's pressure ulcer wound care was completed as ordered. This finding affected two (Residents #4 and #90) of four residents reviewed for pressure wounds. The facility census was 87.Findings include:1. Review of Resident #4's medical record revealed the resident was admitted on [DATE] with diagnoses including Parkinsonism, weakness and peripheral vascular disease. Review of Resident #4's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #4's skin and wound care plan revealed an intervention dated 02/18/26 to administer treatments as ordered by the medical provider. Review of Resident #4's physician orders revealed an order dated 03/05/26 to cleanse the coccyx pressure ulcer with normal saline, apply medical grade honey and calcium alginate to the base of the wound, secured with a bordered foam dressing daily and as needed. Review of Resident #4's Wound Assessment Report dated 03/19/26 revealed the resident had a Stage II (partial-thickness skin loss involving the epidermis and dermis) pressure wound which was improving and measured 0.70 centimeters (cm) length by 0.80 cm width by 0.10 cm depth. Review of Resident #4's medication administration records (MAR) and treatment administration records (TAR) from 03/05/26 to 03/24/26 revealed no documented evidence wound care was completed on 03/07/26, 03/08/26, 03/09/26, 03/10/26, 03/17/26 and 03/18/26. Interview on 03/23/26 at 10:03 A.M. with Regional Nurse (RN) Regional #300 confirmed Resident #4's medical record did not contain documented evidence treatments were completed as ordered for eight dates as identified above. Observation on 03/23/26 at 1:48 P.M. with Licensed Practical Nurse (LPN) #218 of Resident #4's sacrum wound care revealed the dressing was dated 03/21/26. The observation confirmed that the wound care was not completed on 03/22/26 as ordered by the physician. Interview on 03/23/26 at 1:50 P.M. with LPN #218 confirmed Resident #101's sacral dressing was not changed as ordered. 2. Review of Resident #90's medical record revealed the resident was admitted on [DATE] with diagnoses of intraspinal abscess and granuloma, infection of intervertebral disc cervical region and dysphagia. Record review of care plan dated 02/23/26 revealed Resident #90 had impaired skin integrity or at risk for altered skin integrity due to surgical neck incisions and deep tissue injury (DTI), a DTI is a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear, to the left buttock. Interventions included administer treatments as ordered by the medical provider. Review of Resident #90's MDS assessment dated [DATE] revealed the resident was cognitively intact and required substantial/maximal assistance with activities of daily living (ADL) Review of Resident #90's Wound Assessment Report dated 03/05/26 revealed a Stage III pressure ulcer (a full-thickness skin loss injury appearing as a deep crater like wound where subcutaneous fat may be visible) which was improving, measured 3.0 cm wide by 3.0 cm long by 0.10 cm depth. Medical record review for Resident #90 revealed physician orders dated 03/05/26 for wound treatment to a pressure ulcer located on the left buttock which included cleanse with normal saline, apply Triad past to base of wound and secure with silicone bordered superabsorb, and change daily and as needed (PRN). Review of the TAR for the period of 03/01/26 through 3/31/26 showed missed/undocumented treatments on the following dates: 03/08/26, 03/10/26. There was no documented clinical justification for the missed treatments. Interview on 03/23/26 at 11:11 A.M. RN Regional #300 confirmed the wound treatment was ordered as noted but acknowledged treatments were not completed as scheduled. Record review of the undated Skin Care & Wound Management Overview policy revealed in section Treatment: Pressure Ulcer Documentation complete for all pressure ulcers, Skin Impairment Documentation, complete for all skin impairment issues that require measurement to indicate if healing is occurring, review and select the appropriate treatment for the identified skin impairment, obtain a physician's order, document treatment in the Electronic Treatment Administration Record (ETAR), monitor and document progress.

Based on record review, observation, interview and facility policy review, the facility failed to ensure Resident #4's tracheostomy care was completed as ordered. In addition, the facility failed to ensure Resident #3's oxygen tubing was dated and the humidifier canister had available solution for humidification. This finding affected two (Residents #3 and #4) of three residents reviewed for respiratory care. The facility census was 87.Findings include:1. Review of Resident #4's medical record revealed the resident was admitted on [DATE] with diagnoses including Parkinsonism, weakness and peripheral vascular disease. Review of Resident #4's physician orders revealed an order dated 02/10/26 for trach care every shift and as needed. Review of Resident #4's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #4's tracheostomy care plans revealed an intervention dated 03/04/26 to administer treatments per the medical provider's orders and observe for side effects and effectiveness. Review of Resident #4's treatment administration (TAR) revealed the trach care was due dayshift and nightshift. Review of the TAR from 03/01/26 to 03/24/26 revealed no documented evidence trach care was completed on dayshift for the dates of 03/03/26, 03/05/26, 03/08/26, 03/10/26, 03/13/26, 03/17/26, 03/18/26 and 03/19/26. Interview on 03/24/26 at 2:40 P.M. with Registered Nurse (RN) Assistant Director of Nursing (ADON) #294 confirmed the above findings. Review of the undated Tracheostomy Care policy revealed the purpose of the policy was to provide guidance for tracheostomy care for the licensed and competent nurse or respiratory therapist. Process steps may be performed using a different sequence and did not imply incorrect procedure. Maintaining key areas of aseptic technique and working efficiently to resume oxygenation were the critical components of the process. Tracheostomy care was typically completed twice per day and as needed, the inner cannula changed once per day and as needed, and the tracheostomy ties changed three times a week and as needed. Confirm the practitioner order before performing tracheostomy care. 2. Review of Resident #3 's medical record revealed an admission date of 04/09/22 with diagnoses of fluid overload, localized edema, acute posthemorrhagic anemia, gastrointestinal hemorrhage, acute respiratory failure with hypoxia, epilepsy, not intractable, with status epilepticus, type II diabetes mellitus with diabetic chronic kidney disease, chronic kidney disease, morbid (severe) obesity due to excess calorie, bipolar disorder, current episode mixed, adjustment disorder with mixed disturbance of emotions and conduct, chronic venous hypertension (idiopathic) with inflammation of bilateral lower extremity, mild cognitive impairment of uncertain or unknown etiology, diabetic neuropathy, intermittent explosive disorder, personal history of COVID-19, hyperlipidemia, lack of expected normal physiological development in childhood, cognitive communication deficit, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic sinusitis, atrial fibrillation, long term (current) use of insulin, gout, difficulty in walking, muscle weakness (generalized), and need for assistance with personal care. Review of the Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #3 was cognitively intact. This assessment reflected Resident #3 use of oxygen for respiratory failure. Review of the current care plan for Resident #3 has oxygen therapy for respiratory failure and will have no signs and symptoms of poor oxygen absorption. Review of the physician order originally dated 03/03/26 revealed the oxygen tubing and humidifier were to be changed every week on Sundays and as needed. Resident #3 oxygen order was 4 liters per minute (LPM) via nasal cannula continuously. Review of the TAR for March 2026 indicated the oxygen tubing and humidifier were due to be changed on 03/22/26. The oxygen tubing was not dated, and the humidifier cannister was empty. Interview with RN ADON #294 on 03/23/26 at 11:17 A.M. confirmed Resident #3 had an order for her oxygen tubing and humidifier to be changed weekly on Sundays and as needed. ADON #294 confirmed there was no date on the oxygen tubing, and the humidifier canister was empty. Review of the undated facility policy titled, Supplemental Oxygen using Nasal Cannula Policy nasal cannula and tubing will be labeled and dated when opened and revealed all residents utilizing oxygen will have the tubing changed on a weekly basis.

