Every finding on record at Avenue at Wooster

Based on interviews, record review, written statement reviews, and policy review, the facility failed to ensure that medications were given as ordered. This affected four residents (Residents #17, #19, #46, and #55) out of eight residents reviewed for medications. The facility census was 74. Findings include:1. Review of medical record for Resident #17 revealed an admission date of 04/29/26. Diagnoses included but not limited to hypertension, anxiety disorder, and diabetes mellitus with diabetic polyneuropathy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that Resident #17 had intact cognition and required supervision for activities of daily living (ADLs). Review of the physicians' orders for August 2026 revealed a prescribed order for metoprolol one tablet of 50 milligrams (mg) of twice a day. Review of the Medication Administration Record (MAR) for August 2026 revealed that on 08/01/26 metoprolol was not given. Review of the electronic medication administration record (e-MAR) dated 08/02/26 at 3:00 A.M. revealed that Metoprolol Tartrate Oral Tablet 50 mg two times a day related to essential hypertension. Medication was given at an earlier time by dayshift nurse, Nurse Practitioner (NP) #321 was notified. Review of Resident #17's care plan dated 05/11/26 has altered cardiovascular status related to hypertension. Interventions included but not limited to administering medications as ordered. Review of the statement dated 08/01/26 from RN #316 revealed that Resident #17 was missing one 50 mg tablet of metoprolol. 2. Review of medical record for Resident #19 revealed an admission date of 02/17/25. Diagnoses included but not limited to essential hypertension, anxiety disorder, and diabetes mellitus.Review of the quarterly MDS 3.0 assessment dated [DATE] revealed that Resident #19 had moderately impaired cognition and was dependent on staff for ADLs.Review of the physicians' orders for August 2026 revealed a prescribed order for metoprolol one tablet of 50 milligrams (mg) of twice a day. Review of the MAR note for August 2026 revealed that on 08/01/26 metoprolol was not given. Review of the e-MAR note dated 08/01/26 at 11:25 P.M. revealed that metoprolol oral tablet 50 mg two times a day related to essential hypertension. Medication was given at an earlier time; NP #321 was made aware.Review of Resident #19's care plan dated 02/27/25 has altered cardiovascular status related to hypertension. Interventions included but not limited to administer medications as ordered.Review of the statement dated 08/01/26 from RN #316 revealed that Resident #19 was missing one 50 mg tablet of metoprolol. 3. Review of medical record for Resident #46 revealed an admission date of 03/16/24. Diagnoses included but not limited to essential hypertension, anxiety disorder, and Alzheimer's Disease. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed that Resident #46 had moderately impaired cognition and was dependent on staff for ADLs.Review of the physicians' orders for August 2026 revealed a prescribed order for hydralazine one tablet of 50 milligrams (mg) three times a day. Review of the MAR for August 2026 revealed that on 08/01/26 hydralazine was not given. Review of the e-MAR dated 08/02/26 at 2:52 A.M. revealed that hydralazine one oral tablet 50 mg three times a day related to essential hypertension. Medication was given at an earlier time; NP #321 was made aware. Family to be notified 8/2/2026 due to the lateness of the hour by the dayshift nursing supervisor.Review of Resident #46's care plan dated 02/27/25 has hypertension. Interventions included but not limited to administer antihypertensive medications as ordered.Review of the statement dated 08/01/26 from RN #316 revealed that Resident #46 was missing one 50 mg hydralazine. 4. Review of medical record for Resident #55 revealed an admission date of 03/16/24. Diagnoses included but not limited to essential hypertension, major depressive disorder, and Parkinson's Disease. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed that Resident #46 had intact cognition and required partial assistance for ADLs.Review of the physicians' orders for August 2026 revealed a prescribed order for carvedilol (coreg) one tablet of 6.25 mg of twice a day for hypertension. Review of the MAR for August 2026 revealed that on 08/01/26 coreg was given. Review of Resident #55's care plan dated 06/24/26 has altered cardiovascular status related to hypertension. Interventions included but not limited to administer medications as ordered. Review of the statement dated 08/01/26 from RN #316 revealed that there was a packet with 6.25 mg of Coreg for Resident #55 still in the medication cart. It was stated from RN #316 that Resident #55's coreg was signed off on the medication administration record but was not given. Interview on 08/17/26 at 12:10 P.M. with [NAME] Clinical Nurse #320 stated on 08/01/26 she was notified by unit manager Licensed Practical Nurse (LPN) #311 that Registered Nurse (RN) #307 had given multiply resident bedtime medications early. Interview on 08/17/26 at 3:31 P.M. with the Director of Nursing (DON) verified on 08/01/26 RN #307 did not follow the five rights for medication administration and inadvertently gave multiply residents medications at the wrong time. DON also, verified that Resident #17, Resident #19, Resident 46 and Resident #55 did not receive medications as ordered. DON verified she was unable to reach RN #307 for an interview during the survey and RN #307 would not write a statement. Review of the facility policy Medication Administration Preparation and General Guidelines, dated 08/2014 revealed medication medications are administered as prescribed in accordance with good nursing principles and practices. The five rights for medication administration right (right resident, right drug, right dose, right route and right time) are applied for each medication being administer a triple check of these five rights is recommended. This deficiency represents non-compliance investigated under Complaint Number 3097722 and 3096335.

Based on interviews, written staff statements, and record reviews, the facility failed to ensure that residents or resident representatives were notified when medications were not given as ordered. This affected four residents (Residents #17, #19, #46, and #55) out of four residents reviewed for notification of medication errors. This had the potential to affect all residents. The facility census was 74. 1. Review of medical record for Resident #17 revealed an admission date of 04/29/26. Diagnoses included but not limited to hypertension, anxiety disorder, and diabetes mellitus with diabetic polyneuropathy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that Resident #17 had intact cognition and required supervision for activities of daily living (ADLs). Review of the physicians' orders for August 2026 revealed a prescribed order for metoprolol one tablet of 50 milligrams (mg) of twice a day. Review of the Medication Administration Record (MAR) for August 2026 revealed that on 08/01/26 metoprolol was not given. Review of the electronic medication administration record (e-MAR) dated 08/02/26 at 3:00 A.M. revealed that metoprolol Tartrate Oral Tablet 50 mg two times a day related to essential hypertension. Medication was given at an earlier time by dayshift nurse, Nurse Practitioner (NP) #321 was notified. Family to be notified 08/02/2026 due to the lateness of the hour by the dayshift nursing supervisor.Further review of the progress notes and e-MAR notes revealed no notification of metoprolol was given at the wrong time on 08/01/26. Review of Resident #17's care plan dated 05/11/26 has altered cardiovascular status related to hypertension. Interventions included but not limited to administering medications as ordered. Review of the statement dated 08/01/26 from Registered Nurse (RN) #316 revealed that Resident #17 was missing one 50 mg tablet of metoprolol. Interview on 08/17/26 at 2:15 P.M. with Resident #17 revealed that he was not notified of any medication error.2. Review of medical record for Resident #19 revealed an admission date of 02/17/25. Diagnoses included but not limited to essential hypertension, anxiety disorder, and diabetes mellitus. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed that Resident #19 had moderately impaired cognition and was dependent on staff for ADLs.Review of the physicians' orders for August 2026 revealed a prescribed order for metoprolol one tablet of 50 milligrams (mg) of twice a day. Review of the MAR note for August 2026 revealed that on 08/01/26 metoprolol was not given. Review of the e-MAR note dated 08/01/26 at 11:25 P.M. revealed that metoprolol oral tablet 50 mg two times a day related to essential hypertension. Medication was given at an earlier time; NP #321 was made aware. Further review of the progress notes and e-MAR notes revealed no notification of metoprolol was given at the wrong time on 08/01/26. Review of Resident #19's care plan dated 02/27/25 has altered cardiovascular status related to hypertension. Interventions included but not limited to administering medications as ordered.Review of the statement dated 08/01/26 from RN #316 revealed that Resident #19 was missing one 50 mg tablet of metoprolol. 3. Review of medical record for Resident #46 revealed an admission date of 03/16/24. Diagnoses included but not limited to essential hypertension, anxiety disorder, and Alzheimer's Disease. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed that Resident #46 had moderately impaired cognition and was dependent on staff for ADLs.Review of the physicians' orders for August 2026 revealed a prescribed order for hydralazine one tablet of 50 milligrams (mg) three times a day. Review of the MAR for August 2026 revealed that on 08/01/26 hydralazine was not given. Review of the e-MAR dated 08/02/26 at 2:52 A.M. revealed that hydralazine one oral tablet 50 mg three times a day related to essential hypertension. Medication was given at an earlier time; NP #321 was made aware. Family to be notified 8/2/2026 due to the lateness of the hour by the dayshift nursing supervisor.Further review of the progress notes and e-MAR notes revealed no notification of hydralazine was given at the wrong time on 08/01/26. Review of Resident #46's care plan dated 02/27/25 has hypertension. Interventions included but not limited to administering antihypertensive medications as ordered.Review of the statement dated 08/01/26 from RN #316 revealed that Resident #46 was missing one 50 mg hydralazine. 4. Review of medical record for Resident #55 revealed an admission date of 03/16/24. Diagnoses included but not limited to essential hypertension, major depressive disorder, and Parkinson's Disease. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed that Resident #46 had intact cognition and required partial assistance for ADLs.Review of the physicians' orders for August 2026 revealed a prescribed order for carvedilol (Coreg) one tablet of 6.25 mg of twice a day for hypertension. Review of the MAR for August 2026 revealed that on 08/01/26 Coreg was given. Further review of the progress notes and e-MAR notes revealed no notification of carvedilol was not given. Review of Resident #55's care plan dated 06/24/26 has altered cardiovascular status related to hypertension. Interventions included but not limited to administering medications as ordered. Review of the statement dated 08/01/26 from RN #316 revealed that there was a packet with 6.25 mg of Coreg for Resident #55 still in the medication cart. It was stated from RN #316 that Resident #55's Coreg was signed off on the medication administration record. Interview on 08/17/26 at 2:13 P.M. with Resident #55 revealed that she was not informed on 08/01/26 about the medication error. Interview on 08/17/26 at 2:29 P.M. with Director of Nursing (DON) revealed that the facility did not notify Residents #17, #19, #46, and #55 or resident representatives of the medication error that occurred on 08/01/26. Interview on 08/17/26 at 3:31 A.M. with DON revealed that there was no policy for notifying residents or resident representatives. She stated it is common practice. This deficiency represents non-compliance investigated under Complaint Number 3096335.

