Every finding on record at Doverwood Village

Based on observation, staff interview, and facility policy review, the facility failed to ensure that dented cans were removed from the dry storage area in the kitchen. This had the potential to affect all 83 residents residing in the facility. The census was 83.Findings include:Observations of the kitchen dry storage area on 06/23/25 at 10:04 A.M. with the Chef revealed 13 dented cans amongst the canned goods. The dented cans included two (2) seven-pound (lb.) cans of pudding, 2 five lb. cans of spinach, eight (8) six lb. cans of peaches, and one (1) seven lb. can of refried beans. During an interview on 06/23/25 at 10:06 A.M., the Chef stated she and the cooks put the canned food deliveries away. She stated [NAME] #2 stocked the canned peaches the prior Monday. She stated dented cans should be removed from the dry storage and placed in her office so she could submit them for credit and confirmed the dented cans. She stated botulism bacteria could get into the canned food if the dent caused a hole or broke the seal. She stated the dented canned food found should have been removed and returned for credit. She stated she checked the can rack and canned goods and missed the dented cans. She stated the canned goods were received during multiple deliveries. During an interview on 06/25/25 at 10:28 A.M., [NAME] #1 stated she had been with the facility for 16 years. She stated she helped put away orders and checked the canned goods for dents as she put them away. She stated dented cans were stored in the Chef's office and the Chef coordinated replacement canned goods. She stated she did not put away the dented cans of peaches from the prior week's order. She stated dented cans were dangerous because the dent could allow bacteria and germs into the canned food, causing foodborne illness. She stated she always checked for dented cans to protect the residents. On 06/26/25 at 11:43 A.M. and on 06/27/25 at 8:29 A.M., a telephone interview was attempted with [NAME] #2 with no answer received. During an interview on 06/26/25 at 7:24 A.M., [NAME] #3 stated she had worked at the facility for 20 years. She stated she helped stock orders in the dry storage area. She stated canned goods should be screened for dents and, if found, removed from the usable canned food area. She stated the dented cans were put in the Chef's office for credit. She stated dented cans should not be used because they could cause illness to the residents. She stated she did not help stock the last order that was received. She stated the Chef was responsible for checking and screening the canned goods. During an interview on 06/26/25 at 3:50 P.M., the Regional Chef (RC) stated dented cans should be separated and returned for credit. He stated botulism and other foodborne illness could occur if air entered the canned goods. During an interview on 06/26/25 at 3:51 P.M., the Registered Dietitian (RD) stated that dented cans should be set aside and returned for credit. She stated canned goods should be received and inspected while being put away on the racks. She stated dented cans should be screened because, if the seal was broken, botulism could grow in the canned foods.During an interview on 06/27/25 at 10:08 A.M., the Administrator stated food from dented cans would not be served and canned goods should be reviewed and designated for removal if dented. Review of a facility policy titled, Receiving, revised in 06/2015, indicated, the facility will ensure all food items and kitchen supplies purchased are received properly. When a vendor arrives with food, he/she will bring food items and kitchen supplies to the main kitchen and places items in the dry storage room or walk-in. The food will be received by a cook, the dietary manager or designee. After receiving, one of the above personnel will check in the food items and make sure all items ordered are accounted for. If an item is missing, the driver/vendor will be asked to deduct the item from the bill. If an item is of poor quality, it can be refused, and the items should be deducted from the bill.