Based on record review, staff interview and facility policy review, the facility did not ensure resident records contained accurate documentation. This affected three (Residents #2, #11, and #49) of 33 resident records reviewed for medical record accuracy. The facility census was 87. Findings include:1. Record review revealed Resident #49 was admitted [DATE] with diagnoses of Parkinsonism, chronic obstructive pulmonary disease (COPD), and interstitial emphysema. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was cognitively intact and required moderate assistance with toileting hygiene and personal hygiene and maximal assistance with showers dressing, and transfers. Review of the March 2026 physician orders revealed Resident #49 had an order for carbidopa-levodopa-entacapone 200 milligram (mg) tablet every three hours for Parkinson's. The administration times were midnight, 3:00 A.M., 6:00 A.M., 9:00 A.M., 12:00 P.M., 3:00 P.M., 6:00 P.M., and 9:00 P.M.Review of the March 2026 Medication Administration Record (MAR) revealed the nurse did not document receipt of carbidopa-levodopa-entacapone on 03/07/26, 03/14/26, and 03/19/26 at 6:00 P.M.Interview on 03/25/26 at 9:55 A.M. with Assistant Director of Nursing (ADON) #294 confirmed documentation on 03/07/26, 03/14/26, and 03/19/26 at 6:00 P.M. were missing for Resident #49. Review of the progress notes revealed Resident #49 had a care conference on 01/22/26; however, it was not documented until 02/03/26.Interview on 03/26/26 at 8:27 A.M. with the social worker confirmed the care conference was documented late for Resident #49.2. Record review revealed Resident #2 was admitted [DATE] with diagnoses of end stage renal disease, type II diabetes mellitus with diabetic neuropathy, heart failure, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #2 was dependent on staff for toileting hygiene, showers, dressing, and transfers, and maximal assistance for oral hygiene, and personal hygiene.Review of the March 2026 physician orders revealed Resident #2 had orders for docusate sodium (stool softener) 100 mg once daily, frozen nutritional treat one time a day, omeprazole (reduces stomach acid) 40 mg, ferrous sulfate (iron supplement) 325 mg once daily, daily vitals, midodrine hydrochloride (treats low blood pressure upon standing) 10 mg three times daily, and sevelamer carbonate (controls high levels of phosphorus) 800 mg three times daily.Review of the March 2026 MAR revealed the following: the nurse did not document administration of docusate sodium, omeprazole, and vital signs on 03/11/26; frozen treat, ferrous sulfate, midodrine hydrochloride, and sevelamer carbonate on 03/14/25.Interview on 03/25/26 at 9:55 A.M. with ADON #294 confirmed the above documentation was incomplete for Resident #2.3. Record review revealed Resident #11 was admitted [DATE] with diagnoses of severe protein calorie malnutrition, type II diabetes without complications, and unspecified dementia.Review of the quarterly MDS assessment dated [DATE] revealed Resident #11 was moderately cognitively impaired and dependent on staff for toileting hygiene, showers, dressing, personal hygiene, and transfers. Review of the march 2026 physician orders revealed Resident #11 had an order to check placement of the Fentanyl patch (opioid pin medication) every four hours and document placement of patch.Review of the March 2026 MAR revealed placement was not documented on 03/22/26 at 2:00 P.M.Interview on 03/25/26 at 9:55 A.M. with ADON #294 confirmed placement was not checked for Resident #2.Review of the undated Clinical Documentation Standards Policy revealed nurses were to follow the basic standard of practice for documentation including but not limited to providing a timely and accurate account of resident information in the medical record.

Based on record review, observation, interview and facility policy review, the facility failed to provide a resident room that was in good repair for one (Resident #39) of six residents reviewed for physical environment. The facility census was 87.Findings include:A review of medical records for Resident #39 revealed an admission date of 09/24/25. Significant diagnoses included Parkinson's disease without dyskinesia, without mention of fluctuations, and altered mental status.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) with a score of three out of 15, indicating Resident #39 had severe cognitive impairment.Review of the care plan dated 01/13/26 revealed no indications for Resident #39 refused housekeeping and maintenance services.An observation on 03/23/26 at 1:59 P.M. revealed the room for Resident #39 was in general disrepair. The chair rail had splintered wood. Observation on 03/24/26 at 10:01 A.M. revealed the resident's bed was in a low position horizontal to wall with the splintered wood approximately four feet long on the chair rail.Interview with Director of Plant Maintenance #267 on 03/24/26 at 10:06 A.M. confirmed the chair rail was in disrepair and needed replacement at the time of the observation.Review of undated Resident Rights policy revealed it is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety of residents, visitors and employees is a top priority of care.This deficiency represents non-compliance investigated under Complaint Number 2655564.

