Every finding on record at Ayden Healthcare of Wauseon

Based on observation, staff interview, and review of facility policy the facility failed to ensure residents were treated with dignity and respect when a facility staff used profanity. This affected six (#7, #14, #16, #26, #41, and #43) of six residents identified to be in the common area. The facility census was 47.Findings include:Observation on 05/27/26 at 6:28 A.M. revealed Certified Nursing Assistant (CNA) #335 at the nurses' station visually reviewing a piece of paper. CNA #335 stated in a loud tone, I get that she is new, but you are not going to [explicative] me over. Further observation revealed Residents #7, #14, #16, #26, #41, and #43 were in the common area located approximately 10 feet from the nurses' station and within hearing distance. Interview on 05/27/26 at 6:30 A.M. with CNA #335 verified using profanity in front of the residents. Review of the facility provided document titled, Resident Rights, dated 10/03/23, revealed resident's had the right to be treated at all times with courtesy, respect, and full recognition of dignity and individuality. This was an incidental finding discovered during the complaint investigation.

Based on medical record review, observation, resident interview, staff interview and review of facility policy, the facility failed to ensure medication self-administration evaluations were completed. This affected one (#19) of one resident reviewed for medication self-administration. The facility census was 47. Findings include:Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnoses included hypocalcemia, Type II diabetes mellitus, anxiety disorder, depression, hypothyroidism, adjustment disorder with mixed anxiety and depressed mood, paranoid personality disorder, malignant neoplasm of thyroid gland, and mild neurocognitive disorder due to known physiological condition without behavioral disturbance. Review of the Minimum Data Set (MDS) assessment, dated 05/08/26, revealed the resident was cognitively intact. Further review of Resident #19's medical record revealed no evidence a self-administration assessment was completed for the resident to safely self-administer medications or a physician's order was in place for the self-administration of medications.Review of the Medication Administration Review (MAR) for May 2026 revealed Resident #19 received the following morning medications on 05/27/26: cranberry (herbal) oral tablet; cyanocobalamin (vitamin) tablet 500 microgram (mcg); desvenlafaxine succinate ER (antidepressant) oral tablet extended release 24 hour 100 milligram (mg); folic acid (vitamin) tablet one mg; Jardiance (antidiabetic) 25 mg; levothyroxine sodium (thyroid product) oral tablet 200 mcg; levothyroxine sodium oral tablet 50 mcg; montelukast sodium oral tablet 10 mg; prempro (estrogen) oral tablet 0.3-1.5 mg; rosuvastatin calcium (lipid lowering agent) oral tablet 10 mg; vitamin A (supplement) oral tablet 3000 mcg; zinc (supplement) 50 mg; buspirone (anti-anxiety) tablet five mg; calcitriol capsule (supplement) 0.5 mcg two tablets; doxycycline hyclate (tetracycline) 100 mg; calcium acetate tablet 667 mg give three tablets; calcium citrate 1200 mg; renvela 800 mg; Tylenol 325 mg give two tablets; and magnesium oxide (supplement) 400 mg. Observation on 05/27/26 at 9:45 A.M. revealed a medication cup, approximately half full of medications, was on Resident #19's bedside table. Nursing staff were not present in the room. Interview on 05/27/26 at 9:49 A.M. with Therapy #365 verified Resident #19 had unattended medications at bedside. Interview on 05/27/26 at 9:50 A.M. with Resident #19 revealed the nurses left her medications at bedside because she liked to spread them out. Interview on 05/27/26 at 10:06 A.M. with Licensed Practical Nurse (LPN) #360 verified leaving Resident #19's medications unattended at the bedside. Interview on 05/27/26 10:51 A.M. with the Director of Nursing (DON) verified Resident #19 was not assessed to self-administer medications and did not have a physician's order in place to self-administer mediations. The DON stated Resident #19 would be appropriate to self-administer medication. Review of the facility policy titled, Administering Medication, revised December 2012, revealed resident may self-administer their own medications only if the attending physician, in conjunction with the Interdisciplinary Care Planning Team, determined that they had the decision-making capacity to do so safely. This deficiency was an incidental finding discovered during the complaint investigation.

Based on medical record review, observation, resident interview, staff interview and review of facility policy, the facility failed to ensure resident's choices were honored. This affected one (#19) of three residents reviewed for choices. The facility census was 47.Findings include:Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnoses included hypocalcemia, Type II diabetes mellitus, anxiety disorder, depression, hypothyroidism, adjustment disorder with mixed anxiety and depressed mood, paranoid personality disorder, malignant neoplasm of thyroid gland, and mild neurocognitive disorder due to known physiological condition without behavioral disturbance. Review of the Minimum Data Set (MDS) assessment, dated 05/08/26, revealed the resident was cognitively intact. Review of Resident #19's written documentation, dated 3/30/26, revealed the staff pulled her curtain open and used the roommate's trash can to prop open the door. Resident #19 documented propping the door open let in a great amount of light and the nighttime staff were not not letting her sleep. Review of Resident #19's written documentation, dated 04/08/26, revealed nighttime staff used the trash can to prop the door open, preventing the resident from sleeping. The documentation also revealed Resident #19 wore ear plugs, with no success, to aid in her sleep. Review of Resident #19's written documentation revealed on 4/11/26, the resident reported she did not sleep well and had sleep disorders. The resident asked the facility staff to shut the door tight and they did not respect her by leaving it open. Certified Nursing Assistant (CNA) #355 opened the door using the trash can to prop it open and left the light on. Resident #19 documented her eyes hurt from lack of sleep. Review of Resident #19's written documentation, undated, revealed the nighttime facility staff were noisy and would not shut the door or keep it closed. Interview on 05/26/26 at 8:59 A.M. with Resident #19 revealed she had severe insomnia and slept better when it was dark. Resident #19 stated the aides would not allow the door to stay closed at night and they propped the door with her roommate's trash can. Resident #19 stated she asked for the door to stay closed and closed it herself, only for the door to be opened and propped shortly after. Observation on 05/27/26 at 6:05 A.M. revealed Resident #19's door was propped open with a garbage can. Interview on 05/27/26 at 6:20 A.M. with CNA #355 verified Resident #19 did not like the door to her open. CNA #355 stated for the past week she had propped the door open due to the roommate's condition. Interview on 05/27/26 at 6:23 A.M. with Registered Nurse (RN) #398 verified Resident #19 had complained about not sleeping well due to the room door being propped open. Interview on 05/28/26 at 8:45 A.M. with Resident #19 verified the room door had been propped open for months as indicated in the resident's documentation. Review of the facility provided document titled, Resident Rights, dated 10/03/23, revealed residents had the right upon reasonable request to have room doors closed and to have them not opened without knocking, except in the case of emergency or unless not medically advisable as documented in the resident's medical record by the attending physician. This deficiency represents non-compliance investigated under Complaint Number 2991972.