Based on observation , medical record review, review of policy, staff interviews and resident interview, the facility failed to ensure a resident who required physical assitance to get out of bed waa provided timely assitance. This affected one (#34) of three residents observed for assitance. The facility census was 79.Findings include: Review of the medical record for Resident #34 revealed an admission date of 06/05/25. Diagnoses included traumatic subdural hemorrhage, major depressive disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #34 had moderately impaired cognition and was a substantial assistance for transfer. Observation and interview on 05/19/26 at 9:50 A.M. with Resident #34 revealed that he was lying in bed and had the call light being activated. Resident #34 stated that he just pressed the call light and he was ready to get out of bed. Resident #34 stated that he needed staff for transfers, but he was not a Hoyer lift anymore. Observation and interview on 05/19/26 at 9:52 A.M. revealed that Certified Nursing Assistant (CNA) #200 answered the call light, turned it off, and stated that she would have to get someone to assist her with the transfer. Observation on 05/19/26 at 10:25 A.M. revealed Resident #34's was lying in bed, and his call light was not activated. Resident #34 decided to activate the call light again. Observation on 05/19/26 at 10:28 A.M. revealed Licensed Practical Nurse (LPN) #201 revealed that she came into Resident #34's room and turned off the call light and stated that she was just asked to assist with transferring Resident #34 out of bed. LPN #201 stated that CNA #200 was just delivering water to the room next to Resident #34. Observation on 05/19/26 at 10:29 A.M. revealed Physical Therapy Aide (PTA) #202 entered the room and stated that he was asked to assist with a transfer. Observation on 05/19/26 at 10:33 A.M. revealed CNA #200 returned to the room and with the assistance of PTA #202, Resident #34 was transferred out of bed to his wheelchair. Interview on 05/19/26 at 11:10 A.M. with CNA #200 revealed that she had showers to do and there was another CNA and was probably doing a shower. CNA #200 stated that why she was late getting to Resident #34. Interview on 05/19/26 at 12:59 P.M. with Administrator revealed that he had not heard of call lights not being answered and can't say that this morning was acceptable. Review of the facility policy dated 11/2016 with a revision date of 03/2023 titled, Resident Call System, revealed that staff is to respond to resident's call light in a timely manner. This deficiency represents non-compliance investigated under Complaint Number 2992394.

Based on record review, observation, interview, and facility policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a skin wound. This deficient practice affected one resident (Resident #13) out of three residents reviewed for skin wounds. The facility census was 79.Findings include: Review of Resident #13's medical record revealed admission date 09/23/24 with diagnoses including but not limited to left side hemiplegia, history of stroke, type two Diabetes, depression, congestive heart failure (CHF) and high blood pressure.Review of Resident #13's physician's order revealed an order dated 02/28/26 for treatment to buttocks: cleanse with normal saline (NS), pat dry. Apply calcium alginate and cover with dry clean dressing. Further review revealed no orders for Enhanced Barrier Precautions (EBPs) related to the skin wound.Review of Resident #13's care plan revealed no EBP care plan implemented.An observation on 03/05/26 at 11:35 A.M. revealed there was no EBP notification signage or personal protective equipment (PPE) available outside of Resident #13's room for staff use during resident care.An interview on 03/05/26 at 11:35 A.M. with Licensed Practical Nurse (LPN) #353 confirmed there were no EBPs implemented for Resident #13's skin wound. LPN #353 stated EBPs should be implemented for a resident with a skin wound.Reviewed facility policy titled Enhanced Barrier Precautions undated revealed Enhanced Barrier Precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. High contact resident activities include wound care: any skin opening requiring a dressing.This deficiency represents non-compliance investigated under Complaint Number 2726270.

Based on record review, interview, and facility policy review, the facility failed to implement safety measures for a resident who sustained impaired skin integrity from a hot liquid spill. This deficient practice affected one resident (Resident #1) out three residents reviewed for impaired skin integrity. The facility census was 79.Findings include:Review of Resident #1's medical record revealed re-admission date 07/03/23 with diagnoses including but not limited to type two diabetes, high blood pressure, kidney disease, and peripheral vascular disease (PVD).Review of Resident #1's Activities of Daily Living (ADL) care plan dated 05/18/23 and impaired skin integrity care plan dated 02/28/26 revealed no safety measures were implemented related to Resident #1's impaired skin integrity to right forearm.Review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 required assistance with Activities of Daily Living (ADL) tasks.Review of Resident #1's progress note dated 02/13/26 revealed Resident #1's family reported a fluid filled discoloration on Resident #1's right forearm. Resident #1 reported she had spilled some of her coffee on her arm and Resident #1 reported no pain from the area.Review of Resident #1's physician orders revealed an order dated 03/02/26 for treatment of right forearm skim impairment to cleanse with normal saline, apply antibiotic ointment and leave open to air twice daily and as needed (PRN). Further review revealed no orders for adaptive equipment as a safety measure related to Resident #1's impaired skin integrity to her right forearm.Interview on 03/05/26 at 1:50 P.M. with the Regional Nurse Consultant (RNC) #520 confirmed Resident #1 did not have any safety measures/interventions implemented related to the impaired skin integrity sustained to Resident #1's right forearm from spilling hot liquid. RNC #520 stated the facility ordered sippy cups for Resident #1 which were not implemented.Review of the facility's skin policy revised date 01/2023 revealed preventative measures will be implemented in accordance with the resident's assessed risk level and for development of skin integrity impairment and risk factors that may enhance the residents' ability to develop skin integrity impairment.This deficiency represents non-compliance investigated under Complaint Number 2726270.

Based on record review, observation, interview, and facility policy review, the facility failed to maintain pressure reducing measures for a resident with a skin pressure injury. This deficient practice affected one resident (Resident #13) out of two residents reviewed for skin pressure injuries. The facility census was 79.Findings include: Review of Resident #13's medical record revealed admission date 09/23/24 with diagnoses including but not limited to left side hemiplegia, history of stroke, type two diabetes, depression, congestive heart failure (CHF), and high blood pressure.Review of Resident #13's weight listing dated 02/17/26 revealed Resident #13's weight was 168.3 pounds (lb).Review of Resident #13's physician's order revealed an order dated 02/28/26 for treatment to buttocks: Cleanse with normal saline (NS), pat dry. Apply calcium alginate and cover with dry clean dressing.Review of Resident #13's progress note dated 03/03/26 revealed the hospice nurse was updated on open areas to buttock with an air mattress ordered.Observation on 03/05/26 at 11:00 A.M. revealed Resident #1 laying in bed with a low air loss mattress in place. Further observation revealed the resident weight control knob was set at the 600 lb setting.Interview on 03/05/26 at 11:30 A.M. with the facility wound nurse #365 confirmed the low air loss mattress setting for Resident #13 was set at the 600 lbs. setting and Resident #13's weight was 168.3 lbs. The facility wound nurse #365 stated the low air loss mattress is to be set per the weight of the resident and once the low air loss mattress was inflated the setting was not adjusted to Resident #13's weight.Review of the manufacturer's guidelines for a drive low air loss mattress revealed the analog control unit includes easy to use pressure dial that is adjustable to the patient's weight and comfort.Review of the facility's skin policy revised date 01/2023 revealed preventative measures will be implemented in accordance with the resident's assessed risk level and for development of skin integrity impairment and risk factors that may enhance the residents' ability to develop skin integrity impairment.This deficiency represents non-compliance investigated under Complaint Number 2726270.

Based on observation, interview, and review of the facility policy and procedures, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and failed to ensure food was stored properly. This had the potential to affect all residents living at the facility. The facility census 81. Findings include: Observations on 03/17/25 from 8:25 A.M. to 8:35 A.M. during the tour of the kitchen with [NAME] #218 revealed the top of oven and steamer were covered with crumbs and debris. The grill had a missing panel that covered the front right side of the front grill. The panel was stored behind the grill. The [NAME] had large clumps of crumbs floating in the grease. The floor and lower back wall of the stove, oven, steamer and grill were covered with dirt, debris and grease. The freezer had two open bags of onion rings with no label or date. There was an opened brown bag with hashbrown with no label or date and an unopened bag of chicken tender and fish filets with label or date Interview on 03/17/25 between 8:25 A.M. and 8:40 A.M. with [NAME] #218 verified the identified findings and stated they will be taken care of right away. [NAME] #218 stated the staff from prior day did not clean and strain the [NAME]. Follow-up visit on 03/18/25 at 3:03 P.M. with Dietary Manager #325 Revealed the freezer had an open bag of waffles undated and an open bag of onion rings unlabeled and dated. There was a carton of ice cream with no open date. The refrigerator had an open container of humus with an open date of 02/27/25. Interview with the Dietary Manager #325 verified the findings and stated on 03/17/25 he noticed floor and the back wall of grill, steamer and oven were dirty and it was cleaned. Reviewed policy General sanitation of the kitchen, undated revealed food and nutrition services staff will maintain the sanitation of the kitchen. Leftovers are used within 7 days or discarded.