Based on record review, interview and hospice record review, and facility policy review, the facility failed to maintain accurate and consistent wound documentation for a resident receiving hospice services. The facilities wound measurements and staging differed from the hospice nurse's documentation. This inconsistency resulted in incomplete and inaccurate medical records. This affected one resident (#681) of three resident records reviewed for wound care. The facility census was 82. Findings include:Review of the closed medical record revealed Resident #681 was admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain, vascular dementia with behavioral disturbance, mild protein-calorie malnutrition, peripheral vascular disease, vitamin b12 deficiency anemia, dysphagia, functional quadriplegia, personal history of transient ischemic attack (TIA), cerebral infraction without residual deficits, and anxiety disorder. Resident #681 was admitted for respite care and was discharged home on [DATE]. Review of the admission evaluation completed on 07/07/25 at 10:08 A.M. authored by Registered Nurse (RN) #1000 revealed Resident #681 was dependent on two or more staff with all activities of daily living. She was incontinent of bowel and bladder, had diminished safety awareness, and required a Hoyer (mechanical) lift for transfers. She had a red non-blanchable area to the right outer ankle. Review of the admission skin assessment dated [DATE] at 10:38 A.M. authored by RN #1006 revealed Resident #681 had a dark red/maroon area noted to the right ankle that was a suspected deep tissue injury (SDTI). A SDTI is a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Skin-prep (creates a protective, film-like barrier on the skin) and foam dressing were applied. No other impairment was noted upon assessment. Review of the admission physician orders for July 2025 revealed weekly skin assessments, a pressure reducing/relieving mattress every shift for pressure reducing/relieving, Hospice provider RN or Home Health Agency (HHA) visit per Hospice schedule through Grace Hospice, pain level every shift, wound care orders to apply Skin-prep to right ankle and cover with foam dressing daily and as needed (PRN), if dressing becomes soiled or dislodged and every shift for preventative. Review of the admission skin assessment completed by RN #1006 and Wound (NP) #1007 dated 07/08/25 10:38 A.M. revealed Resident #681 had a SDTI to the right ankle. Treatment was to apply Skin-prep with a foam dressing daily and as needed (PRN). No other skin impairment noted. Skin was warm and dry, thin, fragile, intact, no open wound, ecchymosis, non-blanchable erythema to the right ankle measuring 2.0 centimeters (cm) in length by 2.0 cm in width by 0 cm in depth. The peri-wound was intact and fragile with erythema. There was zero percent (%) eschar, zero % granulation, zero % slough, 100% epithelial tissue. The area was described as a Stage I pressure ulcer (Intact skin with non-blanchable redness of a localized area usually over a bony prominence). The treatment plan was to cleanse with normal saline, apply Skin-prep to the base of the wound, secure with bordered foam gauze, and change three times weekly and PRN. Preventative measures included: recommend head of bed limited to 30 degrees or less as tolerated unless contraindicated, float heels while in bed with use of heel boots, apply moisturizer to resident's skin routinely, do not massage over bony prominences, minimize friction and shear by using an approved material to assist with positioning up in bed, continue with turning and repositioning schedule per protocol for pressure prevention, recommend resident out of bed as tolerated for limited intervals of time, alternating activity to minimize pressure, use pillows for positioning to prevent pressure to bony prominences. New recommendations: The resident has a treatment change listed above. Please reference the recommended orders for updated treatments. The resident is currently under hospice services. Goals of care remain to minimize pain and risk of infection. Continue palliative wound management. The risk of complications and/or morbidity/mortality of the patient's management is moderate. Review of the hospice notes dated 07/12/25 authored by Hospice RN #1008 revealed wound care was performed to the unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) to Resident #681's right lateral ankle. The wound measured 1.5 cm by 1.5 cm with 0-25% necrotic tissue slough and 76-100% eschar. The wound was cleansed with wound cleanser, covered with a dry dressing, instructed caregiver/facility staff in wound care. RN #1000 will be notified of new wound and wound care orders. RN #1000 instructed to call hospice for questions, concerns, or change in status. Review of the progress note dated 07/13/25 at 1:30 P.M. authored by Licensed Practical Nurse (LPN) #973 revealed the hospice nurses in this shift to check on Resident #681. No new orders at this time. Plans for the resident to discharge home tomorrow in the A.M. Resident #681 was alert when her name was called and/or with movement The resident remains on side-to-side turns, pad and protect treatments in place as ordered. Review of the Braden Scale for Predicting Pressure Ulcer Risk dated 07/14/25 at 4:10 A.M. completed by LPN #977 revealed Resident #681 was at very high risk for pressure ulcer development. Review of the physician's progress note dated 07/14/25 at 7:51 A.M. revealed a discharge summary stating Resident #681 to be discharged to home today, medication and orders reconciled. I have advised her to follow up with her primary care physician in one week. She is being discharged in stable condition, long-term prognosis is FAIR. Interview with LPN #972 on 10/07/25 at 11:50 A.M. revealed the discharge assessment of Resident #681 only noted was right lateral ankle and was addressed with continuing orders already in place. LPN # 972 was not given any new or additional orders for right ankle wound. No other wounds were noted on discharge skin assessment. Interview with Wound Care RN #1006 on 10/08/25 at 12:48 P.M. revealed she was not given any orders or additional care from Hospice. Interviews with LPN #1000 on 10/08/25 1:14 P.M. revealed she was not notified by Hospice of any worsening wounds or any changes in wound care orders. Interview with the guardian of Resident #681 on 10/08/25 at 3:17 P.M. revealed Resident #681 arrived at home with additional wounds to bilateral feet and pictures were obtained. Both wounds appeared reddened and excoriated. Guardian of Resident #681 indicated she was not aware of any additional wounds, right lateral ankle wound was addressed during respite stay. Interview on 10/14/25 at 3:56 P.M. with Manager of Clinical Operations from Grace Hospice #1008 revealed she followed Resident #681 prior to her admission at Austintown HCC, during her respite stay, and post respite stay. When the resident was admitted on [DATE], she had a pink area to her right outer ankle that had an order to pad and protect. She saw her on Saturday, 07/12/25, and that pink area had deteriorated to an unstageable pressure ulcer. She stated she told the nurse, and there is no evidence the nurse notified the physician. She came to see the resident again on Sunday, 07/13/25, and upon entering the room the resident was sitting up in bed and due to contractures was sitting directly on her feet. It appears staff fed her meal and did not reposition her. Hospice staff repositioned her and went and informed the nurse how she was found. She stated that she believed the facility did not follow the preventative measures to prevent the pressure ulcer from deteriorating from a Stage I pressure ulcer to an unstageable pressure ulcer during her respite stay. (The observation from 07/13/25 of the resident sitting on her feet was not in the hospice record). Interview on 10/16/25 at 10:15 A.M. with Wound Care RN #1006 revealed the Hospice note from 07/12/25 indicated she was notified of Resident #681's right ankle progression to an unstageable pressure ulcer with 76-100% eschar. Wound Care Nurse #1006 stated she was not notified at all of any changes in the wound. She indicated she was not given any new orders for the resident's right ankle wound, and the facility documentation indicated there were no changes in Resident #681's wound care. She documented the right lateral ankle wound as a SDTI on 07/07/25 at 10:38 A.M., and Wound NP #1007 documented the right ankle as Stage I pressure/wound ulcer on 07/08/25 10:38 A.M. Review of the medical record revealed no additional wound assessments completed during Resident #681's respite stay after 07/08/25 including the change in the right ankle wound deteriorating to unstageable on 07/12/25. There was no documented evidence that the physician was notified of the deterioration of the right ankle wound after RN #1000 was notified by Hospice RN #1008 on 07/12/25. Review of the undated facility policy titled Wound Care revealed residents admitted with or develop skin integrity issues will receive treatment as indicated based on location, stage and drainage. This deficiency is an incidental finding identified during the complaint investigation.