Based on review of written staff statements, staff interviews and review of facility policy, the facility failed to ensure residents were free from abuse. This affected one (#16) of four residents reviewed for abuse. The facility census was 47.Findings include:Review of the medical record for Resident #16 revealed an admission date of 04/03/26 with diagnoses of dementia, adjustment disorder, and fracture of the sacrum.Review of the Brief Interview for Mental Status (BIMS) dated 05/19/26 revealed Resident #16 had significant cognitive impairment.Interview on 05/27/26 10:51 A.M. with the Director of Nursing (DON) and the Administrator revealed a report of an allegation of abuse that occurred in the afternoon of 05/26/26 between Licensed Practical Nurse (LPN) #330 and Resident #16. The Administrator stated LPN #300 and Registered Nurse (RN) #315 had knowledge of the incident on the date of occurrence and did not report it at the time of the incident. LPN #300 reported the allegation this morning. Interview on 05/27/26 at 11:30 A.M. with LPN #300 revealed she walked down the north hall when LPN #330 reported to her that Resident #16 was attempting to hit her (LPN #330) and LPN #330 stated she grabbed the wrists of Resident #16 and told the resident, If you hit me, I will hit you back and call the police.Interview on 05/27/26 at 12:37 P.M. with RN #398 revealed she witnessed the incident between Resident #16 and LPN #330 on 05/26/26. RN #398 stated she was attempting to help redirect Resident #16 and was behind her trying to remove Resident #16 from entering the wrong room by maneuvering the wheelchair backwards. RN #398 stated LPN #330 was also present. Resident #16 hit at LPN #330 and LPN #330 grabbed the resident's wrists, pinned them to the armrests on the wheelchair and stated, If your going to hit, I will hit you back and call the cops.Interview on 05/27/26 at 12:47 P.M. with RN #315 revealed she spoke with LPN #330 and she was informed by the nurse that Resident #16 was on the unit attempting to go into a male resident's room. LPN #330 tried to redirect the resident when Resident #16 became combative and LPN #330 reported to RN #315 that she grabbed Resident #16's hands, pinned them to the wheelchair arms and told the resident, If you hit me, I will hit you back and call the police.A telephone interview on 05/27/26 at 1:32 P.M with LPN #330 revealed Resident #16 was trying to enter a male resident's room and when she tried to redirect her, the resident became combative. LPN #330 further stated she grabbed Resident #16's wrists and pinned them to the wheelchair armrests. LPN #330 denied telling Resident #16 that she would hit her back or call the police. Review of the written statement authored by LPN #300 revealed on 05/26/27 she was told by LPN #330 that Resident #16 had been hitting her and LPN #330 held both hands down and told Resident #16, If you hit me, I will hit you back and call the police.Review of the written statement dated 05/27/26 and authored by RN #315 revealed she spoke with LPN #330 on 05/26/26 and LPN #330 reported Resident #16 was attempting to be redirected form entering a male resident's room and the resident became combative. LPN #330 further reported to RN #315 that she grabbed Resident #16 by both wrists, held her arms on the armrests of the resident's wheelchair and stated to Resident #16, If you hit me, I'll hit you back and call the police. Another staff member was able to redirect Resident #16 at that time.Review of the transcribed telephone interview with LPN #330, dated 05/27/26 and completed by the Administrator and DON, revealed LPN #330 stated Resident #16 tried to hit her on her side so she grabbed both of her arms and held them to the arms of her wheelchair. LPN #330 stated, I told her do not hit me or I will call the cops. Further review revealed LPN #330 stated that .nurses are abused everyday and i do not tolerate that. When attempting to explain how her aggressive response may be perceived, LPN #330 cut the Administrator off.Review of the written statement from Human Resource Director (HRD) #305, dated 05/28/26, revealed she observed LPN #330 holding Resident #16's hands down onto her wheelchair and talking very firmly to the resident.Review of the witness statement from RN #398, obtained via telephone interview on 05/27/26, revealed Resident #16 attempted to hit LPN #330. LPN #330 then grabbed Resident #16's wrists and put them on the armrests and the nurses hands were on the armrests. RN #398 then stated LPN #330 stated to Resident #16, You are not going to hit or I will hit you back and then call the cops.Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated October 2022, revealed residents had the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidations, or punishment resulting in physical harm, pain, or mental anguish. An alleged violation was a situation or occurrence that was observed or reported by staff or resident.This deficiency represents non-compliance investigated under Complaint Number 2807211.

Based on review of written staff statements, staff interview and review of the facility policy, the facility failed to ensure staff reported allegations of abuse timely. This affected one (#16) of four residents reviewed for abuse. The facility census was 47. Findings include:Review of the medical record for Resident #16 revealed an admission date of 04/03/26 with diagnoses of dementia, adjustment disorder, and fracture of the sacrum.Interview on 05/27/26 10:51 A.M. with the Director of Nursing (DON) and the Administrator revealed a report of an allegation of abuse that occurred in the afternoon of 05/26/26 between Licensed Practical Nurse (LPN) #330 and Resident #16. The Administrator stated LPN #300 and Registered Nurse (RN) #315 had knowledge of the incident on the date of occurrence and did not report it at the time of the incident. LPN #300 reported the allegation this morning. Interview on 05/27/26 at 11:30 A.M. with LPN #300 revealed she walked down the north hall when LPN #330 reported to her that Resident #16 was attempting to hit her (LPN #330) and LPN #330 stated she grabbed the wrists of Resident #16 and told the resident, If you hit me, I will hit you back and call the police. LPN #300 verified she did not report this to anyone in management following the conversation with LPN #330 on 05/26/26. She stated that following a conversation later in the afternoon with a State Surveyor, she got to thinking and decided to report the incident this morning (05/27/26) when she got to work.Interview on 05/27/26 at 12:47 P.M. with RN #315 revealed she spoke with LPN #330 on 05/26/26 in the afternoon and learned from LPN #330 that she was involved in a situation with Resident #16. LPN #330 reported to RN #315 that Resident #16 became combative. LPN #330 stated to RN #315 that she (LPN #330) grabbed the wrists of Resident #16 and pinned them to the arms of the wheelchair and told the resident, If you hit me, I will hit you back and call the police. RN #315 stated she was enroute to report the incident to the DON and Administrator and got distracted and forgot to follow through.Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated October 2022, revealed residents had the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. Facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH) in accordance with this policy. All incidents and allegations of abuse, neglect, exploitation, mistreatment, and misappropriation must be reported immediately to the Administrator or designee. The Administrator/designee should be notified by informing him/her in person, calling via telephone, or sending an email or text message. The Administrator/designee would notify ODH immediately, but not less than two hours after the allegation was made or the serious bodily injury is identified.This was an incidental finding discovered during the complaint investigation.