Based on observation, resident and resident representative interview, staff interview, medical record review, facility document and policy review, and review of corrective action documents, the facility failed to execute an effective pest control program for the prevention and control of mice in the facility. This affected four (#5, #12, #13, and #20) of 83 residents residing in the facility. The census was 83. Findings include: 1. Review of Resident #5's medical record revealed an admission date of 11/14/24. Diagnoses included major depressive disorder and adjustment disorder with anxiety.Review of a quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 04/09/25, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS assessment indicated Resident #5 had no potential indicators of psychosis. During a concurrent interview and observation in Resident #5's room on 06/23/25 at 9:29 A.M., Resident #5 stated they saw mice in their room. Resident #5 stated they had been seeing the mice since 10/21/24, and stated a family member had also seen them in Resident #5's room. Resident #5 stated the mice would leave when staff opened the door, and the mice would play with the paper traps the facility placed in Resident #5's room. A large black box was observed in the corner of the room with the name of a pest control company engraved on it. Resident #5 stated the facility brought the black box last week, and mice had been seen in the room since then. Resident #5 stated some of the mice were gray and some were darker gray. Resident #5 added the mice had not torn up any of the belongings in their room, but having mice in their room made the resident feel bad. Small black pellets that appeared to be mouse excrement (feces) were observed in Resident #5's closet on the left side in a corner and on a sticky trap on the right side of the closet floor.During an observation in Resident #5's room on 06/24/25 at 11:28 A.M., a small number of black pellets that appeared to be mouse excrement were observed in the left corners of Resident #5's closet. During an interview with Licensed Practical Nurse (LPN) #13 and observation in Resident #5's room on 06/24/25 at 11:31 A.M., LPN #13 looked in Resident #5's closet and stated that the black pellets looked like mouse droppings. LPN #13 stated she had not seen any mice but had heard people scream when they saw mice. LPN #13 stated she had worked at the facility for a year and a half, and there were mice the entire time. LPN #13 stated the mice had become worse in the last couple of months, and the residents had complained about mice. LPN #13 stated she did not feel like there were any risks to the residents and thought that maintenance and the head of housekeeping were responsible for monitoring for pest control.During an interview on 06/25/25 at 8:39 A.M., Certified Nurse Aide (CNA) #7 stated she had seen two mice about two and a half weeks prior in a resident's room. CNA #7 stated residents on the long term care unit had complained about mice, and maintenance was responsible for monitoring pest control. CNA #7 stated Resident #5 was upset regarding the mice.Review of a pest control company invoice dated 06/25/25 revealed no mice activity was found, and the mouse droppings found in Resident #5's room were hard, dry, and not fresh.2. Review of Resident #20's medical record revealed and admission date of 04/29/21. The resident had a diagnosis of major depressive disorder.Review of a quarterly MDS assessment, with an ARD of 05/13/25, revealed Resident #20 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS assessment indicated Resident #20 had no potential indicators of psychosis. During a concurrent interview and observation in Resident #20's room on 06/23/25 at 10:07 A.M., Resident #20 stated there were mice in the facility but not recently. Resident #20 stated that about three or four weeks prior there was a mouse under the bed. Resident #20 stated they were scared of the mice. A small amount of black pellets that appeared to be mouse excrement were observed behind Resident #20's refrigerator.3. Review of Resident #13's medical record revealed an admission date of 10/21/23. Diagnoses included major depressive disorder, generalized anxiety disorder, and adjustment disorder with mixed anxiety and depression.Review of a quarterly MDS assessment, with an ARD of 05/22/25, revealed Resident #13 had a BIMS score of two (2), which indicated the resident had severe cognitive impairment. During an observation in Resident #13's room on 06/23/25 at 10:20 A.M., black pellets that appeared to be mouse excrement were observed under Resident #13's bed.During an interview on 06/25/25 at 9:26 A.M., CNA #18 stated she had started seeing mice and mice droppings about a month prior. CNA #18 stated she had seen a mouse under Resident #13's bed during the day the past month. CNA #18 stated the facility had been using sticky mouse traps and snap traps previously, but about a week ago the facility started using big black mouse trap boxes. CNA #18 stated the residents told her they did not like mice running around in their rooms, and the risks to the residents were that the residents could catch a disease. CNA #18 stated maintenance and housekeeping were responsible for monitoring pests in the building. CNA #18 stated she felt like the facility was trying and that the pest control had become more effective.4. Review of Resident #12's medical record revealed an admission date of 12/02/22. The resident had a diagnosis of macular degeneration.Review of a quarterly MDS assessment, with an ARD of 06/06/25, revealed Resident #12 had a BIMS score of four (4), which indicated the resident had severe