Based on record review, Psychotropic Drug Use policy review, Medication Regimen review, and interview the facility failed to ensure pharmacy recommendations were addressed appropriately by the physician for Resident #9, #16, and #41. The facility also failed to ensure an abnormal involuntary movement scale (AIMS) assessment was completed for Resident #70. This affected four (Resident #9, #16, #41, and #70) out of five residents reviewed for unnecessary medications. The facility census was 81. Findings include: 1. Review of the medical record revealed Resident #9 was admitted on [DATE] with diagnoses that included acute and chronic respiratory failure, major depressive disorder, and anxiety. Review of the pharmacy recommendation dated 02/07/25 revealed Resident #9 received Buspirone (anxiolytic) five milligram (mg) three times a day without a gradual dose reduction (GDR). The pharmacy recommended a reduction to five mg twice a day. If the physician did not agree documentation needed added to the medical record indicating why the GDR would be detrimental to Resident #9's mental or physical health. The recommendation was marked disagreed by Psychiatric Nurse Practitioner #201 on 02/19/25 with a rational of patient refused. The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was cognitively intact. Resident #9 received antianxiety, antidepressant, and anticonvulsant medications. Interview on 03/20/25 at 3:26 P.M. Psychiatric Nurse Practitioner #605 verified the only reason documented for disagreeing with the GDR was Resident #9 refused. Psychiatric Nurse Practitioner #201 also verified there was no documentation of Resident #9 being educated about the benefits of a GDR or why Resident #9 refused to have Buspirone decreased. 2. Review of the medication record revealed Resident #41 was admitted on [DATE] with diagnoses that included respiratory failure, psychosis, mild cognitive impairment, major depressive disorder, anorexia, and obsessive compulsive disorder. The quarterly MDS dated [DATE] revealed Resident #41 had cognitive impairment. The MDS revealed Resident #41 received antianxiety and antidepressant medications. Review of the pharmacy recommendation dated 02/07/25 revealed Resident #41 received Fluvoxamine (antidepressant) 75 mg once a day without a GDR. The pharmacy recommended a reduction to 50 mg a day. If the physician did not agree documentation needed added to the medical record indicating why the GDR would be detrimental to Resident #41's mental or physical health. The recommendation was marked disagreed by Psychiatric Nurse Practitioner #201 on 02/19/25 with a rational of patient refused. Interview on 03/20/25 at 3:26 P.M. Psychiatric Nurse Practitioner #605 verified the only reason documented for disagreeing with the GDR was Resident #41refused. Psychiatric Nurse Practitioner #201 also verified there was no documentation of Resident #41 being educated about the benefits of a GDR or why Resident #41 refused to have Fluvoxamine decreased. 3. Review of Resident #16's medical record revealed the Resident was admitted to the facility on [DATE]. Diagnoses included dementia with psychotic and mood disturbance, heart disease, anxiety and depression. Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had severe impaired cognition and no behaviors. The assessment identified that the resident receives an antipsychotic, antianxiety, antidepressant, and anticonvulsant. Review of the Pharmacist Recommendation dated 01/12/25 revealed gradual dose reduction (GDR) for Depakote 125 milligram (mg). The practitioner marked disagree with the recommendation there was no reason noted. Recommendation dated 02/07/25 revealed gradual dose reduction (GDR) for Risperidone 0.5 mg. The practitioner marked disagree with the recommendation with a note that stated family refused. Review of the Nurse Practitioner (NP) #605 progress note dated 02/19/25 revealed a generic note stating the resident symptoms continue to be well managed with current medication. Modifying the medication has a potential risk for destalinization. The note was not specific to the medications recommended for a GDR. Interview on 03/20/25 at 3:21 P.M. with NP #605 stated she reviews medications for GDRs monthly and documents them in her progress notes. Interview on 03/20/25 at 3:45 P.M. with the Director of Nursing (DON) revealed he reviews GDR with practitioners monthly. The DON was unaware the practitioners were not documenting specific justifications and contraindications of GDRs. Review of the Medication Regimen Review policy dated 12/17 revealed recommendations are acted upon and documented by the facility staff and/or the prescriber. The prescriber accepts and acts upon recommendation or rejects and provides an explanation for disagreeing. Review of the Psychotropic Drug Use policy (no date) revealed an unnecessary drug is any medication that is used in excessive doses, for excessive duration. A GDR must be completed annually unless clinically contraindicated and adequate written justification is provided by the physician as to the reason that a reduction is not justified. 4. Review of Resident #70's medical record revealed initial admission date 09/27/24 and readmission date 01/03/25 with diagnoses including but not limited to right femur fracture, multiple sclerosis (MS), anxiety, depression, and psychosis. Resident #70 had moderately impaired cognition with a Brief Interview of Mental Status (BIMS) score of 12 out of a possible 15 dated 01/04/25. Review of Resident #70's signed physician orders revealed an order dated 01/03/25 for antipsychotic medication Seroquel oral tablet 50 milligrams (mg) give 50 mg by mouth three times a day for delirium and psychosis. The antipsychotic medication Seroquel had initially been implemented on 11/19/24. Review of Resident #70's admission Mimium Data Set (MDS) dated [DATE] revealed Section N - Medications was marked as Resident #70 receiving antipsychotic medication. Review of Resident #70's psychotropic medication use care plan dated 12/04/24 revealed Resident #70 received antipsychotic medication related to psychosis and delirium. There were no target behaviors for the use of antipsychotic medication use. Review of Resident #70's assessments revealed a completed Abnormal Involuntary Movement Scale (AIMS) dated 12/27/24 for the antipsychotic medication Seroquel. There was no completed AIMS assessment dated when the antipsychotic medication Seroquel was implemented on 11/19/24. An interview on 03/25/25 at 1:26 P.M. with MDS Licensed Practical Nurse (LPN) #410 confirmed Resident #70 did not have an AIMS assessment completed upon implementation of the antipsychotic medication Seroquel on 11/19/24. MDS LPN #410 stated there should have been an AIMS completed when the antipsychotic medication was initiated. Review of the facility policy titled, Psychotropic Drug Use undated revealed, Qualified staff will monitor the resident for potential undesirable adverse effects that are associated with the use of psychotropic drugs upon initiation of the psychotropic medication and at minimum every six months utilizing the Abnormal Involuntary Movement Scales as well as monitor for other adverse effects in accordance with CMS and State specific rules and regulations routinely.

Based of closed record review, policy review, review of the facility self-reported incidents, facility investigation review, and interviews, the facility failed to report to the state survey agency an allegation of abuse by a staff member to Resident #72. This affected one (Resident #72) out of one residents reviewed for abuse. The facility census was 81. Findings include: Review of the closed medical record revealed Resident #72 was admitted on [DATE] and discharged [DATE] with diagnoses that included cerebral infarction, aphasia, convulsions, major depressive, anxiety, hemiplegia and hemiparesis. A nursing note dated 01/29/25 at 3:47 P.M. revealed the nurse practitioner was made aware Resident #72 had a fall and Resident #72 could be transferred to the hospital for evaluation. No further documentation of the fall was recorded in the medical record. Review of a written statement, dated 01/29/25 by Receptionist #501, revealed around 2:30 P.M. she witnessed Resident #72 starting to fall. Receptionist #501 went to get the Director of Nursing (DON)but the DON was already heading to Resident #72. The DON said you are done to Resident #72. Receptionist #501 wrote they believed the DON meant Resident #72 was done using the walker. Review of a typed statement, dated 01/29/25 by Human Resource #234, revealed Resident #72 was trying to walk without his walker. The DON asked Resident #72 where his walker was. Resident #72 pointed to it and the DON got the walker for Resident #72. The DON returned to his office. Resident #72 got up to walk and Resident #72 fell . The DON rushed out of his office and told Resident #72 we can't do this. Review of a typed statement, dated 01/29/25 by Receptionist #402, revealed while Resident #72 was waiting in the front lobby to go to an appointment, Resident #72 tried to stand up and fell to the side. The DON came out of his office and while going to Resident #72, the DON raised his voice and said you are done multiple times. Review of a written statement, dated 01/29/25 by Business Office Manager #214, revealed they did not witness the fall but were asked to assist with getting Resident #72 up (from the floor). Review of the facility self-reported incidents from 01/29/25 through 03/13/25 revealed the allegation was not reported to the state survey agency. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #72 was cognitively intact. Resident #72 did have feelings of being down, depressed, hopeless, and feeling bad about self. Review of the plan of care dated 02/19/25 revealed Resident #72 was at risk for falls. Interventions included to assess footwear for proper fit and non-skid soles, encourage the use of call lights, and instruct on safety measures. Interview on 03/17/25 at 2:13 P.M. with a family member of Resident #72 revealed they heard an incident occurred when Resident #72 fell in the front area of the building. The family member stated they were not sure if the DON yelled at Resident #72 but something did not feel right about the situation. Interview on 03/19/25 at 9:36 A.M. a staff member that requested to be anonymous revealed Resident #72 was crying after the fall in the lobby and stated the DON was screaming at him and said Resident #72 could not use his walker anymore. Resident #72 stated he was scared of the DON. The staff member believed several staff had reported the incident to the Licensed Nursing Home Administrator (LNHA). Interview on 03/20/25 at 10:32 A.M. with the LNHA verified a nurse notified him that another staff member had reported concerns of how the DON had spoken to Resident #72. The LNHA stated he got statements from the three witnesses that observed the fall and the DON going to Resident #72. The LNHA stated he was unable to interview Resident #72 because the resident was transferred to the hospital. The LNHA verified he did not report the allegation of possible verbal or emotional abuse to the state agency because he did not think abuse had occurred and was not sure if it should be reported. The LNHA stated the DON had reported yelling out Resident #72's name as the DON was trying to help Resident #72. On 03/20/25 at 12:17 P.M. a staff member that requested to be anonymous stated the DON was stern and the tone of voice was concerning when he went to Resident #72 after the fall. The staff member stated they reported their concern about the tone of voice the DON had used towards Resident #72. On 03/20/25 at 3:48 P.M. the DON verified Resident #72 had several falls. The DON stated Resident #72 fell in the lobby and the DON talked to Resident #72 but did not recall anything concerning about the incident. The DON verified he did tell Resident #72 he could no longer use a walker. Review of the Abuse Prohibition policy revised October 2022 revealed abuse is defined as willful infliction of intimidation or punishment resulting in mental anguish. Types of abuse include mental/emotional abuse. Mental abuse may occur through verbal or nonverbal conduct which causes or has the potential to cause the resident to experience intimidation, fear, shame, humiliation, agitation, or degradation. Ensure that all alleged violations involving abuse or mistreatment are reported immediately, but later than two hours after the allegation is made to the administrator and to other officials (including the State Survey Agency) in accordance with state law through established procedures. This deficiency represents non-compliance investigated under Complaint Number OH00162049.