Based on observation, medical record review, resident and staff interview, review of the menu, review of the menu spreadsheet, review of food product information, and review of facility policies, the facility failed to ensure food was served per the facility menu and spreadsheets. This directly affected one (#23) resident who was ordered a mechanical soft diet, directly affected one (#33) resident who received a pureed diet, and had the potential to affect all 45 residents residing in the facility who received food from the facility. The census was 45. Findings include: 1. Review of the medical record for Resident #23 revealed an admitted [DATE] with diagnoses of type II diabetes mellitus and gastroesophageal reflux disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had intact cognition and was not on a therapeutic diet. Review of a physician order dated 01/16/23 revealed Resident #23 received a regular diet with double protein at breakfast. Observations during breakfast meal service on 08/20/24 beginning at 7:24 A.M. revealed [NAME] #312 was plating meals for breakfast. Observation on 08/20/24 at 7:31 A.M. revealed [NAME] #312 plated Resident #23's breakfast. Observation of the resident's meal ticket revealed he was to receive double protein portions. Further observation revealed [NAME] #312 plated one scoop of eggs, the regular standard portion. Interview on 08/20/24 at 7:34 A.M. with [NAME] #312 confirmed she did not put two servings of eggs on Resident #23's plate because Resident #23 received yogurt as his second portion of protein. Interview and observation on 08/20/24 at 11:59 A.M. with Registered Dietitian (RD) #542 revealed the yogurt provided to Resident #23 as a second protein portion contained three grams (g) of protein. Interview on 08/20/24 at 4:03 P.M. with RD #542 revealed the standard portion of eggs, two ounces, provided 14 g of protein and stated a double portion of protein should provide a total of 28 g protein. RD #542 confirmed Resident #23 received only 17 g protein with the single serving of eggs and the yogurt, and confirmed Resident #23 did not receive the additional 11 g protein he should have per physician order. 2. Review of the weekly menu revealed the regular meal for lunch on 08/20/24 was meatballs and spaghetti with sauce, California blend vegetables, a breadstick, a peanut butter cookie, milk, and coffee or hot tea. Review of the menu spreadsheet for lunch on 08/20/24 revealed a regular texture diet would receive three meatballs and one-half (1/2) cup of pasta with sauce. Further review revealed residents on a mechanical soft (ground meat) diet would receive four ounces of meat and 1/2 cup of pasta with sauce. Interview on 08/19/24 at 9:33 A.M. with Resident #30 revealed he thought meal portion sizes were too small. Interview on 08/20/24 at approximately 11:20 A.M. with [NAME] #312 revealed two of the steam wells in her steam table were broken; therefore, she mixed the spaghetti noodles, sauce, and meatballs together into one pan. [NAME] #312 stated she would normally keep the spaghetti noodles and meatballs in separate pans. Observations during meal service on 08/20/24 beginning at approximately 11:30 A.M. revealed [NAME] #312 plating meals. [NAME] #312 was observed to use a four-ounce ladle (1/2 cup) to scoop two meatballs and noodles with sauce out of the pan. [NAME] #312 pressed the contents of the scoop tight against the pan to ensure she provided the total 1/2 cup. Additional observation during meal service on 08/20/24 beginning at approximately 11:30 A.M. revealed [NAME] #312 using a two-ounce scoop to portion ground meatballs for residents on a mechanical soft diet. Interview on 08/20/24 at 11:59 A.M. with [NAME] #312 confirmed she used a two-ounce scoop for the ground meatballs and provided only one scoop for residents on a mechanical soft diet, unless they had an order for double protein, in which case she would use two scoops of ground meatballs. Interview on 08/20/24 at 12:21 P.M. with [NAME] #312 confirmed she scooped two meatballs and noodles together in the 1/2 cup scoop for residents on a regular diet. Interview on 08/20/24 at approximately 1:15 P.M. with Resident #44 revealed the noon meal tasted good and she wished the portion size was larger. Interview on 08/20/24 at 4:03 P.M. with the DM #540 and concurrent review of the menu spreadsheet confirmed residents on a regular diet did not receive the correct portion of spaghetti noodles due to [NAME] #312 using the 1/2 cup scoop to portion the meatballs together with the spaghetti noodles. Further interview confirmed residents on a mechanical soft diet received two ounces of protein rather than the four ounces defined on the spreadsheet. Interview on 08/21/24 at approximately 3:00 P.M. with DM #540, along with review of meatball product information, revealed the meatballs served were two-ounce meatballs rather than the one-ounce meatballs defined in the recipe. Therefore, residents on a regular diet received two meatballs rather than three as specified in the menu. Additional review of the meatball product information and spreadsheet revealed the substituted meatballs were nutritionally equivalent. Interview on 08/21/24 at approximately 5:00 P.M. with DM #540 confirmed Resident #19 had a diet order for ground meat and would have received ground meatballs and was therefore affected by the undersized portion of protein provided during the noon meal on 08/20/24. 3. Review of the medical record for Resident #33 revealed an admitted [DATE] with diagnosis of dysphagia (swallowing difficulty). Resident #33 was under the care of hospice. Review of the quarterly MDS assessment dated [DATE] revealed Resident #33 had impaired cognition and required supervision or touching assistance for eating. Review of a physician order dated 08/06/24 revealed Resident #33 received a regular diet with pureed textures and thin liquids. Review of the menu spreadsheet for lunch on 08/20/24 revealed residents on a pureed diet would receive pureed meat, pureed spaghetti with sauce, pureed vegetables, pureed breadstick, and a pureed dessert. Observation during meal service 08/20/24 at 12:13 P.M. revealed [NAME] #312 plating Resident #33's pureed meal. Observation revealed [NAME] #312 placed noodles and vegetables on the plate. Observation on 08/20/24 at 12:40 P.M. revealed Resident #33 received her tray with three bowls contained pureed food, one of which was pudding. Interview on 08/20/24 at 12:41 P.M. with DM #540 and concurrent observation of Resident #33's delivered meal confirmed Resident #33 received only vegetables and noodles and did not receive the pureed meatballs. Interview on 08/20/24 at approximately 12:42 P.M. with [NAME] #312 and concurrent observation of Resident #33's delivered meal confirmed Resident #33 did not receive a pureed breadstick with her meal. [NAME] #312 further confirmed she did not puree the breadstick for Resident #33's meal. Review of the policy titled, Portion Control, updated 03/07/21, revealed individuals will receive the appropriate portions of food as outlined on the menu spreadsheets. Review of the policy titled, Food and Nutrition Services, dated 10/2017, revealed each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Based on observation, staff and resident interviews, review of a test tray, and review of the facility policy, the facility failed to ensure meals were palatable, delivered at the proper temperature, and had an attractive appearance. This had the potential to affect all 45 residents in the facility. The census was 45. Findings include: 1. Interview on 08/19/24 at 9:06 A.M., with Resident #5 revealed the food the facility served was usually cold. Interview on 08/19/24 at 9:19 A.M., with Resident #36 revealed the food was always cold. Interview on 08/19/24 at 9:22 A.M., Resident #10 stated the food was sub-par lately. Resident #10 stated the plates and food were cold. Interview on 08/19/24 at 11:16 A.M., Resident #29 revealed food which should be hot was usually served cold. Observation prior to meal service on 08/20/24 at 7:24 A.M. revealed [NAME] #312 taking food temperatures. The temperature of the scrambled eggs was 175 degrees Fahrenheit (F) and the temperature of the French toast was 169 degrees F. Observation during meal service on 08/20/24 at 7:41 A.M. revealed a test tray was plated. Further observation revealed the tray was placed on the tray cart at 7:42 A.M., and the cart left the kitchen at 7:43 A.M. Observation revealed the first meal tray was passed to residents at 7:44 A.M. Continued observation revealed staff passing meal trays until 7:52 A.M. Further observation revealed the test tray was removed from the cart at 7:52 A.M. and carried to the conference room by Dietary Manager (DM) #540. Observation on 08/20/24 beginning at 7:52 A.M. of a meal test tray with DM #540 revealed the eggs were 100 degrees F and the French toast was 85 degrees F. The eggs and French toast were not palatable to taste and temperature. Interview on 08/20/24 at 7:57 A.M., DM #540 agreed the French toast and eggs were not warm enough and revealed she was going to try and warm the plate warmers (a device that, when heated, maintains the temperature of the food on the plate placed in it) in the dishwasher before plating the food to help hold the food temperatures. DM #540 stated the facility did not have a machine to warm the plate warmers. Interview on 08/20/24 at 8:06 A.M., with Resident #5 revealed the eggs were cold again that morning. Interview on 08/20/24 at 8:08 A.M., with Resident #4 revealed her breakfast food was cold that morning. Interview on 08/20/24 at 8:11 A.M., with Resident #23 revealed the eggs were cold that morning. Interview on 08/20/24 at 8:29 A.M., with Resident #36 revealed her breakfast was cold that morning. Interview on 08/20/24 at 10:42 A.M., Resident #10 stated his eggs were cold that morning. 2. Observation on 08/20/24 at 12:40 P.M. revealed Resident #33 received a pureed meal of noodles, vegetables, and pudding. The pureed noodles appeared to be thick with a crack in the smooth surface. Interview on 08/20/24 at 12:41 P.M. with Registered Dietitian (RD) #542 and concurrent observation of Resident #33's tray revealed when RD #542 attempted to confirm the texture of Resident #33's noodles, a thick skin of puree had to be peeled back to access the soft pureed noodles underneath. RD #542 stated the noodles should be replaced with freshly prepared noodles. Review of the policy titled, Food Temperatures, updated 03/07/21, revealed all hot food items must be served to the customer at a temperature of at least 135 degrees F. Review of the policy, Food and Nutrition Services, revised 10/2017, revealed food and nutrition services staff will inspect food trays to ensure the food appeared palatable and attractive. The deficiency represents non-compliance investigated under Complaint Number OH00157049. The deficiency is a recite and represents continued non-compliance to the complaint survey completed on 08/01/24.

Based on observation, review of nutritional supplement directions for use, and staff interview, the facility failed to ensure nutrition supplements were not expired and were used within the appropriate timeframe. This had the potential to affect eight (#12, #17, #19, #25, #31, #38, #45, and #50) residents who received nutrition supplements. The facility census was 45. Findings include: Observation on [DATE] at 11:34 A.M. of the residents' snack refrigerator revealed a box of approximately 25 cartons of four-ounce liquid nutrition supplements. Observation of one carton revealed an expiration date of [DATE]. Observation of the additional cartons revealed they expired in 2025. Review of the directions on the supplement cartons revealed the item should be stored frozen, and thawed under refrigeration. Further review revealed the thawed supplement should be used within 14 days after thawing. Interview on [DATE] at 11:34 A.M. with Social Services Director (SSD) #474 confirmed the single container of nutrition supplement expired [DATE]. SSD #474 further confirmed the box of supplements was undated and therefore could not determine when the supplements were removed from the freezer to thaw. Additionally, SSD #474 confirmed the directions indicated the supplements should be consumed within 14 days after thawing. The facility identified eight residents (#12, #17, #19, #25, #31, #38, #45, and #50) had orders to receive the nutrition supplement stored in the residents' snack refrigerator.