cognitive impairment. During an interview on 06/25/25 at 1:37 P.M., Power of Attorney (POA) #27 stated they saw a mouse about a month prior, and Resident #12's closet was full of mouse feces. POA #27 stated they had seen mouse droppings in the closet even after they had cleaned it but had not seen any mouse droppings in the last week or week and a half. POA #27 stated Resident #12 did not appear to be bothered by the mice, but Resident #12's roommate was bothered by the mice. POA #27 stated Resident #12's roommate was currently in the hospital, but the roommate had reported the mice had gotten into their snacks.During an observation in the hall of the long-term care (LTC) unit on 06/23/25 at 10:59 A.M., three pest control employees were observed going from room to room checking the black boxes that were labeled with the name of the pest control company. Review of pest control service reports from the prior pest control company, for the timeframe from 04/16/25 through 05/09/25, revealed the facility had one rodent bait station, and there was no evidence of activity. There were no pest control service reports provided for the timeframe from 05/10/25 to 06/18/25.Review of pest control service reports from the current pest control company, for the timeframe from 06/19/25 through 06/25/25, revealed 19 bait stations, 10 tin cat traps (mouse traps), and 54 snap traps (mouse traps) were placed in the building. A service report dated 06/23/25 indicated no pest activity had been found.During an interview on 06/24/25 at 8:45 A.M., Housekeeper #16 stated she was not sure how long there were mice in the facility but thought it had been more than a month. Housekeeper #16 stated she was not sure how long the exterminators had been coming to the facility but noted that the mouse situation had improved.During an interview on 06/25/25 at 9:00 A.M., CNA #17 stated she had seen one or two mice but was not sure when that was. CNA #17 stated she had not seen any mice recently. CNA #17 stated residents had not complained recently, and the pest control had improved in the last month. During an interview on 06/25/25 at 9:49 A.M., the Environment Services Supervisor (ESS) stated the mouse problem had just started suddenly about three to four weeks prior. The ESS stated everyone was responsible for monitoring for mice and should put an order in their maintenance system if any mice or droppings were seen. During an interview on 06/25/25 at 10:58 A.M., the Maintenance Director stated he had worked at the facility for three weeks, and glue traps were being used for pest control at that time. During an interview on 06/25/25 at 11:06 A.M. with the Maintenance Director, Regional Maintenance Coordinator (RMC) #19, and RMC #20, the Maintenance Director stated he had checked the mouse traps with the extermination company on 06/23/25, and there were no mice in the traps. RMC #19 stated that three weeks prior the former maintenance director was no longer employed with the facility, and employees told RMC #19 that they had seen mice in the facility. RMC #20 added that all reports of mice came from the LTC unit. RMC #19 stated that when he became aware of mice sightings, he placed glue traps in the residents' closets. RMC #19 stated that he caught two adult mice and some baby mice. RMC #19 stated he always caught two or three mice a year. RMC #19 added that the previous Maintenance Director and previous pest control company did not address the situation correctly. RMC #19 stated the Maintenance Director was responsible for monitoring pest control. During an observation in Resident #5's room on 06/25/25 at 1:27 P.M., the Maintenance Director was observed with a member of the pest control company looking in Resident #5's closet.During an interview on 06/25/25 at 2:09 P.M., the Director of Nursing (DON) stated she had worked in the facility for two months and had never seen any mice or mouse droppings. The DON stated everyone was responsible for monitoring for pests, and the risks to the residents were that they could get an infection. The DON stated her expectation was that if they identified an issue that housekeeping and maintenance would be notified, and the pest control company would come to the facility.During an interview on 06/25/25 at 2:27 P.M., the Regional Administrator (ADM) stated she was the ADM for the facility from November 2023 until March 2025 and was not aware of any pest control issues. The Regional ADM stated a pest control company was coming to the facility twice a month, and she never saw any mice or any mice droppings. The Regional ADM stated a family member for Resident #5 complained in March 2025 or April 2025 about mice, and the facility did a search of Resident #5's room. The Regional ADM stated no one had notified her of any mouse droppings being found. The Regional ADM added that maybe two or three adult mice had been found, and the rest were baby mice. The Regional ADM stated everyone was responsible for monitoring the facility for pests, and there were no risks to the residents unless they ate the mouse droppings. The Regional ADM stated her expectation was to find the issue, treat it, and keep checking.During an interview on 06/25/25 at 3:56 P.M., the ADM stated she began working in the facility in April of 2025 and became aware of the pest problem towards the end of May of 2025. The ADM stated they had a pest control company that came to the facility twice a month. She stated they switched pest control companies in the beginning of June of 2025 because there was an increase in mouse sightings. The ADM stated the pest control company came out on 06/25/2025 and reported the mouse droppings in