Based of record review, Abuse Prohibition policy review, facility investigation, and interviews, the facility failed to thoroughly investigate an allegation of possible abuse by a staff member to Resident #72. This affected one (Resident #72) out of one residents reviewed for abuse. Facility census was 81. Findings include: Review of the medical record revealed Resident #72 was admitted [DATE] and discharged [DATE] with diagnoses that included cerebral infarction, aphasia, convulsions, major depressive, anxiety, hemiplegia and hemiparesis. A nursing note dated 01/29/25 at 3:47 P.M. revealed the nurse practitioner was made aware Resident #72 had a fall and Resident #72 could be transferred to the hospital for evaluation. No further documentation of the fall was recorded in the medical record. Review of a written statement, dated 01/29/25 by Receptionist #501, revealed around 2:30 P.M. she witnessed Resident #72 starting to fall. Receptionist #501 went to get the Director of Nursing (DON)but the DON was already heading to Resident #72. The DON said you are done to Resident #72. Receptionist #501 wrote they believed the DON meant Resident #72 was done using the walker. Review of a typed statement, dated 01/29/25 by Human Resource #234, revealed Resident #72 was trying to walk without his walker. The DON asked Resident #72 where his walker was. Resident #72 pointed to it and the DON got the walker for Resident #72. The DON returned to his office. Resident #72 got up to walk and Resident #72 fell . The DON rushed out of his office and told Resident #72 we can't do this. Review of a typed statement, dated 01/29/25 by Receptionist #402, revealed while Resident #72 was waiting in the front lobby to go to an appointment, Resident #72 tried to stand up and fell to the side. The DON came out of his office and while going to Resident #72, the DON raised his voice and said you are done multiple times. Review of a written statement, dated 01/29/25 by Business Office Manager #214, revealed they did not witness the fall but were asked to assist with getting Resident #72 up (from the floor). Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #72 was cognitively intact. Resident #72 did have feelings of being down, depressed, hopeless, and feeling bad about self. Interview on 03/20/25 at 10:32 A.M. Licensed Nursing Home Administration (LNHA) verified a nurse notified him that another staff member had reported concerns of how the DON had spoken to Resident #72. The LNHA stated he got statements from the three witnesses that observed the fall and the DON going to Resident #72. The LNHA stated he was unable to interview Resident #72 because the resident was transferred to the hospital. The LNHA verified statements were not obtained from the nurse that reported the incident, staff that provided care to Resident #72 before being transferred to the hospital, or the DON. The LNHA stated he talked to the DON and the DON reported yelling out Resident #72's name as the DON was trying to help Resident #72. On 03/20/25 at 12:17 P.M. a staff member that requested to be anonymous stated the DON was stern and the tone of voice was concerning when he went to Resident #72 after the fall. The staff member stated they reported their concern about the tone of voice the DON had used towards Resident #72. On 03/20/25 at 3:48 P.M. the DON verified Resident #72 had several falls. The DON stated Resident #72 fell in the lobby and the DON talked to Resident #72 but did not recall anything concerning about the incident. The DON verified he did tell Resident #72 he could no longer use a walker and the DON verified he was not asked to write a statement about the incident. Review of the Abuse Prohibition policy revised October 2022 revealed abuse is defined as willful infliction of intimidation or punishment resulting in mental anguish. Types of abuse include mental/emotional abuse. Mental abuse may occur through verbal or nonverbal conduct which causes or has the potential to cause the resident to experience intimidation, fear, shame, humiliation, agitation, or degradation. Ensure that all alleged violations involving abuse or mistreatment are reported immediately, but later than two hours after the allegation is made to the administrator and to other officials (including the State Survey Agency) in accordance with state law through established procedures.

Based on observation, medical record review, interview and policy review the facility failed to ensure residents were provided their hearing aides/amplifiers to assist with their identified hearing loss. This affected one (Resident #16) three residents reviewed for activities of daily living. Findings Include: Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia with psychotic and mood disturbance, heart disease, anxiety and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had severe impaired cognition, and moderate hearing impairment. Review of the Care Plan dated 03/01/25 revealed the resident was at risk for communication related to a hearing deficit and dementia. Interventions included be conscious of position when in groups, allow adequate time to respond, and repeat if necessary. The plan did not include information on hearing devices. Observation on 03/18/25 at 8:00 A.M. revealed the resident was sitting in the dining room. Resident #16 was not observed to be wearing a hearing device. Interview on 03/18/25 at 8:41 A.M. with Resident #16's daughter stated staff were not putting on her hearing amplifiers. Interview with Licensed Practical Nurse (LPN) #335 on 03/19/25 at 2:50 P.M. revealed Resident #16 loses personal items often due to her cognition. The resident had a habit of wrapping her dentures and hearing aids/amplifiers in paper towels and putting them in the garbage. LPN #335 stated Resident #16 had hearing amplifiers, however she did not know where they were. Observation on 03/20/25 at 8:25 A.M. of Resident #16 revealed she was not observed wearing a hearing device. Interview on 03/20/25 at 8:30 A.M. with Certified Nursing Assistant (CNA) #247 revealed the resident wore hearing amplifiers but the hearing amplifiers had been missing for about a week. CNA #247 verified Resident #16 was not wearing her hearing amplifiers. Interview on 03/20/25 at 9:00 A.M. with LPN #254 stated she found the hearing amplifiers in Resident 16's room. Interview on 03/20/25 at 9:30 A.M. with the MDS Nurse #410 verified Resident #16 did not have the hearing amplifiers applied this week. MDS #410 stated she put in a new order to apply hearing amplifiers in the A.M. and remove in the P.M. and to keep them in the medication cart. MDS #410 stated she updated the care plan to reflect the new information. Review of the facility policy titled Activities of daily living, revealed the facility will ensure a resident is given the appropriate treatment and service to maintain or improve his or her ability to conduct the activities of daily living.

Based on closed record review, facility investigation review, and interview, the facility failed to implement appropriate fall prevention interventions for Resident #9 after a fall. This affected one (Resident #9) of four residents reviewed for accidents. The facility census was 81. Findings include: Review of the closed medical record revealed Resident #9 was admitted on [DATE] with diagnoses that included acute and chronic respiratory failure, peripheral vascular disease, chronic kidney disease, major depressive disorder, anxiety, osteophyte left hip, and osteoporosis. A nursing note dated 02/23/25 at 10:08 P.M. revealed the nurse was called to Resident #9's room. Resident #9 had fallen out of the (shower) chair while being transferred into the shower. Resident #9 stated the Certified Nursing Assistant (CNA) hit the lip going into the shower. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was cognitively intact. Resident #9 required substantial to maximum assistance with bathing. Review of the plan of care dated 03/04/25 revealed Resident #9 was at risk for an actual fall with major injury. The only intervention in place was to send Resident #9 to the emergency department. Interview on 03/18/25 at 3:41 P.M. with CNA #383 revealed Resident #9 fell out of the shower chair. CNA #383 was attempting to pull the shower chair over the lip into the shower stall. Interview on 03/18/25 at 3:57 P.M. with the Director of Nursing (DON) revealed staff were educated on using the seatbelt when moving residents in a shower chair. The DON stated Resident #9 refused to use the seatbelt. The DON verified no other interventions were put in place. Interview on 03/19/25 at 4:12 P.M. with Resident #9 revealed she was afraid to have the seatbelt in place when being transferred because of the shower chair tipping and Resident #9 being strapped to the shower chair. Resident #9 stated she preferred a shower to a bed bath and she had not received a shower since she had returned to the facility. Resident #9 stated she would feel safe if there were two staff members present while the shower chair was being put into the shower. An additional interview on 03/19/25 at 5:14 P.M. the DON revealed Resident #9 had not wanted to get in the shower. The DON verified no training or education had been provided to staff about Resident #9's individualized safety measures for Resident #9's specific needs and abilities. The DON verified he was not aware Resident #9 would feel safer with two staff providing care. The DON stated he would educate the staff and update the care plan for two staff members to assist Resident #9 with showers. On 03/19/25 at 5:28 P.M. a new order was written for Resident #9 to have two staff assistance with all showers. A new intervention was added to Resident #9's plan of care on 03/19/25 for two staff to assist with all showers. Interview on 03/20/25 at 7:46 A.M. Resident #9's daughter revealed she had suggested that two staff members be present when putting Resident #9 in the shower. The daughter also stated the facility staff did not provide any information on how they would provide Resident #9 a shower and keep Resident #9 safe. This deficiency represents non-compliance investigated under Complaint Number OH00162049.

Based on record review, policy review, and interview, the facility failed to ensure there was consistent communication between the facility and the dialysis center regarding Resident #15's hemodialysis treatments. This affected one (Resident #15) of one residents reviewed for dialysis. The facility census was 81. Findings include: Review of the medical record revealed Resident #15 was admitted on [DATE] with diagnoses that included hemiplegia, aphasia, convulsions, and dependence on renal dialysis. Review of physician orders revealed Resident #15 received hemodialysis three times a week on Tuesday, Thursday, and Saturday. Review of Resident #15's medical record from 01/02/25 to 03/15/25 revealed there were missing dialysis visit notes for the last 30 dialysis treatments. Out of the 30 times Resident #15 was sent out of the facility for a dialysis treatment, 14 of those visits did not have a dialysis visit notes to indicate what Resident #15's pre-weight and dry weight (weight after dialysis) were, what the resident's vital signs were, what medications were administered, and how Resident #15 tolerated the dialysis treatment during each visit. Interview on 03/20/25 at 3:38 P.M. with Unit Manager (UM) #353 verified there were dialysis communication sheets missing and adequate communication was not occurring between the facility and Resident #15's dialysis center. UM #353 acknowledged the dialysis center was not sending a dialysis visit note for Resident #15 that let the facility nurse know what Resident #15's pre-weight and dry weight was when Resident #15 received hemodialysis. There was also no communication of any medications that may have been administered to Resident #15 or how Resident #15 tolerated the dialysis treatment. The Dialysis Monitoring policy revised 12/2022 revealed the facility will maintain ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.