Based on medical record review, staff interview, and policy review, the facility failed to ensure residents were provided a timely written discharge notice. This affected one (#30) of two residents reviewed for discharges from the facility. The facility census was 45. Findings included: Review of Resident #30's medical record revealed the resident was admitted on [DATE]. Diagnosis included schizoaffective disorder, asthma, congestive heart failure, dementia, bipolar, and benign lipomatous neoplasm of skin and subcutaneous tissue. Review of Resident #30's quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a moderate cognitive function. Review of Resident #30's medical record revealed on 04/19/24 the resident was transferred to a behavioral unit in the local hospital due to increased behaviors throughout the day where the resident was admitted . The physician ordered a hospital/psychiatric evaluation. Interview with Business Office Manager #348 on 08/21/24 at 11:20 A.M. verified Resident #30, nor his family or financial power of attorney, received a written transfer notification. Business Office Manager #348 revealed she was unaware one was required. Review of the facility policy titled, Transfer and Discharge (including AMA), dated November 2021, revealed for emergency transfers/discharges the facility must provide a transfer notice as soon as practicable to resident and representatives.

Based on observation, staff interview, medical record review, review of fall investigations, review of facility guidelines, and review of the facility policy, the facility failed to ensure neurological checks were performed per facility guidelines, and failed to ensure fall interventions were in place as care planned. This affected one (#31) of one resident reviewed for falls. The facility census was 45. Findings include: Review of the medical record for Resident #31 revealed an admitted [DATE] with diagnoses of anxiety and Alzheimer's disease. Review of the annual comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had impaired cognition, used a walker and wheelchair for mobility, required substantial/maximal assistance for transfers, and was able to ambulate ten feet with supervision or touching assistance. Further review revealed Resident #31 had two or more falls without injury since the previous assessment dated [DATE]. Review of a progress note dated 12/29/23 revealed Resident #31 was found on the floor sitting next to her bed at 2:00 A.M. Resident #31 was assessed and found to have no injuries. Further review revealed the facility implemented a scoop mattress and updated the care plan. Review of Resident #31's current care plan revealed she was at risk for falls. Interventions to prevent further falls included a scoop mattress on her bed, implemented 12/29/23. Review of the fall risk assessment completed 06/07/24 revealed Resident #31 used a walker and wheelchair for ambulation and had at least one fall in the previous month. Review of a progress note dated 06/23/24 revealed Resident #31 fell on her way to the bathroom. Further review revealed Resident #31 indicated she had pain to the back of her head. Review of the neurological evaluation assessments revealed neurological assessments were performed on Resident #31 on 06/23/24 at 1:45 P.M., at 2:05 P.M., at 2:20 P.M., and at 4:41 P.M. Review of a progress note dated 07/28/24 revealed Resident #31 was found on the floor in her room by her bed. Review of the fall investigation dated 07/28/24 revealed Resident #31 was observed sleeping in her bed on 07/27/24 at 11:55 P.M. and was found on the floor next to her bed on 07/28/24 at 12:01 A.M. Further review revealed Resident #31 was assessed and found to have no injuries. Additional review revealed no indication the scoop mattress was in place at the time of the fall. Observation and interview on 08/20/24 at 9:15 A.M. with Licensed Practical Nurse (LPN) #516 confirmed Resident #31's mattress was a standard mattress and not a scoop mattress. Observation on 08/21/24 at approximately 8:30 A.M. revealed Resident #31 sitting in a chair next to her bed. Further observation revealed the mattress on her bed was a scoop mattress. Interview on 08/21/24 at 10:09 A.M. with the Director of Nursing (DON) revealed neurological assessments should be completed initially after a fall and then hourly for four hours. The DON further confirmed the neurological assessments were not completed per facility protocol after Resident #31's fall on 06/23/24. Interview on 08/21/24 at 10:13 A.M. with the DON confirmed Resident #31 had an intervention on her care plan from 12/2023 for a scoop mattress. The DON could not explain why the scoop mattress was not in place during the observation on 08/20/24, and confirmed the facility replaced the scoop mattress during the survey. Review of the Utilization Data Assessment (UDA) Guidelines provided by the facility, revised 08/16/24, revealed neurological assessments should be completed initially after a fall and then hourly for four hours as indicated. Review of the policy titled, Falls and Fall Risk; Managing, revised 03/2018, revealed the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling.

Based on medical record review, review of a hemodialysis communication binder, staff interview, and review of the facility policy, the facility failed to ensure hemodialysis access sites were monitored as care planned, and failed to ensure communication between the hemodialysis clinic and the facility regarding a resident's hemodialysis and services was maintained. This affected one (#200) of one resident reviewed for hemodialysis. The facility census was 45. Findings include: Review of the medical record for Resident #200 revealed an admitted [DATE] with diagnoses of type II diabetes mellitus and end stage renal disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #200 had intact cognition, received hemodialysis, and was on a therapeutic diet. Review of the current care plan for Resident #200 revealed he received hemodialysis. Interventions included monitoring the hemodialysis site for signs or symptoms of infection or bleeding. Review of the physician order dated 08/12/24 revealed Resident #200 attended hemodialysis every Monday, Wednesday, and Friday. Review of the undated Pre-Dialysis communication assessment revealed staff assessed Resident #200's vitals signs and hemodialysis site. Review of the undated Post Dialysis communication assessment revealed staff assessed Resident #200's vital signs and hemodialysis site. Review of the electronic medical record for Resident #200 revealed no Pre-Dialysis communication assessment or Post Dialysis communication assessment were completed on Monday, 08/12/24 or Wednesday, 08/14/24. Further review of Resident #200's medical record revealed no documentation of staff monitoring the resident's hemodialysis site. Review of the Treatment Details Report dated 08/12/24 and 08/14/24 confirmed Resident #200 received hemodialysis treatments both days. Interview on 08/20/24 at 3:33 P.M. with Nurse Supervisor (NS) #428 and concurrent review of Resident #200's hemodialysis communication binder revealed no communication sheets were completed by the facility and sent to the hemodialysis clinic on 08/12/24 or 08/14/24. Interview on 08/20/24 at 3:57 P.M. with Assistant Director of Nursing (ADON) #472 confirmed the Pre and Post Dialysis communication assessments were not completed on 08/12/24 and 08/14/24 for Resident #200. ADON #472 stated the assessments were not initiated upon his admission. Interview on 08/22/24 at 9:36 A.M. with the Director of Nursing (DON) confirmed there was no evidence of assessments of Resident #200's hemodialysis site were contained in the resident's medical record between 08/10/24 and 08/16/24. Review of the policy, Hemodialysis Access Care, revised September 2010, revealed staff should check for signs of infection at the access site when performing routine care and at regular intervals.