Based on observation, interview, record review, and facility policy review the facility failed to ensure Resident #78's immediate care and service needs were assessed and orders initiated at the time of admission. This affected one resident (#78) of two residents reviewed for admissions. In addition, the facility failed to ensure Resident #55 received wound treatments according to physician orders. This affected one resident (#55) of four residents reviewed for wound treatments. The facility census was 80. Finding included: 1. Review of the closed medical record for Resident #78 revealed an admission date of 03/08/25 at 6:07 P.M. and a discharge from the facility per resident request on 03/10/25 at 12:45 P.M Diagnoses included local infection of the skin, subcutaneous tissues, non-pressure ulcer of the right and left lower legs with fat layer exposed, peripheral vascular disease, type II diabetes, hypertension, Chronic Obstructive Pulmonary Disorder (COPD), and major depressive disorder. Review of Resident #78's progress notes dated 03/08/25 to 3/10/25 revealed there was no evidence of an admission note to the facility, no evidence the physician was notified of arrival and no evidence the admitting staff verified admission orders with the physician. Review of Resident #78's Hospital After Visit Summary (AVS) dated 03/08/25 revealed Resident #78 had been hospitalized from [DATE] to 03/08/25 with a diagnosis of foot infection. Resident #78 was discharged from the hospital with the following medication orders: Daptomycin (antibiotic) 800 milligram (mg) Intravenously (IV) every 24 hours for 14 days (next dose due to be given on 03/09/25), Oxycodone-acetaminophen (narcotic pain medication) 5-325 mg one tablet daily as needed for pain for three days (last dose given on 03/08/25 at 9:56 A.M.), Humulin (insulin to treat diabetes) R U-500 Kwik Pen 500 Unit/milliliter (ml) inject 120 units with breakfast, 50 units with lunch and 120 units with dinner (last dose given on 03/08/25 at 11:50 A.M.), albuterol sulfate 108 microgram (mcg)/Actuation (act), inhale two puffs into lungs every six hours as needed, apixaban (blood thinner) 5 mg take one tablet by mouth once a day starting on 03/09/25, bumetanide (diuretic) one mg tablet by mouth every day in the morning, citalopram (antidepressant) 20 mg tablet take one tablet daily (last dose given on 03/08/25 at 9:51 A.M., lisinopril (high blood pressure treatment) 10 mg tablet daily (last dose given on 03/08/25 at 9:51 A.M.), metoprolol (blood pressure treatment) 100 mg tablet by mouth daily (last dose given on 03/08/25 at 9:51 A.M.), mometasone-formoterol 200-5 mcg/act inhale 2 puffs in the morning and in the evening, Mujaro 2.5 mg once a week, multivitamin with minerals one tablet by mouth daily, pregabalin (anti-convulsant) 300 mg capsule by mouth twice a day for convulsions twice a day (last dose given on 03/08/25 at 9:51 A.M.), tamsulosin 0.4 mg take two capsules daily to equal 0.8 mg (last dose given on 03/08/25 at 9:51 A.M.) . There were also orders for wound care treatments to the bilateral lower extremities, rehabilitation therapy order and infectious disease protocol for IV therapy including standing orders for laboratory work, IV flushing orders, and IV dressing change orders. Review of Resident #78's physician orders revealed it was not until 03/10/25 that the following were initiated as orders: all facility standing orders for monitoring oxygen saturation and documenting results every shift due to COPD, Physical Therapy (PT) eval, Occupational Therapy (OT) eval, height, weight times four weeks upon admission, vital signs every shift times 72 hours then daily, COVID-19 testing as needed/may use PCR or POC testing, weekly skin assessment to be completed and documented, read tuberculosis (TB) skin test number one and number two with documentation of results on Medication Administration Record (MAR), ensure the resident is on a pressure reducing/relieving mattress every shift, consults with Audiology, Dental, Optometry, Ophthalmology and/or Podiatry as needed, monitor for pain every shift, and a wound care consult. Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) dated March 2025 confirmed the aforementioned orders were not initiated until 03/10/25. Further review of Resident #78's physician orders revealed medications were not reconciled at the time of admission and the following orders were not initiated until 03/09/25: Daptomycin 500 mg IV, Oxycodone 5-325 mg, bumetanide 1 mg, metoprolol 100 mg, albuterol 108 mcg/act, tamsulosin 0.4 mg give two capsules to equal 0.8 mg, Mounjaro 2.5 mg/0.5 ml injection, pregabalin 300 mg two times a day for convulsions, and citalopram 20 mg for depression. Further review of Resident #78's Medication Administration Record (MAR) dated March 2025 confirmed Daptomycin, Oxycodone, bumetanide, metoprolol, albuterol, tamsulosin, Mounjaro, pregabalin and citalopram were not initiated until 03/09/25. Interview on 06/10/25 at 4:03 P.M. with the Director of Nursing (DON) revealed Licensed Practical Nurse (LPN) #631 was the admitting nurse for Resident #78 and did not complete any of the admission assessments required for new admissions, nor did they initiate any of the admitting physician orders from the hospital. Interview on 06/11/25 at 9:23 A.M. with the DON revealed they confirmed on admission, nursing staff were to complete a medication reconciliation, implement all orders obtained from the hospital, and notify the physician of resident arrival. The DON confirmed admission orders for Resident #78 were not initiated on the day of admission of 03/08/25 and were completed between 03/09/25 and 03/10/25 by Registered Nurse (RN) #712 causing medications, treatments and assessments to be missed for Resident #78. The DON also confirmed LPN #631 was issued an Employee Corrective Action final written warning for Performance/Policy Violation and Safety/Carelessness, due to: the staff member failing to comply with the admission policy of initial assessment and order entry in a timely manner of first hour of admission, interfering with medication delivery for treatment, initial assessment of wound and IV site not completed, and no orders for care entered. No admit vital signs were obtained, or height and weight. admission was not touched by shift change. This occurrence led to delay in medications and treatments being administered. Review of the undated facility policy titled admission Evaluation, revealed it was the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. A systematic evaluation is completed by a licensed nurse upon admission/readmission to assist in determining the most effective and appropriate care needs of each resident admitted to the center. Under the Procedure section staff are to complete the admission Initial UDA and appropriately triggered assessments electronically as soon as feasible but within 24 hours. Second, staff were to prioritize resident needs with appropriate interventions to include but not limited to, meeting immediate physical needs including assessment of pain, provide social and emotional support, identify any culturally specific needs, consider elopement risk, consider pressure injury risk, provide toileting needs, complete medication reconciliation, and consider last meal eaten and provide hydration. 2. Review of the medical record for Resident #55 revealed an admission date of 02/01/24 with diagnoses including chronic embolism and thrombosis of right and left femoral veins (blood clots to the legs), varicose veins of the left lower extremity with ulcer, peripheral vascular disease (PVD) (disorder that restricts the blood flow to the arms, legs and other parts of the body) and diabetes mellitus. Review of the physician's orders for June 2025 revealed Resident #55 had an order to cleanse the wound to his right posterior lower leg with normal saline and apply collagen (wound treatment) particles, cover with xeroform (non-adhering wound dressing), pad and wrap with kerlex (gauze wrap) daily and as needed dated 06/05/25. There were no physician's orders for wound care to the left leg. Review of treatment administration record (TAR) for June 2025 for Resident #55 revealed the nursing staff had documented on 06/08/25 that his treatment to his right lower leg was completed. There were no orders for wound treatments to the left leg. Review of the nursing progress notes from 06/07/25 through 06/09/25 for Resident #55 revealed there was no documentation related to his left lower leg having an open area, the physician being updated or a treatment being ordered. Observation on 06/09/25 at 1:43 P.M. of Resident #55 revealed he had wound treatments to bilateral lower legs. The dressings were dated 06/07/25. Observation and interview on 06/09/25 at 1:45 P.M. with Licensed Practical Nurse (LPN) #600 verified Resident #55 had a venous ulcer to the back of his right lower leg. She stated his treatment should have been completed daily and was not done on 06/08/25 as ordered. LPN #600 stated she did not know why he had a dressing on the left lower leg. She verified the dressings to bilateral lower extremities were dated 06/07/25. Resident #55 stated nursing staff had not performed the treatment to his right lower leg on 06/08/25. Interview and observation on 06/09/25 at 1:53 P.M. with Registered Nurse (RN) #609 revealed the dressing to the right lower leg was adaptic (non-adhering wound dressing) with a dry dressing and rolled gauze to secure the treatment in place. RN #609 stated Resident #55 previously had scabs to the front of his left leg due to his PVD. Observation revealed an open area to the front of his left leg. RN #609 stated the scabs must have come off and the nurse placed a dressing. She verified she was not updated on the resident's open area to his left leg. Interview on 06/09/25 at 1:59 P.M. with LPN #600 verified her initials were on the TAR on 06/07/25 and she had placed the dressing on Resident #55's left lower leg. She stated she placed the same treatment that was on the right lower extremity. LPN #600 stated she had not updated the physician, received an order for the left lower extremity or documented in the resident's medical record. Review of the facility policy titled, Skin Care and Wound Management Overview, undated, revealed the facility should review and select the appropriate treatment, obtain a physician's order and document treatment in the treatment administration record. This violation represents non-compliance investigated under Master Complaint Number OH00164793 and Complaint Number OH00163639.