Based on medical record review, observations, staff interview, and facility policy review the facility failed to ensure dietary dining equipment was made available for residents requiring adaptive dining equipment to maintain independence with eating. This deficient practice affected one Resident (Resident #14) out of one resident reviewed for use of dining adaptive equipment. The facility census was 81. Findings Include: Review of Resident #17's medical record revealed admitted [DATE] with diagnoses including but not limited to stroke with right side hemiplegia, squamous cell carcinoma of the scalp, and type two Diabetes. Resident #14 had moderate cognitive impairment with a Brief Interview of Mental Status (BIMS) score of nine out of a possible 15 dated 01/28/25. Resident #17 required assistance from staff to complete Activities of Daily Living (ADL) tasks and was independent with eating. Review of Resident #17's signed physician orders revealed an order dated 08/23/24 for no added salt, low concentrated sweets, regular texture with thin liquids diet and an order dated 12/13/24 for Device Use: Adaptive Dining Equipment: Plate guard at meals every shift. Review of Resident #17's Treatment Administration Record (TAR) dated 03/01/25 to 03/19/25 revealed the order for Device Use: Adaptive Dining Equipment: Plate guard at meals every shift was marked as being completed. Review of Resident #17's assessments revealed a Dietary assessment dated [DATE] with a plate guard marked as being used during meals. Review of Resident #17's Dietary care plan dated 01/30/25 revealed interventions included to provide adaptive equipment as ordered to improve self-feeding. Review of Resident #17's weight listing dated 10/01/24 to 03/05/25 revealed Resident #17's weights were stable with no weight loss noted. Observation on 03/17/25 at 10:37 A.M. revealed Resident #17 sitting at a table in the unit lounge finishing the breakfast meal, there was no plate guard attached to the plate or lying on the tray. Resident #17's dietary slip had adaptive equipment marked as a plate guard. Observation on 03/18/25 at 9:08 A.M. revealed Resident #17 sitting at a table in the unit lounge eating the breakfast meal, there was no plate guard attached to the plate or lying on the tray. Observation on 03/18/25 at 11:40 A.M. revealed Certified Nursing Assistant (CNA) #385 serving Resident #17's lunch tray in the unit lounge. There was no plate lying on the tray and CNA #385 did attach a plate guard to Resident #17's plate. Interview on 03/18/25 at 11:55 A.M. with CNA #385 confirmed Resident #17 did not have a plate guard available on the meal trays. CNA #385 stated the adaptive equipment used for eating and drinking is provided by the kitchen and comes on the meal trays for use by either the Resident or the staff. Interview on 03/18/25 at 1:41 P.M. with Dietary Supervisor #325 revealed therapy or nursing will give dietary a list of who needs adaptive equipment for dietary purposes and then we will put that on their ticket and then when the food is served the equipment will be placed on the tray. For a plate guard, it makes the lid stick up, so we place it on the tray and then the floor staff will attach it to the plate when they serve the food. Review of the facility's policy tilted, Assistive Devices Policy undated revealed, Assistive devices shall be provided to residents who need them for all meals to maintain or improve their ability to eat independently. Adaptive equipment is made available at mealtime by Dining Services.

Based on record review, Antibiotic Stewardship policy review, and interviews, the facility failed to ensure the appropriate antibiotics were administered for Resident #9 and #23. The facility also failed to ensure Resident #46 did not receive duplicate antibiotic therapy. This affected three (Resident #9, #23, and #46) out of five residents reviewed for unnecessary medications. Facility census was 81. Findings include: 1. Review of the medical record revealed Resident #9 was admitted on [DATE] with diagnoses that included acute and chronic respiratory failure, chronic kidney disease, and history of urinary tract infections. A nursing note dated 10/10/24 at 12:04 A.M. revealed Resident #9 was straight cathed to obtain a urine sample. A nursing note dated 10/10/24 at 6:34 P.M. revealed a new order was obtained for Resident #9 to start Macrobid (antibiotic) 100 milligram (mg) twice a day for urinary tract infection (UTI). A nursing note dated 10/11/24 at 3:18 A.M. revealed Resident #9 started Macrobid for possible UTI. A nursing note dated 10/13/24 at 2:08 A.M. revealed the on call provider was informed of Resident #9's allergies, current antibiotic order, and what antibiotic came back as susceptible. The on call provider asked for Resident #9's renal function. Resident #9 did not have any recent labs results in the chart. The on call provider stated it was not an emergency to change Resident #9's antibiotic and to call back in the morning. A nursing note dated 10/13/24 at 8:16 A.M. revealed the nurse practitioner reviewed the urine culture and discontinued the Macrobid and started Resident #9 on Levaquin (antibiotic) 250 mg daily for three days to culture and sensitivity results. A nursing note dated 12/02/24 at 9:49 P.M. revealed Resident #9 was straight cathed to obtain a urine sample. A nursing note dated 12/04/24 at 9:25 P.M. revealed Resident #9's urine sample leaked and a new sample was needed. Resident #9 could not be straight cathed at that time due to vaginal cream had already been inserted. A nursing note dated 12/06/24 at 5:25 P.M. revealed a new order was received to start Resident #9 on Keflex 500 mg twice a day for seven days while waiting for the urinalysis and culture and sensitivity results. A nursing note dated 12/08/24 at 3:22 P.M. revealed Resident #9 was positive for pseudomonia aeruginosa. The current antibiotic could be discontinued. A nursing note dated 12/09/24 at 2:17 P.M. revealed Resident #9 was ordered Cefdinir (antibiotic) 300 mg every 12 hours for 10 days due to elevated white blood count and to help manage UTI symptoms. The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was cognitively intact. Interview on 03/19/25 at 9:46 A.M. Licensed Practical Nurse (LPN) #335 verified doctors start antibiotics before urine results come back if there was a positive urine dip. Interview on 03/19/25 at 2:59 P.M. Unit Manager (UM) #353 verified Resident #9 was ordered antibiotics for a possible UTI prior to the urinalysis or culture and sensitivity results being received. UM #353 verified Resident #9 was started on antibiotics on 10/10/24 and 12/06/24 that had to be changed after the culture and sensitivity results were received. Interview on 03/20/25 at 11:54 A.M. Certified Nurse Practitioner (CNP) #600 verified antibiotics were ordered sometimes without waiting for urinalysis or culture and sensitivity results. Review of the antibiotic stewardship policy revised 12/2016 revealed when a culture and sensitivity was ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified or discontinued. 2. Review of the medical record revealed Resident #23 was admitted on [DATE] with diagnoses that included type 2 diabetes and chronic kidney disease. The quarterly MDS dated [DATE] revealed Resident #23 was cognitively intact. Review of nursing note dated 02/27/25 at 2:44 P.M. revealed a new order was received for a urinalysis with culture and sensitivity due to Resident #23 had complaints of lower right back pain. A nursing note dated 02/28/25 at 3:22 P.M. revealed a urine sample was collected. A nursing note dated 02/28/25 at 5:33 PM. revealed Resident #23 was started on Cefuroxime (antibiotic) 500 mg twice a day for 14 days. A nursing note dated 03/06/25 at 8:53 A.M. revealed the urinalysis results were reviewed and no new orders were received. On 03/07/25 at 11:16 A.M. Resident #23's urine results were reviewed and new orders were received to hold Cefuroxime and start Cefdinir (antibiotic) 300 mg twice a day for seven days. Interview on 03/19/25 at 9:46 A.M. LPN #335 verified doctors start antibiotics before urine results come back if there was a positive urine dip. Interview on 03/19/25 at 3:02 P.M. UM #353 verified Resident #23 was ordered antibiotics for a possible UTI prior to the urinalysis or culture and sensitivity results being received. UM #353 verified Resident #23 was started on antibiotics on 02/28/25 that had to be changed after the culture and sensitivity results were received. Interview on 03/20/25 at 11:54 A.M. Certified Nurse Practitioner (CNP) #600 verified antibiotics were ordered sometimes without waiting for urinalysis or culture and sensitivity results. Review of the antibiotic stewardship policy revised 12/2016 revealed when a culture and sensitivity was ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified or discontinued. 47569 3. Review of Residnet #46's medical record revealed admitted [DATE] with diagnoses including but not limited to systemic sclerosis, asthma, Chronic Obstructive Pulmonary Disease (COPD), kidney atrophy, and heart failure. Resident #46 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 dated 02/25/25. Resident #46 was frequently incontinent of urine and required moderate assistance from staff for toileting. Review of Resident #46's laboratory results dated [DATE] for Urinalysis Culture and Sensitivity (UACS) revealed abnormal results indicating a urinary tract infection (UTI) . Review of Resident #46's signed physician orders revealed an order dated 01/24/25 for antibiotic Macrobid oral capsule 50 milligram (MG) give 50 MG by mouth at bedtime (HS) for urinary tract infection (UTI) prevention and an order dated 02/27/25 for antibiotic Ciprofloxacin 500 MG to give 500 MG two times a day for five days for UTI. Review of Resident #46's Medication Administration Record (MAR) dated 02/27/25 to 03/04/25 revealed the order for antibiotic Macrobid 50 MG was marked has being administered every HS with no documentation of the antibiotic not being administered or held. Further review of Residnet #46's MAR dated 02/27/25 to 03/04/25 revealed the order for antibiotic Ciprofloxacin 500 MG was marked as being administered two times a day for five days. An interview on 03/20/25 at 11:40 A.M. with Certified Nurse Practitioner (CNP) #600 revealed when a resident is currently receiving an antibiotic for UTI and their laboratory results are received with indications of a UTI, another antibiotic will be ordered and the current antibiotic will be placed on hold for the duration of the new antibiotic therapy. Once the new antibiotic therapy has been completed, the exisisting antibiotic therapy will be reinstated. Review of the facility policy titled, Medication Management dated 08/14 revealed, The interdisciplinary team reviews the resident's medication regimen for efficancy and actual or potential medication - related problems. An interview on 03/20/25 at 11:57 A.M. with Licensed Practical Nurse (LPN) Unit Manager (UM) #353 confirmed Resident #46 had received both antibiotics Macrobid 50 MG daily and Ciprofloxacin 500mg twice daily for a total of five days between 02/27/25 to 03/04/25.