Based on observation, resident and staff interview, and medical record review, the facility failed to ensure resident's food preferences were followed. This affected two (#20 and #26) of seven residents reviewed for food preferences. The facility census was 45. Findings Included: 1. Review of Resident #26's medical record revealed an admitted [DATE]. Diagnosis included diabetes mellitus, absence of right toes, and iron deficiency anemia. Review of Resident #26's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact. The resident had no natural teeth and required set up or clean up assistance for eating. Review of Resident #26' most recent care plan revealed she suffered from anemia and diabetes mellitus type two. The resident was at risk for hyper/hypoglycemia episodes related to diabetes mellitus type two. Review of Resident #26's physician order revealed an order dated 01/18/24 for a regular diet, regular texture, and thin consistency. No chips or sharp foods were to be served. Interview with Resident #26 on 08/20/24 at 8:21 A.M. revealed her meals have not been served per her preferences. She stated she needed to loose 100 pounds and requested a low carbohydrate diet due to the diabetes mellitus. For lunch she ordered a hot dog, salad, fruit, and gelatin. Resident #26 requested hot dogs for lunch and dinner. Observation on 08/20/24 at 11:59 A.M. in the kitchen during meal service revealed [NAME] #312 plating Resident #26's meal. [NAME] #312 stated Resident #26 always asked for a hot dog, but none were available. [NAME] #312 decided to send Resident #23 spaghetti. Concurrent interview with [NAME] #312 confirmed the facility did not have hot dogs for Resident #23 who always requested hot dogs. Review of Resident #26's meal ticket which was located on her meal tray on 08/20/24 at 12:22 P.M. revealed she preferred hot dogs with no bun, applesauce, tossed salad with French dressing, plain gelatin and no lemonade. Her dislikes were carrots, green beans, ham, sandwiches and chili powered items. Observation of Resident #26's meal tray on 08/20/24 at 12:22 P.M. revealed she was served spaghetti with one meatball, a long bread stick, gelatin, applesauce, salad with French dressing and milk. Interview with Dietary Manager (DM) #540 on 08/20/24 at 12:38 P.M. revealed Resident #26 failed to receive the requested menu items due to the facility being out of hot dogs. 44815 2. Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses of type II diabetes mellitus and mild protein-calorie malnutrition. Review of the annual comprehensive MDS assessment, dated 07/08/24, revealed Resident #20 had impaired cognition. Review of Resident #20's meal ticket revealed she disliked spaghetti. Observation on 08/20/24 at 12:23 P.M. during meal service revealed [NAME] #312 plating Resident #20's meal. [NAME] #312 placed spaghetti noodles on Resident #20's plate and began to portion out ground meatballs when [NAME] #312 verbally identified Resident #20's meal ticket indicated a dislike for spaghetti. Continued observation revealed [NAME] #312 was involved in a conversation with DM #540 and upon returning to plate meals, [NAME] #312 plated spaghetti for Resident #20. Interview and observation on 08/20/24 at 12:39 P.M. in the dining room with Licensed Practical Nurse (LPN) #456 confirmed Resident #20 received spaghetti. Further interview with concurrent observation of Resident #20's meal ticket confirmed it listed a dislike of spaghetti. Interview on 08/20/24 at 12:40 P.M. with Resident #20 confirmed she did not like spaghetti. Review of the policy, Food and Nutrition Services, dated 10/2017, revealed each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Reasonable efforts will be made to accommodate resident choices and preferences. This deficiency represents non-compliance investigated under Complaint Number OH00157049.

Based on review of the medical record, observation, interview, and policy review, the facility failed to ensure a resident with an indwelling urinary catheter was placed on enhanced barrier precautions. This affected one (#5) of one resident reviewed for urinary catheters. The facility census was 45. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE]. Diagnoses included multiple sclerosis, urinary retention, neuromuscular dysfunction of the bladder, malignant neoplasm of right kidney, osteoarthritis, and venous insufficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition. Review of a progress note dated 06/10/24 at 10:58 A.M. revealed Resident #5 would be returning from the hospital with an indwelling urinary catheter. Observation on 08/19/24 at 9:06 A.M. revealed Resident #5 had an indwelling urinary catheter. Further observation revealed the resident was not on enhanced barrier precautions (EBP). There was no EBP sign inside or outside the room and no personal protective equipment available outside the room. Interview on 08/19/24 at 11:43 A.M., the Director of Nursing (DON) revealed the resident had a urinary catheter since returning from the hospital. The DON revealed the resident should have been placed on enhanced barrier precautions. Review of the policy titled, Enhanced Barrier Precautions, dated 08/2022, revealed enhance barrier precautions should be implemented for residents with Multi Drug Resistant Organisms (MDRO) and residents with wounds and/or indwelling medical devices (central line, urinary catheter, feeding tube, tracheostomy, ventilator) regardless of MDRO colonization status.

Based on observation, staff interview, resident interview, and policy review, the facility failed to ensure food was served warm and palatable. This had the potential to affect all residents who receive food from the facility's kitchen. The facility census was 47. Findings include: Observation on 08/01/24 at 7:40 A.M. of meal delivery to the south hall revealed the door to the meal delivery cart was left open between delivery of each tray. Observation on 08/01/24 at 7:42 A.M. of meal delivery to the south hall revealed 11 plate covers (from previously delivered trays), one undelivered resident tray, and a tote of condiments on top of the meal delivery cart. Interview on 08/01/24 at 7:47 A.M. with State tested Nursing Assistant (STNA) #219 revealed the top of the meal delivery cart for the south hall had 11 plate covers (from previously delivered trays), one undelivered resident tray, a tote of condiments on top, and the door was let open in-between delivering trays. Concurrent interview on 08/01/24 at 7:47 A.M. with STNA #219 revealed they receive multiple complaints daily from residents regarding the temperature at which meals are served and they warm up resident meals multiple times a day per request of residents. Observation on 08/01/24 at 7:54 A.M. of meal delivery to the north hall revealed door to the meal delivery cart was left open between delivery of each tray. Interview on 08/01/24 at 7:55 A.M. with STNA #225 revealed the door was left open in-between delivering trays. Concurrent interview on 08/01/24 at 7:55 A.M. with STNA #225 revealed meals are often delivered to residents too cold and residents request them to be reheated to a more acceptable temperature. A test tray on 08/01/24 at 8:00 A.M. was sampled with Licensed Practical Nurse (LPN) #173 which revealed the breakfast sausage was cold and not palatable. Interview on 08/01/24 at 8:48 A.M. with the Director of Nursing (DON) revealed the facility steam table and plate warmer are broken and awaiting replacement. Interview on 08/01/24 at 9:20 A.M. with Resident #3 and Resident #4 revealed the food is rarely warm and they often request for it to be re-heated to their liking. Interview on 08/01/24 at 9:47 A.M. with Resident #35 revealed the food is often served cold and not to their liking. Interview on 08/01/24 at 9:55 A.M. with LPN #173 revealed that there are frequent resident complaints regarding the temperature of the food. Review of facility policy entitled, Food and Nutrition Services, dated October 2017, on 08/01/24 at approximately 10:40 A.M., revealed each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional needs and special dietary needs, taking into consideration the preferences of each resident. This deficiency represents non-compliance investigated under Complaint Number OH00155728.

Based on medical record review, observation, staff interview, and resident interview, the facility failed to ensure residents had a safe, clean, comfortable environment. This affected one resident (#35) and had the potential to affect an additional 36 residents (#1, #2, #3, #4, #5, #6, #7, #9, #10, #11, #12, #13, #14, #15, #17, #19, #20, #21, #22, #23, #25, #26, #27, #29, #31, #32, #33, #34, #38, #39, #40, #42, #43, #44, #45, #46, ) residing in the facility. The facility census was 47. Findings include: Review on 07/24/24 at approximately 2:00 P.M. revealed Resident #35 was admitted on [DATE] with diagnoses of severe protein-calorie malnutrition, non-ST elevation myocardial infarction (NSTEMI), acidosis, peripheral vascular disease (PVD), unsteadiness on feet, adult failure to thrive, anorexia, right foot drop, hypertension (HTN), drug induced constipation, cognitive communication deficit, muscle wasting and atrophy, muscle weakness, dysphagia, difficulty in walking, hypomagnesia, and depression. Review of the most recent Minimum Data Set (MDS) dated [DATE] revealed intact cognition. Further review of the MDS revealed Resident #35 utilized a manual wheelchair. Observation on 07/24/24 at 7:45 A.M. of the north hall revealed five wheelchairs, one BrodaChair, three walkers, and one lift lining the right side, and one dining cart and two isolation carts on the left side of the north hall. Interview on 07/24/24 at 7:51 A.M. with the Director of Nursing (DON) verified these findings. Observation on 07/24/24 at 7:52 A.M. revealed Resident #35 was unable to wheel themself down the north hall in their wheelchair due to the equipment lining the hall. Interview on 07/24/24 at 7:52 A.M. with Resident #35 revealed it is common for this to occur as there is frequently a lot of equipment lining the hall. Observation on 07/24/24 at 8:15 A.M. revealed four wheelchairs, five walkers, three lifts, 3 isolation carts, and one portable vital sign machine lining the left side of the south hall. Interview on 07/24/24 at approximately 8:20 A.M. with the DON verified these findings. Interview on 07/24/24 at 8:27 A.M. with Resident #27 revealed they frequently have trouble navigating the north and south halls due to the presence of the equipment. Interview on 07/24/24 at 8:37 A.M. with Resident #7 revealed they frequently have trouble navigating the north and south halls due to the presence of the equipment. Interview on 07/24/24 at 8:45 A.M. with State tested Nursing Assistant #207 revealed it is common for equipment to be present in both facilities halls.