Based on observation, interview, record review and review of facility policy, the facility did not ensure wound assessments accurately identified date of onset of a pressure ulcer and wound treatments were implemented as ordered by the physician for Resident #77. This affected one resident (Resident #77) of four residents reviewed for pressure ulcers. The facility census was 80. Findings include: Review of the closed medical record for Resident #77 revealed an admission date of 12/13/24 with diagnoses including osteomyelitis (infection of the bone) of the left foot and ankle, peripheral vascular disease (disorder that restricts the blood flow to the arms, legs and other parts of the body) and cellulitis (skin infection where the skin is swollen, painful and warm to the touch). Review of the hospital After Visit Summary, dated 12/13/24, revealed at the time of discharge from the hospital, Resident #77 had no pressure ulcers, but did have treatments in place for surgical incisions to his femoral left leg, left leg and left toe. Review of the nursing admission evaluation dated 12/13/24 for Resident #77 revealed he had no pressure ulcers. It was noted he had surgical incisions to the groin, left thigh, left lower leg and left toes. Review of the nursing notes for Resident #77 dated from 12/13/24 through 12/16/24 revealed the nursing staff had not documented any information to identify a pressure ulcer on right buttocks. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #77 revealed he had one Stage III pressure ulcer that was present upon admission. Review of the care plan for Resident #77, dated initiated 12/27/24 revealed he was admitted to the facility with a stage III pressure ulcer to his right buttock. Interventions included administer medications and treatments as ordered by medical provider, apply barrier creams post incontinence episodes, complete weekly skin checks and daily wound assessments. Review of the Wound Assessment Report, dated 12/17/24 by Nurse Practitioner (NP) #714 revealed she saw Resident #77 for the first time for a Stage III pressure ulcer (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) to the right buttocks. NP #714 stated it was 5.0 centimeters (cm) in length, 1.0 cm in width and 0.10 cm in depth and was present on admission. She ordered the facility nursing staff to cleanse the right buttock with normal saline, apply Triad Cream (wound care product designed to treat and protect skin from damage due to pressure ulcers) and leave open to air twice daily and as needed. Review of the Wound Assessment Report, dated 12/26/24 by NP #714 revealed she saw Resident #77 again for his right buttocks Stage III pressure ulcer. NP #714 stated the wound was now 4.0 cm in length, 2.0 cm in width and .2 cm in depth. NP #714 provided a new order for the nursing staff to cleanse the right buttock with normal saline and apply Triad Cream and a bordered foam daily and as needed. Review of the physician's orders and treatment administration record from December 2024, revealed NP #714's orders were not implemented for Resident #77's pressure ulcer of the right buttocks until 12/26/24. Interview on 06/11/25 at 2:37 P.M. with Registered Nurse (RN) #609 revealed she rounded with NP #714 and saw Resident #77 on 12/17/24. She verified NP #714 provided an order for treatment to Resident #77's right buttocks Stage III pressure ulcer. RN #609 stated NP #714 entered her own treatment orders in the computer and must have missed putting Resident #77's order in for his right buttocks. RN #714 verified that prior to NP #714 initially seeing Resident #77's right buttock pressure ulcer on 12/17/24 there had been no skin assessment nor other documentation in the medical record to reflect Resident #77 had a pressure ulcer upon admission yet it was documented as present upon admission in the MDS and wound assessment report. Interview on 06/12/25 at 11:28 A.M. with NP #714 verified she assessed Resident #77 on 12/17/25 and provided an order for Triad Cream to his right buttocks. She stated she had forgot to enter his order for the Stage III pressure ulcer into the computer until she returned again on 12/26/24. She stated his wound mildly worsened, however, due to his medical condition worsening could be expected as unavoidable and it was not due to the lack of treatment with the Triad Cream from 12/17/24 to 12/25/24. NP #714 stated she was notified Resident #77 was admitted with the pressure ulcer and she assessed him four days later. Review of the facility policy titled, Skin Care and Wound Management Overview, undated, revealed the facility should review and select the appropriate treatment, obtain a physician's order and document treatment in the treatment administration record. This violation represents non-compliance investigated under Master Complaint Number OH00164793 and Complaint Number OH00163639.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #184's enteral feedings were administered as ordered. This affected one resident (Resident #184) of two residents reviewed for enteral nutrition. The facility census was 80. Findings include: Review of the medical record for Resident #184 revealed an admission date of 05/23/25 with diagnoses including cerebral infarction (stroke), hemiplegia affecting right side (paralysis), dysphagia (difficulty swallowing) and cognitive communication deficit. Review of the physician's orders for June 2025 for Resident #184 revealed she had an order for enteral feedings every shift at 60 milliliters (mL) an hour for 20 hours via the pump dated 06/03/25. Review of the Medication Administration Record (MAR) for June 2025 for Resident #184 revealed Registered Nurse (RN) #625 signed off her enteral feed order on 06/09/25 prior to 10:47 A.M. as administered as ordered. Observation on 06/09/25 at 10:40 A.M. of Resident #184 revealed her enteral feeding was running at 50 mL per hour. Observation and interview on 06/09/25 at 10:52 A.M. with RN #625 verified Resident #184's enteral feeding was running at 50 mL per hour and should be at 60 mL per hour. Review of the facility policy titled, Enteral General Nutritional (tube feeding) Guidelines, undated, revealed feeding the enteral feed through the electronic pump, nursing staff should verify the practitioner's order including the volume and rate to be infused.