Based on medical record review, observations, and staff interviews the facility failed to ensure pressure reducing devices were in place for residents at risk for developing pressure injuries. This affected one resident (Resident #1) of two residents reviewed for pressure injuries. The facility census was 81. Findings include: Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses including but not limited to stroke with right side hemiplegia, type two diabetes, and vascular dementia. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of three out of 15 and required assistance from staff to complete bed mobility, transfers, and personal hygiene tasks. Further review revealed the resident was at risk for the development of pressure injuries with interventions in place including pressure reducing mattress, pressure reducing device in the wheelchair, and turning/repositioning program. Review of the physician orders revealed an order dated 08/21/21 to encourage the resident to float the bilateral heels on pillows while in bed every shift, an order dated 11/18/24 for treatment to bilateral heels apply skin prep and leave open to air every day shift every Monday, Wednesday, and Friday for skin care and prevention, an order dated 11/18/24 for treatment to bilateral lower extremities for pressure relieving boots while in bed every shift for skin care and prevention, and an order dated 12/17/24 for device use for bilateral heel lift suspension boots every shift every day for skin prevention. Review of Resident #1's Treatment Administration Record (TAR) dated 03/01/25 to 03/19/25 revealed the order dated 12/17/24 for device use of bilateral heel lift suspension boots every shift every day for skin prevention was marked as being completed for every shift. Review of Resident #1's care plan dated 04/10/23 revealed Resident #1 had the potential for impaired skin integrity and pressure injury development with interventions including the use of heel boots as tolerated. Review of Resident #1's progress notes dated 03/01/25 to 03/19/25 revealed no documentation revealing Resident #1 refused to wear the pressure reducing boots to the bilateral lower extremities. Observation on 03/17/25 at 11:30 A.M. revealed Resident #1 was resting in bed, watching television. There was a pair of pressure reducing green boots laying on the window seat in the room. Resident #1 did not have any pressure reducing devices on her bilateral lower extremities. Observation on 03/18/25 at 8:20 A.M. revealed Resident #1 was resting in bed eating the breakfast meal. The pressure reducing green boots were lying on the window seat in the same position as the day before. Observation on 03/18/25 at 2:40 P.M. revealed Resident #1 returned to her room with staff assisting in positioning Resident #1 in bed. The pressure reducing green boots continued be located on the window seat in the room. Observation on 03/19/25 at 7:10 A.M. revealed Resident #1 sleeping in bed with out any pressure reducing devices on the bilateral lower extremities. The pressure reducing green boots were lying on the seat of the high back chair located in her room. Interview on 03/18/25 at 2:42 P.M. with Certified Nursing Assistant (CNA) #375 revealed Resident #1 would refuse to wear the pressure reducing boots. The CNA's will report the refusal to the nurse who will document the refusal in the progress notes. Interview on 03/19/25 at 11:18 A.M. with Licensed Practical Nurse (LPN) #254 confirmed Resident #1 did not have the pressure reducing boots in place and the TAR dated 03/19/25 was marked as having the pressure reducing boots in place.