Based on observations, staff interviews, and policy review, the facility failed to ensure residents were safely smoking. This affected one (Resident #48) of one resident observed for smoking. The facility census was 47. Findings include: Observation on 08/01/24 at 7:35 A.M. revealed Resident #48 outside of the facility at the end of the north hall smoking a cigarette unattended in a non-designated smoking area with no flame-retardant receptacle to extinguish smoking materials into. Concurrent observation on 08/01/24 at 7:35 A.M. of Resident #48 revealed Resident #48 extinguish their cigarette with their hand and place unused portion in their pocket. Observation on 08/01/24 at 7:53 A.M. of Resident #48 revealed a package of cigarettes in their left sock. Interview on 08/01/24 at 8:33 A.M. with the Director of Nursing (DON) revealed the facility is implementing a new smoking policy on 08/01/24, but the residents and staff have not been educated on it. Concurrent interview on 08/01/24 at 8:33 A.M. with the DON revealed Resident #48 has a locked drawer in his room to store his cigarettes and lighter in. Concurrent interview on 08/01/24 at 8:33 A.M. with the DON revealed they also saw Resident #48 smoking a cigarette unattended in a non-designated smoking area with no flame-retardant receptacle to extinguish smoking materials into during their morning rounds. Concurrent interview on 08/01/24 at 8:33 A.M. with the DON revealed a facility nurse had provided Resident #48 with their cigarettes earlier in the morning as they had a doctor's appointment their adult son was providing transportation to. Review of facility policy titled, [NAME] Healthcare Smoking Policy, dated June 2023, on 08/01/24 at approximately 10:30 A.M. revealed smoking is only permitted in the designated smoking areas. Supervised designated smoking area for the residents is in the courtyard off the dining hall. All cigarettes and lighters will be placed into the residents' smoke bag and given to staff. Cigarettes and lighters are not to be left with residents or in resident's rooms at ALL. This is an incidental finding found during the course of the complaint investigation.

Based on observation, staff interview, medical record review, policy review, and review of information from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to assess and monitor pressure ulcers to prevent the deterioration of wounds. This resulted in Actual Harm when Resident #36 was admitted to the facility with a Stage 2 pressure ulcers (partial thickness skin loss into but no deeper than the dermis) to the coccyx and a Stage 2 pressure ulcer to the ankle that were not assessed and monitored regularly. Subsequently, both pressure ulcers declined and was assessed as Unstageable (full thickness tissue loss but is either covered by extensive necrotic tissue or by eschar) 15 days after admission. This affected one (#36) of two residents reviewed for pressure ulcers. The facility identified two residents in the facility with pressure ulcers. The facility census was 39. Findings include: Review of the medical record for Resident #36 revealed an admitted [DATE] and readmitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During the admission, Resident #36 was hospitalized from 02/06/22 to 02/11/22. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was in a persistent vegetative state, required extensive assistance of two staff for bed mobility, toileting, and personal hygiene, and was totally dependent for eating. Further review revealed Resident #36 was admitted with two stage 2 pressure ulcers. Review of the Admission Nursing Observation dated 01/20/22 revealed Resident #36 was admitted with a Stage 2 pressure ulcer to his coccyx measuring 5.0 centimeters (cm) in length, 5.0 cm in width, and no depth was documented. Resident #36 also admitted with a Stage 2 pressure ulcer to his left ankle measuring 5.0 cm width, 4.0 cm length and 1.0 cm depth. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 01/22/22 to 01/23/22, to cleanse coccyx wound with normal saline, pat dry apply clean dry foam dressing, change every 72 hours, and as needed if dressing soiled, loose, or off. An order dated 01/23/22 to 02/06/22, to cleanse coccyx wound with normal saline, pat dry, apply adhesive foam dressing daily, dressing is to be changed twice daily due to incontinence and as needed if dressing is soiled or dislodged. Review of the treatment administration record (TAR) for January 2022 revealed Resident #36 had a body audit completed, no review or measurements of the coccyx or left ankle pressure ulcers were documented. Review of the medical record revealed no evidence of weekly skin grid assessments including measurements and staging of pressure sores between 01/20/22 and 02/03/22. Review of the Weekly Skin assessment dated [DATE] revealed no measurements of the coccyx or left ankle pressure ulcers. Review of the Skin Grid Pressure assessment for Resident #36 dated 02/04/22 revealed his coccyx pressure ulcer increased, measured 7 cm length, 10 cm width, the depth was unable to be determined, and the wound had declined and was Unstageable. Review of the Skin Grid Pressure assessment for Resident #36 dated 02/04/22 revealed his left ankle pressure ulcer measured 2.5 cm length, 1.5 cm width, the depth was unable to be determined, and the wound had declined and was Unstageable. Interview on 02/16/22 at 11:44 A.M., with the Assistant Director of Nursing (ADON) #61, revealed Skin Grid assessments were expected to be completed once weekly by staff nurses, and verified no Skin Grid assessments were completed for Resident #36 between 01/20/22 and 02/03/22. Further interview revealed the physician was notified regarding the worsened pressure ulcers on 02/04/22, and no orders were received from the physician before Resident #36 discharged to the hospital on 02/06/22. ADON #61 stated the Wound Care Nurse visited the facility once every two weeks and was unable to visit the resident on her scheduled day due to inclement weather. Observation and staff interview on 02/16/22 at 2:46 P.M., of wound care to Resident #36 by Licensed Practical Nurse (LPN) #38 revealed a coccyx wound that was uncovered due to staff removing during incontinence care due to soilage. The wound had no odor, and the pressure ulcer was about the size of a peach that was last measured at 7 cm length, 10 cm width, and the depth was unable to be determined. The wound bed was pink around the edges and had a moderate amount of tan/gray slough in the center. The wound was cleansed with wound cleanser and patted dry and then covered with a foam dressing and was dated and initialed. LPN #38 was assisted by State tested Nurse Aide (STNA) #39. Resident #36 remained comfortable throughout the procedure and had a low air loss mattress to the bed. Review of the policy titled, Prevention of Pressure Injuries, revised April 2020, revealed the facility would perform risk skin assessments weekly for existing pressure injury risk factors. Further review of the policy revealed the facility would evaluate, report and document potential changes in the skin, and review the interventions and strategies for effectiveness on an ongoing basis. Review of the National Pressure Injury Advisory Panel Stages revealed a Stage 2 Pressure Injury was described as: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). An Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed.

Based on review of staff schedules, staff on duty hours daily postings, staff timecards and staff interviews, the facility failed to ensure a Registered Nurse (RN) was on duty for eight hours a day seven days a week. This has the potential to affect 39 of 39 residents in the facility. The census is 39. Findings include: Review on 02/15/22 at 9:00 A.M., of the staff schedules for 02/12/22 revealed no RN was scheduled to work. Registered Nurse (RN) #56 was scheduled from 2:30 A.M. until 6:30 A.M. on 02/13/22. Further review of staff schedules for Sunday, 02/13/22 revealed one (RN) #39 scheduled from 6:30 A.M. until 12:30 P.M. Review of staff on duty hour postings on 02/15/22 at 9:05 A.M., revealed zero registered nurse hours on Saturday, 02/12/22 and six register nurse hours on Sunday, 02/13/22. Review of timecard on 02/16/22 at 8:48 A.M., for RN #56 revealed a clocked in at 2:58 A.M. on 02/13/22 and clocked out at 7:09 A.M. on 02/13/22 for a total of 4.08 hours. Review of timecard on 02/16/22 at 8:50 A.M., for RN #39 revealed a clocked in on 02/13/22 at 6:29 A.M. and clocked out at 11:59 A.M. for a total of 6.53 hours. Interview on 02/15/22 at 4:25 P.M., with the Director of Nursing #13 confirmed there was not a RN on duty for Saturday, 02/12/22 for eight hours. Interview on 02/15/22 at 4:28 P.M., with Administrator #48 verified there was not a RN on duty for Saturday, 02/12/22. Interview with Business Office Manager #4 verified staffing schedules are for a twenty-four-hour period, 6:30 A.M. through 6:30 A.M.