Based on record review, interview and review of facility policy, the facility failed to ensure dialysis residents were monitored before and after dialysis treatments, and daily weights were obtained according to physician order for Resident #4. This affected one resident (Resident #4) out of two residents reviewed for dialysis. The facility census was 80. Findings include: Review of Resident #4's medical record revealed an admission date of 12/08/23. Diagnoses included end stage renal disease, dependence on renal dialysis, chronic diastolic congestive heart failure, hyperlipidemia, disorders of bone density, Gastro-Esophageal Reflux Disease (GERD), hypertensive heart and Chronic Kidney Disease (CKD), type II diabetes mellitus, anxiety, and major depressive disorder. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition. They required setup or clean up assistance for eating, substantial to maximal assistance for oral hygiene, upper body dressing, personal hygiene, and bed mobility. They were dependent on staff for toileting hygiene, showers, and lower body dressing. Review of Resident #4's care plan date 10/05/24 revealed the resident was on dialysis therapy related to CKD three times a week. Interventions and goals indicated the resident would be free from signs and symptoms of complications from hemo-dialysis. Staff were to administer medications per medical provider's orders including monitoring weights daily and completing a pre and post dialysis assessment every dialysis treatment day. Review of Resident #4's physician orders dated June 2025 revealed there were orders for staff to obtain daily weights related to congestive heart failure and dependency on renal dialysis. There was an order for pre and post dialysis assessments to be completed every Tuesday, Thursday, and Saturday. Review of Resident #4's pre dialysis assessments revealed there were no pre dialysis assessments completed on 04/01/25, 04/03/25, 04/10/25, 04/15/25, 04/17/25, 04/22/25, 04/29/25, 05/01/25, 05/06/25, 05/13/25, 05/15/25, 05/20/25, and on 06/07/25. Review of Resident #4's post dialysis assessments revealed there were no post dialysis assessments completed on 04/15/28, 04/22/25, 04/29/25, 05/10/25, 05/15/25, 05/17/25, 05/29/25, and on 06/07/25. Review of Resident #4's daily weights from 04/01/25 through 06/05/25 revealed daily weights were not completed on 04/01/25, 04/02/25, 04/03/25, 04/06/25, 04/07/25, 04/09/25, 04/10/25, 04/14/25, 04/15/25, 04/16/25, 04/20/25, 04/21/25, 04/23/25, 04/24/25, 04/25/25, 04/27/25, 04/28/25, 04/30/25, 05/01/25, 05/04/25, 05/05/25, 05/06/25, 05/07/25, 05/08/25, 05/09/25, 05/10/25, 05/11/25, 05/12/25, 05/13/25, 05/14/25, 05/15/25, 05/16/25, 05/17/25, 05/18/25, 05/19/25, 05/21/25, 05/22/25, 05/26/25, 05/28/25, 05/29/25, 05/30/25, 06/01/25, 06/02/25, 06/03/25, 06/04/25, and on 06/05/25. Interview on 06/09/25 at 1:52 P.M. with Registered Nurse (RN) #610 revealed the Certified Nursing Assistants (CNA) obtain the resident's weight and notify the nurse of results so they can be documented. RN #610 stated there was no other place they would document the weights except for in the Electronic Medical Record (EMR) under the weight/vitals tab. Interview on 06/11/25 at 3:51 P.M. with Dietician #715 revealed they confirmed Resident #4 was on daily weights related to their diagnosis of congestive heart failure and the need for hemo-dialysis. Dietician #715 confirmed the daily weights are not being done per physician orders. Interview on 06/12/25 at 11:57 A.M. with the Regional Director of Clinical Operations (RDCO) revealed they confirmed there were multiple missing pre and post dialysis assessments for Resident #4 as well as multiple missing daily weights from 04/01/25 to 06/12/25 with no explanation given as to why. The RDCO stated staff are to complete a pre and post dialysis assessment on each dialysis day and the daily weights should be completed and documented daily per physician orders. Review of the undated facility policy titled Hemodialysis Care and Monitoring, revealed the facility uses this policy to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. The facility is responsible to provide resident centered care to meet the resident's need for dialysis, provide a method for coordination and collaboration between the nursing home and the dialysis facility, provide outside dialysis services with an agreement between the facility and a Medicare Certified Dialysis facility, Provide a method for on-going communication and collaboration for the development and implementation of dialysis care plan. The facility will provide pre and post dialysis assessments and weights per physician orders.

Based on record review and interview, the facility failed to ensure medications were obtained timely from the pharmacy to meet resident needs. This affected two residents (Resident #64 and #78) of eight residents reviewed for medication administration. The facility census was 80. Findings include: 1. Review of Resident #64's medical record revealed an admission date of 05/03/25 with diagnoses including local infection of the skin and subcutaneous tissue, cellulitis of Left Lower Extremity (LLE), displaced bicondylar fracture of left tibia, type II diabetes mellitus, hypertension, major depressive disorder, and acute embolism and thrombosis of deep vein of left lower extremity. Review of Resident #64's admission Minimum Data Set (MDS) 3.0 assessment revealed the resident had intact cognition, was independent with eating, required setup or clean up assistance with oral hygiene, partial to moderate assistance with upper dressing,, personal hygiene, and bed mobility. Resident #64 required substantial to maximal assistance with toileting hygiene and showers and was dependent on staff for lower body dressing. Review of the Medication Administration Record (MAR) for May 2025 for Resident #64 revealed nursing staff documented not administered/not available from the pharmacy on 05/03/25 for the following medications: Amlodipine 10 Milligrams (mg), Atorvastatin 40 mg for lipids daily, Colace 100 mg for constipation, Duloxetine 90 mg daily for depression, Hydrochlorothiazide (HCTZ) 12.5 mg for hypertension daily, Lisinopril 40 mg daily for hypertension, Oxybrutrin 5 mg daily for urinary health, protonix 40 mg daily for GERD, Pioglitazone 30 mg daily for diabetes, Synthroid 88 micrograms (mcg) daily for hypothyroidism, Vitamin D 50 mcg for supplement, metformin 500 twice a day for diabetes, and Ceftriaxone 2 gm IV daily for soft tissue infection. Interview on 06/11/25 at 10:01 A.M. with Resident #64 revealed her medications were not available to be administered to her on the date of admission to the facility. She stated she had to wait a day to a day and a half before all her medications were available to be administered. Resident #64 stated because she did not receive her medications, she just felt like laying in bed, not going to therapy and not taking a shower because she felt nauseated and had some pain. 2. Review of the closed medical record for Resident #78 revealed an admission date of 03/08/25 at 6:07 P.M. and discharged from the facility per resident request on 03/10/25 at 12:45 P.M Diagnoses included local infection of the skin, subcutaneous tissues, non-pressure ulcer of the right and left lower legs with fat layer exposed, peripheral vascular disease, type II diabetes, hypertension, Chronic Obstructive Pulmonary Disorder (COPD), and major depressive disorder. Review of Resident #78's MAR dated March 2025 revealed on 03/09/25 the resident did not receive their Citalopram 20 mg daily for depression, pregabalin 300 mg twice a day for convulsions, and Daptomycin 500 mg IV daily for infection due to not being available from the pharmacy. Interview on 06/11/25 at 9:49 A.M. with Licensed Practical Nurse (LPN) #513 revealed LPN #513 did not always have the resident medications to give the residents because the medications were not being made available from the pharmacy and were not in the Nexus system (automated pill dispenser). LPN #513 stated they must make multiple phone calls to the pharmacy to inquire about where the medications are. LPN #513 stated with new admissions it is not uncommon if their medications are not available to give for approximately a day to a day and a half due to not arriving from the pharmacy in a timely manner. LPN #513 verified medications not administered as ordered for Resident #64 due to not being available to give to Resident #64. Interview on 06/11/25 at 9:23 A.M. with the DON verified Resident #78 had missed physician ordered medications due to the medications not being available to give to Resident #78. Interview on 06/11/25 at 1:02 P.M. with LPN #510 revealed there are times when medications do not arrive from the pharmacy timely. LPN #510 stated it can take up to a day and a half to get certain meds, including IV antibiotics and any medications not available in the Nexus system. Review of the facility policy titled, Pharmacy Services, revised 09/01/21, stated the pharmacy would supply medications that were needed and deliver the medications to the facility. This deficiency represents non-compliance investigated under Complaint Number OH00163639.