Based on observation, open and closed medical record review, resident, staff and Wound Care Certified Nurse Practitioner (WCCNP) interviews and review of facility policies, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention and treatment program to ensure residents' skin impairments were assessed, physician notification was made for treatment orders and treatment was initiated timely. Actual Harm occurred on 09/29/24 to Resident #54, who was at risk for developing pressure ulcers, when the facility identified the resident had impaired skin upon readmission from the hospital but failed to assess and describe the wound, failed to notify the physician for treatment orders and further failed to initiate any treatments until 10/11/24. Subsequently, on 10/14/24, the wound was described as a Stage III pressure ulcer (full-thickness loss of skin that extended to the subcutaneous tissue, but did not cross the fascia beneath it) on the sacral area and required excisional debridement. This affected three residents (#54, #82 and #71) of three residents reviewed for pressure ulcers. The facility census was 80. Findings include: 1. Record review for Resident #54 revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included rhabdomyolysis (breakdown of muscle tissue that released damaging protein into the blood), morbid severe obesity, saddle embolus (blood clot) of pulmonary artery and muscle weakness. Review of the nursing progress note dated 09/29/24 at 12:31 P.M., completed by Licensed Practical Nurse (LPN) #249, revealed Resident #54 arrived at the facility via emergency medical technician (EMT). Resident #54 was alert and oriented to person, place and time. Documentation included Resident #54 had a small open area to the left buttock. Wound nurse was notified at the time of the admission. The progress note provided no measurements or further description of the open area to Resident #54's left buttock or evidence of physician notification for treatment orders. Review of the Nursing Admission assessment dated [DATE] at 6:50 P.M., completed by LPN #249, revealed Resident #54 was admitted on [DATE] at 12:06 P.M. Resident #54 had an open area to the left buttocks. The document included no assessment of the wound, including measurements or further description of the wound, or physician notification for treatment orders. Review of the Braden Scale for Predicting Pressure Ulcers dated 09/30/24 at 1:19 A.M., completed by Registered Nurse (RN) #310, revealed Resident #54 was at mild risk for a pressure ulcer development. Review of the wound care note dated 09/30/24 at 7:45 A.M., completed by Wound Care Certified Nurse Practitioner (WCCNP) #320, revealed Resident #54 was seen for a right medial shin distal venous ulcer. Further review revealed no evidence the wound to Resident #54's left buttock was assessed or any treatments for the wound were ordered at this time. Additional review of Resident #54's medical record from 09/30/24 through 10/10/24 revealed no evidence the open area identified on 09/29/24 was further assessed or treatment initiated for the area. Review of the care plan, dated 10/03/24, revealed Resident #54 had potential for impaired skin integrity and pressure ulcer development related to morbid obesity and impaired mobility. Interventions included pressure redistribution mattress to the bed and refer to the facility wound nurse as needed. Review of the admission Minimum Data Set (MDS) assessment, dated 10/04/24, revealed Resident #54 was cognitively intact. Resident #54 had impairment to both sides of the lower extremities; used a wheelchair for mobility; was (staff) dependent for toileting, bed mobility and transfers; and required set up or clean up assistance with personal hygiene. Resident #54 was frequently incontinent of urine and always incontinent of bowel. The MDS indicated Resident #54 did not have a pressure ulcer, was at risk for pressure ulcers, and had one venous and arterial ulcer. Resident #54 had a pressure reducing device to the chair and bed. Review of the skin pressure ulcer wound note dated 10/11/24 at 3:00 A.M., completed by LPN #351, revealed Resident #54's gluteal cleft (the groove between the buttocks) was reddened and an order was added to apply cream every shift daily. Further review of the medical record revealed no evidence of further assessment of the area, including measurements and description, or physician notifications were made. Review of the Treatment Administration Record (TAR) for October 2024 revealed an order, with a start date of 10/12/24, was added for Triad Hydrophilic wound dress external paste, apply to left upper buttock topically every day shift. Review of the TAR confirmed the treatment was initiated 10/12/24. Review of the wound care note dated 10/14/24 at 9:16 A.M., completed by WCCNP #320, revealed nursing requested evaluation of a new, concerning area on the sacrum (the triangular bone at the base of the spine that connects the spine to the pelvis). The evaluation indicated Resident #54 had a full thickness Stage III pressure ulcer, measuring 1.1 centimeters (cm) in length by (x) 2.4 cm in width x 0.1 cm depth, and identified as a clustered wound. The wound bed was 70% granulation and 30 % slough. The evaluation further included the resident had the following contributing factors: resident was poorly compliant with offloading, incontinence and overall poor medical condition, making the presence of the wound unavoidable. Other factors contributing to the unavoidable wound included morbid obesity. As per the National Pressure Ulcer Advisory Panel (NPUAP) protocols, even though there is slough/eschar present, it does not obscure the extent of tissue loss. It is therefore acceptable to call this a stage III pressure wound with shallow granulation tissue with intervening slough. Excisional debridement was performed using a curette. The tissue debrided went down to subcutaneous tissue. Tissue removed included slough. Post debridement measurements were 1.1 cm. x 2.4 cm. x 0.2 cm. New orders were given to cleanse with normal saline (NS), apply silver alginate and bordered foam dressing every day and as needed. Interview on 10/15/24 at 3:10 P.M. with Resident #54 revealed she was aware of the wound on her sacral area. Resident #54 stated after her admission to the facility, she returned to the hospital due to a blood clot in her lungs. Resident #54 stated she had the wound when she returned from the hospital, but dressings/treatment just started this week. Resident #54 stated staff asked her if she was aware of the wound when they turned her and provided incontinence care, but nothing was done until recently. Resident #54 reached her hand back to the dressing on her buttock area and stated, It was the same wound the dressing is on now, it's the same one I came back from the hospital with, in the crack of my butt. Concurrent observation revealed Resident #54 did not have a low air loss (LAL) mattress on her bed. Interview on 10/15/24 at 3:42 P.M. with State tested Nursing Assistant (STNA) #279 revealed she frequently worked with Resident #54 and confirmed the wound currently being treated on the resident's sacrum was the same area as the wound she readmitted to the facility with from the hospital. STNA #279 further stated the wound was not covered with a dressing until recently. Interview on 10/15/24 at 3:44 P.M. with STNA #265 revealed Resident #54 had the wound (pointing to the crease of the buttocks) since she readmitted from the hospital. STNA #265 stated, I saw it many times while providing care. Interviews on 10/16/24 between 11:20 A.M. and 1:58 P.M. with LPN #257 revealed he was the facility's wound care nurse. LPN #257 confirmed Resident #54 did not have a LAL mattress and further stated LAL mattresses were usually provided for residents if they had a Stage III pressure ulcer or multiple Stage II pressure ulcers. LPN #257 revealed he did not provide a LAL mattress unless the WCCNP ordered one, even though facility policy indicated one would be appropriate for Resident #54. LPN #257 revealed the expectation was for nursing to assess and measure an identified skin impairment and notify the physician and administration. LPN #257 denied he was made aware of the wound on Resident #54's buttocks until 10/14/24 (15 days after the initial identification). Observation on 10/16/24 at 11:20 A.M. of wound care for Resident #54, provided by LPN #257 and LPN/Unit Manager (UM) #324 revealed the open wound was located inside the crease, on the left side, of the buttocks (sacral) area. A telephone interview on 10/16/24 at 2:02 P.M. with WCCNP #320 confirmed he consulted with Resident #54 for wound care needs. WCCNP #320 confirmed he assessed Resident #54's wound to the right medial shin on 09/30/24 but was not told of any other wounds at that time. WCCNP #320 revealed the first time he was made aware of the wound on Resident #54's buttock/sacral area was on 10/14/24 (15 days after identification). WCCNP #320 then stated his documentation on 10/14/24 that the wound was unavoidable was incorrect. WCCNP #320 further stated he only documented unavoidable if the resident had a pressure ulcer that developed in house and Resident #54 readmitted with the wound. WCCNP #320 stated he would correct his documentation. WCCNP #320 confirmed the wound should have been treated at the time it was discovered on 09/29/24 to prevent the wound from worsening. A telephone interview on 10/16/24 at 4:14 P.M. with LPN #249 revealed, when asked if the current wound being treated on Resident #54's buttocks/sacral area was the same wound she identified upon readmission, LPN #249 quickly stated, Yes. I don't know. I don't remember. I don't think I am going to be able to remember, that was two weeks ago. I am not going to be able to remember. LPN #249 revealed she notified LPN #257 of Resident #54's wound on 09/29/24 at 6:58 P.M. via text message and LPN #257 replied Ok thank you. LPN #249 verified she did not notify the physician of the open wound because she notified LPN #257. A follow-up interview on 10/17/24 at 11:23 A.M. with LPN #249, per request of UM #258, revealed she now recalled the location of the wound on Resident #54's buttock upon readmission from the hospital. LPN #249 stated she and STNA #279 completed a skin check for Resident #54 and the wound currently being treated was under the area she identified upon readmission. LPN #249 stated the area she observed was at the top of her butt, not the same area. LPN #249 pointed to the top of the buttock area, near the left hip, and stated it was right here. LPN #249 confirmed she did not measure the wound, notify the physician or get an order for treatment. LPN #249 stated she notified the wound care nurse, LPN #257, per protocol. A follow-up interview on 10/17/24 at 11:28 A.M. with STNA #279, per request of UM #258, confirmed she assisted LPN #249 with Resident #54's skin check when she returned from the hospital. STNA #279 stated, It's the same. She had that wound when she came back from the hospital. I saw it when she came back from the hospital, it's the same wound. It just got bigger and worse. I am not changing my mind, it's the same. Interview on 10/17/24 at 1:43 P.M. with UM #258 revealed if a wound was found on a resident, the nurse should chart the appearance of the wound, obtain measurements, notify the physician, get an order for treatment and notify the Director of Nursing (DON) and wound care nurse. UM #258 verified none of those were done for Resident #54 on 09/29/24, except notification to the wound care nurse. 2. Review of the closed medical record for Resident #82 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included cerebral infarction, hemiplegia and hemiparesis. Review of the care plan dated 10/02/23 revealed Resident #82 had potential for impaired skin integrity and pressure ulcer development related to impaired mobility, bladder incontinence and colostomy status. Interventions included following the facility's policy and protocols for prevention and treatment of skin breakdown. Review of the progress note dated 12/05/23 at 4:48 P.M., completed by Registered Nurse (RN) #311, revealed the nurse was made aware the resident's heels were red and squishy. Skin prep was placed on bilateral heels and floated on a pillow. Also noted was an open area to the buttocks. This area was cleansed with NS and a patch was placed. Further review of Resident #82's medical record revealed no evidence of what type of patch was placed on the open wound on the resident's buttocks. Additionally, there was no evidence the wound was assessed, including measurements and description of the wound, and no physician notification was made of the wound for treatment orders. Review of a physician note dated 12/06/23 at 12:14 P.M., completed by Certified Nurse Practitioner (CNP) #322, revealed no identification or documentation of an open wound to Resident #82's buttocks or treatment ordered for the wound. Review of the nursing note dated 12/06/23 at 3:23 P.M., completed by LPN #238, revealed the nurse was informed the resident had a sore to the coccyx area by the STNA, after giving the resident a bed bath. The STNA stated it has a dressing on it but it's coming off. The nurse went to the room to assess the area and noted a partially covered area to the coccyx, with blood noted. The area was cleansed with NS and patted dry. The area measured approximately 10.0 cm x 12.5 cm. Skin prep applied. Review of a physician order, dated 12/06/23 at 3:27 P.M. and discontinued on 12/07/23, revealed to cleanse sacral wound with NS, pat dry, do not wipe, apply xeroform and CDD (clean dry dressing) two times a day (BID) and as needed (PRN). Review of the TAR revealed the treatment was not initiated. Review of a physician order, dated 12/07/23 at 9:37 A.M., revealed to cleanse sacral wound with NS, pat dry, apply medi-honey and foam dressing every day shift and as needed for wound care. Review of the TAR revealed the treatment was not initiated until 12/08/23. Review of the Pressure Ulcer Wound Record, dated 12/11/23, revealed Resident #82's wound was first observed on 12/06/23. The wound was an unstageable pressure area to the left buttocks, measuring 9.9 cm x 13.6 cm x undetermined depth. The note indicated debridement of the wound was done to reduce bacterial load and promote healing. Review of the significant change MDS dated [DATE] revealed Resident #82 was severely cognitively impaired; had impairment to one side of the upper and lower extremities; required substantial /maximum (staff) assistance with toileting and personal hygiene; partial/moderate (staff) assistance with bed mobility; and was dependent for transfers and wheelchair mobility. Resident #82 was at risk for pressure ulcers and had one unstageable pressure ulcer that was not present upon admission. Interview on 10/17/24 at 4:08 P.M. with LPN #257 verified Resident #82's wound was initially identified in the medical record on 12/05/23, but not assessed, an no notification was made to the physician for treatment orders. LPN #257 further confirmed a treatment order entered on 12/06/23 was not initiated and the treatment order entered on 12/07/23 was not initiated until 12/08/23 (three days after the initial identification of the wound). LPN #257 stated the initial assessment should have included measurements, a description of the wound appearance and any drainage. In addition to the physician, LPN #257 stated nursing was to inform him, as the wound care nurse, and the DON. LPN #257 stated, They don't always notify me either. I will hear on wound day, Mondays, about oh so and so has a wound. They don't always tell me. LPN #257 revealed on 01/01/24, he put out an in-service for nurses and stated, I put the in-service out because I was not getting notified, and neither was the doctor, of new wound issues so residents weren't getting treatments. LPN #257 revealed he did not recall why Resident #82's treatment order was not obtained or implemented timely. Interview 10/18/24 at 3:49 P.M. with UM #258 and LPN #312 confirmed the facility had no evidence Resident #82 received treatment for the wound identified on 12/05/23 until 12/08/23. Review of the nursing in-service, dated 01/01/24, revealed when the nurse is notified of a new wound on a resident and the wound care nurse is not available, the nurse must get an order for the treatment and do the treatment. Document where the wound is and notify the wound care nurse. Even on weekends, notify the wound care nurse of wounds and, if not sure, ask what treatment should be done. 3. Record review for Resident #71 revealed an admitted [DATE]. Diagnoses included Hodgkin lymphoma, severe protein calorie malnutrition, diabetes mellitus and anorexia. Resident #71 received Hospice services. Review of the Admission Assessment, dated 09/12/24 at 6:42 P.M., completed by LPN #239, revealed Resident #71 had no wounds noted to the sacral/coccyx area. Review of the admission MDS, dated [DATE], revealed Resident #71 was cognitively intact, occasionally incontinent of urine and always continent of bowel. Resident #71 was at risk for pressure ulcers, had no unhealed pressure ulcers and a pressure reducing device was in the chair and bed. Review of the care plan, dated 09/20/24, revealed Resident #71 had potential for impaired skin integrity and pressure ulcer development relate to severe protein calorie malnutrition, underweight and decreased endurance and mobility. Interventions included follow facility policies/protocols for the prevention/treatment of skin breakdown and refer to the facility wound nurse as needed. Review of the nursing progress note dated 09/29/24 at 6:10 P.M., completed by LPN #256, revealed the nurse was alerted to the resident complaining of pain on the bottom. The note further stated an open area was observed on the resident's coccyx measuring 2.5 cm x 1 cm, without depth. The wound bed was pink and pain with palpation. The note stated the resident felt pain in his bottom during transportation to an appointment and he felt the pain got worse and worse with every bump. Review of Resident #71's physician orders revealed an order dated 09/30/24 to cleanse sacrum wound with NS, pat dry, apply medi-honey and calcium alginate then cover with border foam every day shift Monday, Wednesday and Friday for wound care. Review of the wound care note dated 09/30/24 at 7:00 A.M., completed by WCCNP #320, revealed Resident #71 had a full-thickness Stage III sacral wound that measured 1.7 cm x 0.7 cm x 0.1 cm. The wound base was 60% granulation, 20% slough and 20% adipose with scant serosanguinous exudate. Additionally, the note stated even though there is slough/eschar present, it does not obscure the extent of tissue loss. It is therefore acceptable to call this a stage III pressure wound. Sharp/excisional debridement was performed using a curette. Review of the wound care note dated 10/14/24 at 9:45 A.M., completed by WCCNP #320, revealed sharp/excisional debridement was performed using a curette to remove slough. Review of the Nutritional assessment dated [DATE], documented by Registered Dietitian (RD) #323, revealed Resident #71 was underweight. Resident #71's skin was documented as intact. There was no evidence Resident #71 had been reassessed by RD #323 following the identification of the pressure ulcer on 09/29/24. Observation on 10/16/24 at 10:45 A.M. of Resident #71's room revealed the resident did not have a LAL mattress on his bed. Interview on 10/16/24 at 11:20 A.M. with LPN #257 confirmed Resident #71 did not have a LAL mattress as an intervention to help aid the treatment and/or prevention of the resident's pressure ulcer, even though facility policy indicated one would be appropriate for the resident due to having a stage III pressure ulcer. Interview on 10/18/24 at 10:13 A.M. with RD #323 revealed she just copied and pasted information from Resident #71's previous nutritional assessment into the assessment dated [DATE]. RD #323 stated she was aware Resident #71 had a pressure ulcer, even though the assessment indicated the resident's skin was intact. RD #323 went on to state she had not locked the assessment yet; it was not completed, and she would not have done anything different to treat Resident #71's pressure ulcer. Interview on 10/18/24 at 11:13 A.M. with the Administrator revealed he would have expected the Dietitian to assess Resident #71 to determine if interventions were needed at the time the pressure ulcer was first identified. Review of the facility policy titled Skin Measurement and Assessment, revised August 2022, revealed upon admission or upon identification of a skin condition, the licensed nurse will document the area noted. If a resident develops or is admitted with a wound, an assessment is performed, and the wound is measured and assessed for the wound characteristics. During assessment of the wound, documentation will address the following: the type of wound, the stage of the wound, a description of the wound's characteristics, and a description of dressings and treatment. The physician, RD, Wound Consultant, and responsible party will be notified of the new skin development and an order for the treatment will be obtained. Dressing changes/treatment are performed by the licensed nurse as per the physician's order and documented on the TAR. Review of the facility policy titled, Pressure Ulcer Prevention and Intervention, revised January 2023, revealed to notify the physician and responsible party of any changes in skin condition. All the mattresses provided to each resident are pressure-redistributing. Additional pressure support may be implemented per resident assessment as needed. Stage three and four and unstageable pressure ulcers included evaluation for specialty mattress or bed, alternating air mattress, low air loss. Document all findings in the medical record. Review of the facility policy titled, Nutrition and Wound Management, revised May 2023, revealed residents with pressure wounds will be assessed for optimal nutrition intervention. Nursing notifies dietitian/designee as soon as a pressure wound of any stage is identified. Nutrition assessment to determine interventions included protein and calories consumed as necessary, usual fluid intake, calorie, protein and fluid needs, use of supplements, tolerance and acceptance, medication review, vitamin and mineral use and labs per orders. Recommendations are made to improve intake and promote healing. This deficiency represents noncompliance investigated under Complaint Numbers OH00158050 and OH00157487.