Based on observations, staff interviews, infection control log reviews and review of policies, the facility failed to store, prepare, and distribute foods in a safe, sanitary manner. This affected 38 of 38 residents who received food from the kitchen. The facility identified one (#36) resident had an order for nothing by mouth. The facility census was 39. Findings include: Observation on 02/14/22 at 9:26 A.M., revealed the reach-in refrigerator contained a container of chili dated 01/27/22, and a container of chili with meat dated 01/30/22, and an undated Styrofoam container of cupcakes. Interview at the time of the observation, with the Cook #60, confirmed the chili was beyond its use-by date and the cupcakes were undated. Observation on 02/14/22 at 9:31 A.M., revealed a box of sprouting and rotted red skinned potatoes in the dry storage area. Interview at the time of the observation, with the Cook #29, confirmed the potatoes were sprouting and rotted. Observation on 02/14/22 at approximately 9:34 A.M. revealed four and a half gallons of chocolate milk labeled best if used by 02/11/22. Interview at the time of the observation, with Cook #29, confirmed the chocolate milk was past its best if used by date. Observation on 02/15/22 at 11:03 A.M., revealed Cook #60 used a thermometer to check the temperature of Salisbury steak, zucchini, and mashed potatoes without sanitizing it between food items. Observation on 02/15/22 at 11:10 A.M., revealed Cook #60 pureed Salisbury steak in the food processor. After removing the pureed Salisbury steak, the Cook #60 rinsed the food processor container and blade off with water using a spray nozzle. The Cook #60 then filled the food processor with zucchini. Interview at the time of the observation, with Cook #60 confirmed he used only water to rinse the food processor and confirmed remnants of Salisbury steak remained in the food processor with the zucchini. Further observation revealed the Cook #60 proceeded to use the contaminated food processor to puree the zucchini, then placed the contaminated pureed zucchini on the steam table in preparation for food service. Interview on 02/15/22 at 11:22 A.M., with Cook #60 confirmed he did not sanitize the thermometer between uses, and revealed no sanitizer wipes were available in the kitchen. Observation on 02/15/22 at 11:40 A.M., revealed Cook #60 served the contaminated zucchini to residents on a pureed diet. Observation on 02/16/22 at approximately 9:25 A.M., revealed Cook #29 using the three compartment sink to wash containers used for food distribution. The wash compartment contained soapy water, the rinse compartment contained clear water, and the sanitizer compartment was empty. Cook #29 washed, rinsed, and placed the dishes in the empty sanitizer compartment to dry. Observation on 02/16/22 at 9:30 A.M., revealed Cook #29 collected wet dishes from the empty sanitizer compartment and put them away on a shelf. Interview at the time of the observation, with Cook #29 revealed the sanitizer compartment of the sink did not hold water due to a defect with the drain. Further interview with Cook #29 confirmed she did not sanitize the dishes before putting them away while they were still wet. Interview on 02/16/22 at approximately 9:33 A.M., with Cook #60 revealed the sanitizer sink would hold water, the drain had to be manually held open to drain the sink. Interview on 02/17/22 at 7:45 A.M., with the Maintenance Supervisor #68 revealed he was aware of the problem with the three compartment sink in the kitchen. He verified the sanitizer compartment will hold water, though it must be manually drained. Review of the infection control logs reveled there have been no food born related illness in the facility. Review of the policy titled, Taking Accurate Temperatures, updated 03/07/21, revealed a clean, rinsed, sanitized, and air-dried thermometer is needed to take temperatures. Review of the policy titled, General Food Preparation and Handling, updated 03/07/21, revealed all food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. Review of the policy titled, Food Storage, updated 03/07/21, revealed date marking will be visible on all high-risk food to indicate the date by which a ready-to-eat food should be consumed or discarded, and leftover food shall be dated and used within three days or discarded.

Based on review of the facility Legionella Control Risk Management Plan, staff interview and review of facility policy, the facility failed to monitor and implement control measures to prevent Legionella growth. This had the potential to affect 39 of 39 residents in the facility. The facility census was 39. Findings include: Review of the facility risk management plan for Legionella Control, updated 11/2021, revealed thee facility identified pipe work with low flow in several areas and would flush the areas weekly. Also, the facility would monitor the hot water system, measure the temperature weekly and make adjustments if the temperature was below 140 degrees Fahrenheit. Additionally sink basin and shower heads would be cleaned monthly of scale and lime build up to ensure proper water flow. Furthermore the facility would test the water system for colony forming units (CFUs) of Legionella per milliliter of water. Interview on 02/16/22 at 2:51 P.M., with the Administrator verified the facility had not been flushing water in low flow areas, and had not monitored water temperatures of the hot water system. The Administrator also verified there was no documentation the facility had cleaned sink basin and shower heads to ensure proper water flow. The Administrator revealed the facility had not completed testing of the water system for Legionella. Review of the facility policy titled Legionella Water Management Program, dated 07/2017, revealed the purpose of the water management program was to identify areas in the water system where Legionella bacteria could grow and spread, and to reduce the risk of Legionnaire's disease. Further review of the policy revealed the facility would implement specific measures to control the introduction and/or spread of Legionella and monitor the effectiveness of the control measures.