Based on observation, interview and record review the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed when administering Intravenous (IV) medications for Resident #64. This affected one resident (Resident #64) out of three residents reviewed for Enhanced Barrier Precautions. The facility census was 80. Findings include: Review of Resident #64's medical record revealed an admission date of 05/03/25 with diagnosis including local infection of the skin and subcutaneous tissue, cellulitis of Left Lower Extremity (LLE), displaced bicondylar fracture of left tibia, type II diabetes mellitus, hypertension, major depressive disorder, and acute embolism and thrombosis of deep vein of left lower extremity. Review of Resident #64's admission Minimum Data Set (MDS) 3.0 assessment revealed the resident had intact cognition, was independent with eating, required setup or clean up assistance with oral hygiene, partial to moderate assistance with upper dressing, personal hygiene, and bed mobility. Resident #64 required substantial to maximal assistance with toileting hygiene and showers and was dependent on staff for lower body dressing. Review of Resident #64's care plan dated 05/21/25 revealed a care plan initiated related to Resident #64 had an infection, cellulitis of the LLE and was on IV antibiotics. Goals and interventions included the resident would be free from signs and symptoms of complications related to the infection. Staff were to administer antibiotics per medical providers orders, observe for side effects and effectiveness and report abnormal findings to medical provider. Additionally, there was a care plan for Enhanced Barrier Precautions (EBP) due to providing care to the resident with a history or colonized multi-drug-resistant organism. The care plan also consisted of Resident #64 was currently on IV therapy for antibiotics. The resident would be free of signs and symptoms of infection at IV insertion site, staff to administer IV medications and flushes per medical providers orders and report any abnormal findings. Review of Resident #64's physician orders dated June 2025 revealed the resident was in EBP related to Peripherally Inserted Central Catheter (PICC) when administering medication, dressing or bathing, showering, transferring in room or therapy gym, personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting. Staff to administer Ceftriaxone Sodium 2 grams (gm) IV every 24 hours for soft tissue infection until 06/12/25 at 11:59 P.M. Observation on 06/11/25 at 9:54 A.M. of IV antibiotic administration for Resident #64 by Licensed Practical Nurse (LPN) #513 revealed LPN #513 did not wear proper Personal Protective Equipment (PPE) including a gown and gloves. Interview on 06/11/25 at 10:03 A.M. with LPN #513 revealed they verified Resident #64 was in EBP and stated they should have worn proper PPE including a gown and gloves to administer Resident #64's IV antibiotics. Review of the undated facility policy titled Enhanced Barrier Precautions revealed Enhanced Barrier Precautions is an infection control intervention designed to reduce transmission of multi-drug-resistant organisms. Personal Protective Equipment required is a gown and gloves. EBP are indicated for residents with any of the following including indwelling medical devices for example central lines such as PICC lines. Review of the facility policy titled Intermittent Infusion, last revised 12/2014 revealed under General Guidance number three Administration sets used for intermittent therapy will be changed every 24 hours.

Based on record review and interview the facility failed to ensure showers were completed as scheduled and preferred for Resident #7, #8, #36 and #42 who required staff assistance for showers. This affected four Residents (Residents #7, #8, #36, and #42) out of four residents reviewed for showers. The facility census was 83. Findings include: 1. Review of Resident #7's medical record revealed an admitted [DATE]. Medical diagnoses include hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, repeated falls, epilepsy, and muscle weakness. Review of Resident #7's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition and was dependent on staff for toileting hygiene and showers. Review of Resident #7's care plan dated 10/10/24 revealed they were to have a shower every Tuesday, Thursday and Saturday. Review of Resident #7's shower documentation dated 09/19/24 to 10/12/24 revealed the resident did not receive their shower on 09/21/24, 09/26/24, 10/01/24, 10/08/24, and 10/10/24. 2. Review of Resident #8's medical record revealed an admitted [DATE]. Medical diagnoses included necrotizing fasciitis, stage four pressure ulcer to sacral region, type two diabetes mellitus, morbid obesity, hypertension, and lack of coordination. Review of Resident #8's quarterly MDS 3.0 assessment dated [DATE] revealed the resident had intact cognition and was dependent on staff for toileting hygiene and required partial to moderate assistance for showers. Review of Resident #8's care plan dated 09/19/24 revealed the resident was to have a shower on Tuesday, Thursday, and Saturday. Review of Resident #8's shower documentation dated from 09/17/24 to 10/12/24 revealed the resident did not receive their shower on 09/21/24, 09/24/24, 10/01/24, 10/08/24, 10/10/24, and 10/12/24. 3. Review of Resident #36's medical record revealed an admitted [DATE]. Medical diagnoses included neuroleptic induced parkinsonism, schizoaffective disorder, anxiety disorder, pressure ulcer of right hip, viral hepatitis C, and hypertension. Review of Resident #36's end of skilled stay MDS 3.0 assessment dated [DATE] revealed the resident had slightly impaired cognition and required substantial to maximal assistance for toileting hygiene, personal hygiene, and showers. Review of Resident #36's care plan dated 08/30/24 revealed the resident was to receive showers on Tuesday, Thursday, and Saturday. Review of Resident #36's shower documentation dated 09/16/24 to 10/15/24 revealed the resident did not receive showers on 09/17/24, 09/19/24, 09/21/24, 09/24/24, 09/26/24, 09/29/24, 10/03/24, 10/12/24, and 10/15/24. 4. Review of Resident #42's medical record revealed an admitted [DATE]. Medical diagnoses included necrotizing fasciitis, encephalopathy, altered mental status, sepsis, alcohol abuse, hypertension, need for assistance with personal care, and anxiety disorder. Review of Resident #42's Medicare Five Day MDS 3.0 assessment dated [DATE] revealed the resident had slightly impaired cognition and required substantial to maximal assistance with toileting hygiene, personal hygiene, and showers. Review of Resident #42's care plan dated 07/22/24 revealed the resident was to have showers on Monday, Wednesday, and Friday. Review of Resident #42's shower documentation dated 09/09/24 to 10/14/24 revealed the resident did not receive a shower on 09/13/24, 09/20/24, and 10/04/24. Interviews conducted on 10/15/24 from 11:15 A.M. to 4:30 P.M. with Registered Nurse (RN) #800, RN #801, RN #802, Licensed Practical Nurse (LPN) #803, LPN #804, and State tested Nursing Assistant (STNA) #805 and STNA #806 revealed showers were done most of the time, but some are not and that Resident #7, #8, #36 and #42 did not always receive showers as scheduled and preferred. There was no reason as to why the showers were not done when asked. Interviews conducted on 10/15/24 from 11:25 A.M. to 4:40 P.M. with Residents #7, #8, #36, #40, #41, #42, and #50 revealed they did not always get their showers as scheduled or per their preference. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00157322.

Based on observation, record review, review of facility policy, and interview the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed for Resident #8. This affected one resident (Resident #8) out of four residents reviewed for infection control. The facility census was 83. Findings include: Review of medical record for Resident #8 revealed an admitted [DATE]. Medical diagnoses included necrotizing fasciitis, pressure ulcer of the sacral region stage four, type two diabetes mellitus, morbid obesity, hypertension, and neuromuscular dysfunction of the bladder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 had intact cognition, required set up or clean up assistance with oral hygiene, was independent with eating, was dependent on staff for toileting hygiene, and required partial to moderate assistance for showers, dressing, personal hygiene, and bed mobility. Review of Resident #8's physician orders dated October 2024 revealed the resident was in Enhanced Barrier Precautions related to wound and ostomy. Observation made on 10/15/24 at 11:00 A.M. of wound care for Resident #8 performed by Registered Nurse (RN) #800 and RN #801 revealed wound care was completed per physician orders. Resident #8 was in Enhanced Barrier Precautions (EBP) with appropriate signage and Personal Protective Equipment (PPE) supplied, however RN #800 and RN #801 did not wear the supplied PPE including gowns while performing care. Interview on 10/15/24 at 11:15 A.M. with RN #800 and RN #801 revealed they confirmed Resident #8 was in EBP and they should have worn PPE during wound care including gowns. Review of the undated facility policy titled Enhanced Barrier Precautions revealed enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of Multi Drug Resistant Organisms (MDRO) that employs hand hygiene, targeted gown and glove use, during high contact resident care activities that include; Dressing, Bathing/Showering, Transferring, Providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care, any skin opening requiring a dressing. This deficiency represents non-compliance as an incidental finding during investigation of Complaint Number OH00157322.