Based on medical record review, staff interview and review of facility policy, the facility failed to implement treatment for a venous wound timely. This affected one resident (#56) of three residents reviewed for wounds. The facility census was 80. Findings include: Record review for Resident #56 revealed an admitted [DATE]. Diagnoses included intervertebral disc degeneration lumbarsacral and peripheral vascular disease (PVD). Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/12/24, revealed Resident #56 was moderately cognitively impaired. Resident #56 had no impairment to the upper extremities and had impairment to both sides of the lower extremities. Resident #56 required substantial/maximum (staff) assistance for bed mobility, and partial/ moderate assistants for personal hygiene. Review of the skin/wound note dated 10/30/23 at 2:36 P.M., completed by Licensed Practical Nurse (LPN) #257 revealed Resident #56 was seen by wound care today. Resident #56 had a wound related to venous - chronic osteomyelitis (bone infection). right heel -planter surface. Further review revealed to apply adaptic, abdominal pad (ABD) and secure with kerlix daily and as needed (PRN). Review of the skin: non pressure ulcer area note dated 10/31/23 at 2:10 P.M., completed by LPN #257, revealed Resident #56 had a venous stasis ulcer to the right heel, first observed on 10/30/23. The area measured 3.1 centimeters (cm) by (x) 2.6 cm with undetermined depth. The wound bed was 60 % granulation and 40% scabbing The new treatment order included Adaptic/ABD/Kerlix every Monday, Wednesday and Friday. Review of a progress note dated 11/07/23 at 9:27 A.M., completed by Registered Nurse (RN) #311, revealed to cleanse Resident #56's right heel with normal saline (NS), pat dry, apply xeroform and wrap with kerlix on Monday, Wednesday, Friday and PRN. Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) for October 2023 revealed there was no treatment documented to Resident #56's right heel on either record. Review of the TAR for November 2023 revealed an order with a start date of 11/07/24 to cleanse Resident #56's right heel with NS, pat dry, apply xeroform and wrap with kerlix on Monday, Wednesday, Friday and PRN every day shift for wound care. Further review revealed the treatment was not initiated until 11/08/23. Interview on 10/18/24 at 5:19 P.M. with LPN #257 confirmed Resident #56 was found to have a wound first observed on 10/30/24 to the right heel. LPN #257 confirmed he received orders on 10/30/23 for care and treatment of the wound but the order was not entered into the resident's electronic medical records until 11/06/23 for the nurses to see the order and administer the treatment. LPN #257 verified care for Resident #56's right heel wound was not initiated until 11/08/23 until 11/06/23. put into the electronic medical record (EMR) for the nurses to see the order and administer the treatment until 11/06/23 to start 11/07/23 then the wound care was not initiated until 11/08/23 (nine days after it was identified). LPN #257 revealed he forgot to put the order in the EMR. Review of the facility policy titled Skin Measurement and Assessment, revised August 2022, revealed upon admission or upon identification of a skin condition, the licensed nurse will document the area noted. The physician, Registered Dietitian, Wound Consultant, and responsible party will be notified of the new skin development and an order for the treatment will be obtained. Dressing changes/treatment are performed by the licensed nurse as per the physicians order and documented on the TAR. This deficiency represents noncompliance investigated under Complaint Number OH00157487.

Based on medical record review, staff interview and policy review, the facility failed to notify the physician or nurse practitioner regarding significant weight loss and ensure the dietitian's recommendations for weight loss were addressed. This affected two (Residents #63 and #66) of three residents (#57, #63 and #66) who were identified as having an unplanned weight loss. The facility census was 79. Findings include: 1. Record review revealed Resident #63 was admitted on [DATE] with diagnoses that included but were not limited to displaced intertrochanteric fracture of left femur, anxiety disorder, and dementia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #63 had moderately impaired cognition and was independent for eating. Review of Resident #63's recorded weights revealed the following: 05/09/24 - 96.0 pounds (lbs). which was a 9.09 percent (%) weight change in less than 30 days and 18.64 % change over 180 days. 04/03/24 - 105.6 lbs. 03/21/24 - 107 lbs. which was a 6.14 % weight change in less than 30 days. 03/12/24 - 114.5 lbs. 11/21/23 - 118.0 lbs. Review of the nutritional documentation dated 02/11/24 and 02/23/24 revealed Registered Dietitian (RD) #206 made recommendations for an appetite stimulant. Further review of the medical record and review of physician's progress notes revealed that Resident #63's significant weight loss was not evaluated or addressed by the physician or nurse practitioner and the appetite stimulant that Registered Dietitian #206 recommended was not addressed. Interview on 05/23/24 at 11:21 A.M. with Registered Dietitian (RD) #206 revealed she recommended an appetite stimulant on 02/11/24 and 02/23/24 for Resident #63 but nursing did not communicate her recommendations to the physician or nurse practitioner. RD #206 stated she thought nursing informed the physician or nurse practitioner about weight loss. Observation of the lunch meal service on 05/23/24 at 12:10 P.M. revealed Resident #63 was receiving cues to eat from staff. Interview on 05/23/24 at 12:44 P.M. with the Director of Nursing (DON) revealed that she spoke to Nurse Practitioner (NP) #209 and NP#209 stated she was not aware of any weight loss for Resident #63. The DON stated that she thought RD #206 notified the doctor and RD #206 thought nursing notified the doctor. Review of the facility policy with a revision date of 12/2022 revealed there should be a documented clinical basis for any conclusion that nutritional status or significant weight change were unlikely to stabilize or improve (e.g. Physician's documentation as to why the weight loss was medically avoidable). 2. Record review revealed Resident #66 was admitted on [DATE] with diagnoses that included but were not limited to morbid obesity, diabetes mellitus, and major depressive disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #66 had moderately impaired cognition and was independent for eating. Review of Resident #66's recorded weights revealed the following. 05/09/24 - 293.0 pounds (lbs.) which was a 16.29 percent (%) weight change in less than 30 days. 04/03/24 - 331.3 lbs. Review of the nutritional documentation revealed Registered Dietitian (RD) #206 was aware of and monitoring Resident #66's weight loss. Further review of the medical record and review of physician's progress notes revealed that Resident #66's significant weight loss was not evaluated or addressed by the physician or nurse practitioner. Interview on 05/23/24 at 11:21 A.M. with Registered Dietitian (RD) #206 revealed Resident #66 had a significant weight loss and RD #206 had recommended that the former dietary manager update Resident #66's food preferences because Resident #66 ate a big breakfast and then picked the rest of the day. RD #206 stated that she thought nursing informed the physician or nurse practitioner about weight loss. Interview on 05/23/24 at 12:44 P.M. with Director of Nursing (DON) revealed that she spoke to Nurse Practitioner (NP) #209 and NP#209 stated that she was not aware of any weight loss for Resident #66. The DON stated that she thought RD #206 notified the doctor and RD #206 thought nursing notified the doctor. Review of the facility policy with a revision date of 12/2022 revealed that there should be a documented clinical basis for any conclusion that nutritional status or significant weight change were unlikely to stabilize or improve (e.g. Physician's documentation as to why the weight loss was medically avoidable. This deficiency represents non-compliance investigated under Complaint Number OH00153099.

Based on observation, interview with staff, and review of facility policy, the facility failed to ensure the kitchen staff wore beard nets and hair nets appropriately to prevent contamination of food. This affected all 76 residents in the facility who ate meals from the kitchen except Resident #37 who the facility identified as receiving nothing by mouth (NPO). The facility census was 77. Findings included: Observation during meal preparation on 03/12/24 at 10:40 A.M. revealed Cook #400 and Dietary Aide (DA) #401 were not wearing a beard net on their beard while preparing food. Also, Dietary Aide #402 did not have her front bangs under her hair net while preparing drinks. On 03/12/24 at 11:00 A.M. an interview with Dietary Mangers # 105 confirmed Cook #400, DA #401 and DA #402 did not have on beard nets or have all hair appropriately covered while preparing food in the kitchen. Review of the undated facility policy titled, Employee Sanitation Practices, revealed all employees would wear hair restraints including hairnets, hat and/or beard covers to prevent hair from contacting exposed food. This deficiency represents non-compliance investigated under Complaint Number OH00151601.