Based on medical record review, review of facility policies and staff and resident interviews, the facility failed to provide physician ordered treatments to resident's with non-pressure skin impairments. This resulted in actual harm when the surgical area beneath Resident #45's splint was not checked for three days and the resident developed an open wound with exposed surgical hardware. In addition, the facility failed to monitor wounds and complete wound care as ordered for two (#10 and #20) additional residents of three total residents reviewed with skin impairments. The facility identified five current residents with skin impairments requiring dressing changes. The facility census was 38. Findings include: 1. Review of Resident #45's medical record revealed an admission date of [DATE]. Resident #45 was discharged to the emergency roiagnom on [DATE] and did not return to the facility. Medical [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's speech was clear and she was sometimes understood and sometimes understood others. Staff assessment for cognition revealed the resident's cognition was severely impaired. She required extensive assistance with one staff member for bed mobility, transfers, walking, locomotion, dressing, eating, toilet, and personal hygiene. She received scheduled pain medication. Review of the resident's orthopedic discharge instructions dated 08/16/18, revealed the resident had an open reduction, internal fixation (ORIF) surgery of the right olecranon (bony tip of the elbow near the end of the ulna bone). The resident was in a splint which was to be kept clean and dry and she was scheduled for an orthopedic follow up in ten to fourteen days. Review of the orthopedic follow up visit on 08/28/18 revealed the resident's right elbow incision was clean and dry with no drainage. Sutures were removed. Review of the resident's orthopedic physician's orders [REDACTED]. She was to follow up with the orthopedic physician in three weeks. Review of the resident's orthopedic follow up visit on 09/18/18 revealed the right elbow fracture was stable and orders were to continue splint to right elbow, ok to remove to shower or change clothes. No right elbow ROM, right elbow skin checks daily. Follow up with orthopedic physician in three weeks. Review of the resident's shower sheets revealed she received a shower on 09/26/18 from State tested Nursing Assistant (STNA) #64 and on 09/29/18 from STNA #65. Review of the resident's (MONTH) Treatment Administration Record (TAR) revealed the resident's daily skin check was not completed from 10/01/18 through 10/03/18. Review of the resident's nursing notes revealed a skin audit was performed with no new skin issues noted on 09/26/18. There were no further nursing notes until 10/03/18 at 6:24 P.M., when the Director of Nursing (DON) documented the resident complained of increased pain to her right ulna (bone between elbow and wrist). She was medicated with narcotic pain medication at 4:00 P.M., after redirection, distraction, activity, and toileting were ineffective. The right elbow area was assessed at 6:00 P.M. and it was noted a pin was visible and the resident's skin was slightly reddened with a scant amount of yellowish serosanguineous drainage noted. The area was sore to touch. The physician was notified. At 7:35 P.M., the physician gave an order to send the resident to the emergency room . Review of Resident #45's hospital emergency room documentation dated 10/03/18 revealed a complaint of right elbow pain with surgical hardware exposed at the olecranon. No fever and no drainage from the area but apparently quite painful as resident was crying when the elbow was manipulated. It was unknown how long hardware had been exposed. The resident's daughter reported the nursing home facility reported the area was being cleansed daily. The resident was wearing a splint that has apparently worn through. The course of treatment progress comments included skin breakdown was significant. The plan was for observation given risk of infection and further complication of significantly exposed hardware. Review of a hospital document titled Report of Operation dated 10/04/18, revealed the preoperative [DIAGNOSES REDACTED]. The operation was metal removal complex closure with Z-plasty (an orthopedic technique in which one or more Z-shaped incisions are made) on right elbow. Indications included the resident underwent [REDACTED]. The resident had basically healed the fracture in a fibrous union but apparently while at the nursing home has basically worn through her skin to metal on the posterior part of her elbow. Originally, the surgeon thought this was wound dehiscence (surgical complication in which a wound rupture along a surgical incision) but on better inspection the wound had actually healed, and the dehiscence was medial to that and right over previously intact skin. Operative summary included standard incision was made over the previous incision but to veer to include the open area. The metal could be seen easily from across the room and through the defect which measured approximately 3.0 centimeters (cm) x 2.0 cm. The metal was removed, and the incision closed. Care will not be provided by the nursing home previously caring for her. Continued review of the hospital documentation revealed the resident was discharged on [DATE] to a different skilled nursing home. Interview with Licensed Practical Nurse (LPN) #53 on 10/23/18 at 4:47 P.M., verified the order to check the resident's elbow daily was not documented on the Treatment Administration Record (TAR) as being completed 10/01/18 through 10/03/18. Telephone interview with STNA #64 on 10/24/18 at 3:20 P.M., verified she gave the resident a shower on 09/26/18. She stated she covered the resident's arm with plastic when she gave her a shower. She stated she did not see the resident's arm without her splint. She did not seem to be in a lot of pain on 09/26/18. Telephone interview with STNA #65 on 10/24/18 at 2:03 P.M., revealed she never took the resident's splint off. She stated she did not actually give her a shower on 09/29/18. She gave her a bed baths because she had a splint on. She stated when she dressed her she put something big on her, so it would not hurt the splint. She stated the last week or two the resident was at the facility she was a little whinier and complaining, holding her right arm. She notified the nurse but could not remember which one. She does not know if the nurse followed up. Interview with STNA #68 on 10/24/18 at 2:48 P.M., revealed she worked full time on Resident #45's hall and never seen anyone remove the splint from the resident's arm. She verified she worked on 10/03/18, when the resident was sent to the hospital. She also worked on 10/02/18 and notified the nurse that Resident #45 seemed to be in more pain as she was so anxious and pointing at her elbow. She stated the nurse gave Resident #45 pain medication, but she did not know if the nurse observed the resident's skin under the splint. She stated the resident's daughter was at the facility on 10/03/18 and was helping her get ready for bed. The resident's daughter noticed the resident was acting different, so her daughter took her sling off and looked at it. The resident's daughter told the DON, who was working the floor, the resident's hardware was sticking out of her arm. Interview with the DON on 10/23/18 at 4:30 P.M., verified she was working Resident #45's hall on 10/03/18 when she was sent to the emergency room . She stated Resident #45 seemed to be holding her elbow more and she had administered her pain medication and checked her vital signs earlier. She verified Resident #45 had an open area to the right elbow and hardware was visible. She stated there was no bleeding, but there was some yellow drainage on the ace wrap. She thought it was being checked daily but verified the order for the daily wound check right elbow was not on the (MONTH) TAR. Interview with LPN #53 on 10/24/18 at 3:55 P.M., verified she worked on Resident #45's hall on 10/02/18 and did not visualize Resident #45's skin under her splint. She stated Resident #45 did not seem to want her to touch her and she did not want to put her through more trauma. Review of a facility policy titled Medication and Treatment Administration Guidelines updated on 03/18 revealed treatment orders were to be transcribed or electronically entered then noted by the licensed nurse. The licensed nurse noting an order is responsible for accurate transcription and initiation of orders. 2. Review of Resident #20's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's MDS assessment dated [DATE] revealed she had a brief interview for mental status (BIMS) score of 13, indicating minimal impairment in cognition. The resident had one venous/arterial ulcer, a [MEDICAL CONDITION], infection of the foot, and a surgical wound. She was receiving surgical wound care and application of dressings to the feet. Review of the resident's physician's orders [REDACTED]. On 10/10/18, the order was changed to start [MEDICATION NAME], abdominal (ABD) pad, kerlix, then coban daily, cleanse with normal saline. Review of the resident's TAR revealed the resident's wound care was documented as being completed on 10/05/18, 10/09/18 or 10/14/18. Review of the resident's nursing notes revealed no documentation of refusals of dressing changes on the dates. Continued review of the medical record revealed no weekly wound assessment or measurements of the resident's left heel wound except for a wound care physician note on 10/10/18. Review of the resident's wound care physician notes revealed she was seen by the wound nurse on 10/10/18 with wound measurements of 8.0 cm x 7.2 cm x 0.1 cm. The wound was described as a diabetic wound ulcer with pressure components. The wound showed improvement with no signs of infection. Exposed bone was noted. A small amount of serous drainage was noted. Peri-wound skin was intact. Interview with Resident #20 on 10/23/18 at 2:19 P.M., revealed she does not receive daily dressing change to her left heel. She stated the only nurse that completed her dressing change was LPN #51. She stated she does not say anything to the other nursing staff because she figured they should know what they were supposed to do. Interview with LPN #51 on 10/23/18 at 12:34 P.M., revealed she has had residents tell her dressings were not always completed as ordered. She stated Resident #20 had told her dressings were not being completed daily. She stated there were times she noticed the resident's dressing change was not signed off on the TAR as being completed. Interview with the DON on 10/24/18 at 9:46 A.M., verified Resident #20's dressing changes were not documented as completed on 10/05/18, 10/09/18 or 10/14/18. She provided wound measurements from 10/24/18 which showed a decrease in size of the wound from the 10/10/18 assessment. Interview with Quality Assurance Consultant #55 on 10/24/18 at 1:45 P.M., verified there were no weekly wound assessments completed for Resident #20. She stated the facility nursing staff should have completed weekly wound grids, but did not. 3. Review of Resident #10's medical record revealed an admission date of [DATE]. Medical [DIAGNOSES REDACTED]. Review of the resident's MDS assessment dated [DATE] revealed the resident was independent for decision making and her memory was ok. Review of the resident's physician's orders [REDACTED]. Review of the resident's TAR revealed the wound care was not signed off on 10/21/18 as being completed. Review of the resident's nursing notes revealed no entry regarding a refusal on 10/21/18. Continued review of the resident's medical record revealed [REDACTED]. Interview and observation with Resident #10 on 10/23/18 at 11:22 A.M., revealed she gets a dressing change to her right outer foot. She stated she was thought she was supposed to have the dressing changed once daily. She stated it was last changed on Sunday, 10/20/18. Observation of the dressing at the time of the interview revealed it was very small and undated. Interview with the DON on 10/24/18 at 9:46 A.M., verified Resident #10's dressing change was not documented as completed on 10/21/18. Interview with Quality Assurance Consultant #55 on 10/24/18 at 1:45 P.M., verified there was no wound assessment completed for Resident #10's [MEDICAL CONDITION]. Review of a facility policy titled Medication and Treatment Administration Guidelines updated on 03/18, revealed documentation requirements included treatments administered were documented immediately following administration. Review of the facility Skin Practice Guide Process Flowchart dated 2013, revealed the facility should initiate a skin alteration record for a skin alteration. This deficiency substantiates Complaint Number OH 529.