Based on record review, staff interview, and facility policy, the facility failed to have advance directives in the physical medical record as required. This affected one resident (#56) of 19 residents reviewed for advanced directives. The facility census was 65. Findings include: Review of electronic medical record for Resident #56 revealed an admitted [DATE] with pertinent diagnoses of hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side, nontraumatic intracerebral hemorrhage (ruptured blood vessel in the brain), dysphagia (difficulty swallowing) following cerebral infarction, Bell's Palsy (a type of facial paralysis), major depressive disorder, and anxiety disorder. Review of the 09/21/23 quarterly Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and required substantial/max assistance for eating, oral hygiene, and upper body dressing and was dependent on staff for lower body dressing. Further review of the medical record revealed Resident #56 had a physician order dated 07/14/23 for an advanced directive to be a do not resuscitate comfort care arrest (DNRCC-A) code status. Review of the DNR Comfort Care form scanned into Resident #56's electronic medical chart, which was signed by the nurse practitioner on 07/14/23, confirmed Resident #56 had an advanced directive to be a DNRCC-A code status. Review of the Resident #56's paper (hard) medical record on 11/22/23 at 2:45 P.M. with Regional Director of Clinical Operations #475 revealed there was no DNR Comfort Care form in the chart. Interview on 11/22/23 at 2:45 P.M. with the Regional Director of Clinical Operations #475 verified Resident #56's physical medical record did not have the DNR Comfort Care form in the chart as required. Review of undated facility policy Advance Directive (Resident's Right to Choose), revealed upon admission should the resident have an Advance Directive, copies would be made and placed on the hard chart medical record as well as communicated to the staff.

Based on observation, record review, review of policy and interviews, the facility failed to ensure gastrostomy tube (G-tube) medications were administered using proper technique. This effected one resident (Resident #49) of three residents reviewed for G-tube medication administration. The facility census was 65. Findings include: Review of Resident #49's medical record revealed an admitted [DATE]. Diagnoses included acute respiratory failure with hypoxia, atrial fibrillation, major depressive disorder, moderate protein-calorie malnutrition, dysphagia and hypertension. Review of Resident #49's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had severely impaired cognition and required maximal assistance by one to two staff members for all Activities of Daily Living (ADLs). All medications were provided through his G-tube. Review of Resident #49's physicians orders revealed orders for all medications to be given via G-tube including an order for Hydralazine 25 milligrams (mg) every eight hours for hypertension. Observation of medication administration on 11/21/23 at 2:00 P.M. by Licensed Practical Nurse (LPN) #427 for Resident #49 of administration of Hydralazine 25 mg via gastrostomy tube (G-tube) revealed LPN #427 used ice water from the nursing cart to dissolve medication for administration and used ice water to flush G-tube before and after medication administration. Interview on 11/21/23 at 2:15 P.M. with LPN #427 revealed he confirmed he used ice water to dissolve the medication and used ice water to flush the G-tube before and after medication administration. LPN #427 confirmed the water was ice cold and he was supposed to use tepid or room temperature water for administration and flush. Interview on 11/21/23 at 2:30 P.M. with the Director of Nursing (DON) revealed staff were to use room temperature or tepid water to dissolve medications and with flushes before and after each medication. She stated they are not to use ice water. Review of the undated facility policy titled Medication Administered by Enteral Tube, revealed under the procedure section letter I stated to dilute medication with 10-30 milliliters of tepid (not hot or cold) water. Under section III titled Administration of Medications via G-tube letter J revealed 15 milliliters of tepid water to be used to flush before and after medication administration.

Based on interview, observations, and record review the facility failed to ensure appropriate infection control practices were followed in regard to oral suctioning of respiratory secretions for Resident #4, and hand hygiene and glove use with wound care for Resident #3. This affected two residents ( #4 and #3) of five residents reviewed for infection control practices. The facility census was 65. Findings include: 1. Record review for Resident #4 revealed an admitted [DATE]. Diagnoses included cerebral palsy, dysphagia, unspecified psychosis, convulsions and anxiety. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment dated for 10/31/23 revealed the resident had severe cognitive impairment. Resident #4 was dependent for all care including Activities of Daily Living. Review of Resident #4's physician orders dated 11/10/23 revealed orders to change suction tubing and canister once per week on Sundays and as needed. Nursing staff to suction resident orally as needed. Observation on 11/20/23 at 10:20 A.M. of the suction canister used to hold mucus secretions removed from the residents mouth and throat appeared as three-fourth full of yellow mucus. On the top of the mucus, there was a thick layer of green, bubbly or foamy textured substance that had the appearance of a green mold or biofilm. Interview on 11/20/23 at 10:35 A.M. with Licensed Practical Nurse (LPN) #427 verified the canister was almost full, undated, and the contents of container was yellow mucus. On the top of the mucus, there was a thick layer of green, bubbly or foamy textured substance that had the appearance of a green Interview on 11/20/23 at 10:38 A.M. with the Director of Nursing revealed she confirmed the canister was full, undated, and almost full of yellow mucus. On the top of the mucus, there was a thick layer of green, bubbly or foamy textured substance that had the appearance of a green. She could not confirm when the canister was last changed due to the canister and tubing were undated. 47568 2. Review of the medical record for Resident #3 revealed an admitted [DATE]. Diagnoses included multiple sclerosis, cellulitis of the left lower limb, quadriplegia, type two diabetes mellitus, and peripheral vascular disease. Review of physician orders for Resident #3 revealed an order dated 11/01/23 that stated wound care for right heel included to cleanse with wound cleanser, apply iodosorb (medicated wound ointment) to wound base, cover with abdominal pad and wrap with kerlix. The dressing was to be changed three times a week on Monday, Wednesday and Friday. Observation of wound care for Resident #3's right heel wound on 11/22/23 at 7:50 A.M. was completed by Licensed Practical Nurse (LPN) #404 and LPN #453. Observation revealed LPN #404 and #453 performed hand hygiene, donned personal protective equipment (PPE) and entered the room. The gathered wound dressing supplies were placed on the cleaned bedside table on a barrier. LPN #404 then removed soiled dressing. LPN #453 then cleansed the wound with wound cleanser. Once completed cleansing wound, LPN #453 then doffed the dirty gloves and donned clean gloves without performing hand hygiene. LPN #453 then applied a new clean wound dressing to Resident #3's right heel. LPN #404 and #453 then discarded supplies, doffed PPE and washed hands prior to exiting resident's room. Interview on 11/22/23 at 8:20 A.M. with LPN #453 confirmed when she doffed the dirty gloves after she had cleaned Resident #'3 wound bed, she did not perform hand hygiene before donning a clean pair of gloves to apply the new dressing. Review of facility policy titled Personal Protective Equipment Gloves dated 07/01/17 revealed staff were to perform hand hygiene before donning and after doffing gloves.

Based on interview and record review, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 65 residents in the facility. Findings include: Review of [NAME] PBJ Staffing data report revealed facility triggered for low weekend staffing and one star staffing for fiscal year quarter two of 2023. Interview on 11/21/23 at 5:05 P.M. with the Administrator revealed they submit the facility staffing data to the corporate office who then reports the data to CMS. The Adminstrator revealed the way the facility staffing data was transposed from the coporate office who submitted the data to CMS was late and/or not accurate which resulted in the trigger of low weekend staffing and one star for staffing for Quarter Three of 2023.