Resident #5's room were old. The ADM stated that the risks to the residents were that they could get sick, and everyone was responsible for monitoring for mice or mice droppings. The ADM stated her expectation was to continue the interventions and keep the facility as pest-free as they could.During an interview on 06/26/25 at 10:29 A.M., a Pest Control Technician (PCT) stated their company came to the facility on [DATE] and set up all new exterior and interior rodent traps. The PCT stated two traps were placed in each resident's room, for a total of 54 traps. The PCT stated the traps were placed inside secure boxes (the black boxes) to protect the residents, and there had been no activity found since the traps were placed. The PCT stated the mouse droppings in Resident #5's room were old because the droppings were gray, brittle, dry, and had no odor. The PCT stated if there was an active infestation then they would have caught a mouse in one of the 54 traps that were set. The PCT stated that usually a mouse would be caught within 24 to 48 hours. The PCT added that the facility had followed all the recommendations from the pest control company and were doing everything to ensure the facility was pest-free.During an interview on 06/25/25 at 3:56 P.M., the ADM stated the facility staff decluttered and cleaned all resident rooms. Every resident was provided with a plastic tub to store their snacks, and families were asked to keep all the food in containers. The ADM stated that on 06/03/25 a notice was sent to the families to see if they wanted to help clean the residents' rooms. The ADM stated the pest control company came almost every day for the first week of June 2025 and searched the entire building for entry points. The ADM stated that on 06/05/25 the pest control company placed metal mouse traps around the facility. Then on 06/06/25 the pest control company placed three additional outdoor big black box mouse traps. The ADM added that on 06/06/25 they decluttered, shampooed, and cleaned all the rooms on the LTC unit. The ADM stated the facility also obtained two outside cats to assist with pest control, hired a company to remove trees and brush around the facility on 06/08/25, and had the air conditioner units sealed to prevent points of entry.Review of a facility policy titled, Pest Control, revised in 06/2021, revealed, the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.This deficiency represents non-compliance identified under Master Complaint Number OH00166955 (iQIES Complaint Number 1372879) and Complaint Number OH00162627 (iQIES Complaint Number 1372877).

Based on observation, staff interview, medical record review, and facility document and policy review, the facility failed to ensure services were provided to meet professional nursing standards of clinical practice when staff failed to date or initial intravenous tubing or a peripherally inserted central catheter line dressing when changed and failed to date and initial a wound dressing as required. This affected one (#41) of five residents reviewed for care and services. The census was 83. Findings include: Review of Resident #41's medical record revealed the resident admitted to the facility on [DATE] and most recently admitted the resident on 06/06/25. Medical diagnoses included acute osteomyelitis of the left ankle and foot and osteomyelitis of the vertebra, sacral, and sacrococcygeal region.Review of an admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/12/25, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident had severe cognitive impairment. The MDS assessment indicated Resident #41 had one stage 3 (full-thickness skin loss), one stage four (4) pressure ulcer (full-thickness skin and tissue loss), and a surgical wound. The MDS assessment further revealed Resident #41 received intravenous (IV) antibiotics during the look-back period.Review of Resident #41's care plan report included a focus area initiated 06/06/25 that indicated the resident had the potential for infection due to the presence of an IV site (a peripherally inserted central catheter [PICC] in the right upper extremity). Interventions directed staff to change the dressing to the IV site per clinician orders and to change the tubing every 24 hours. Resident #41's care plan report included a focus area initiated on 06/06/25 that indicated the resident had an infection of the sacrum, left ankle, and acute osteomyelitis. Interventions directed staff to administer antibiotic medications as ordered. Resident #41's care plan report included a focus area initiated on 06/06/25 that indicated the resident was on IV medications related to osteomyelitis. Interventions directed staff to observe the right arm PICC dressing every shift and change the dressing and record observations of the site every Sunday and as needed. Resident #41's care plan report included a focus area initiated on 06/21/25 that indicated the resident had a large skin tear to the right forearm related to fragile skin. Interventions directed staff to administer treatments as ordered and monitor for effectiveness.Review of Resident #41's order summary report contained an order dated 06/06/25 that directed staff to change the resident's IV tubing every 24 hours, one time a day; to change the PICC dressing and needleless connector every week and as needed (pro re nata; prn) for soiled dressing; and to change the PICC dressing and needleless connector every week and prn every day shift every Sunday. The order summary report also contained a physician order dated 06/21/25 to cleanse the right forearm skin tear each day shift with normal saline, pat dry, apply gauze, and cover with retention tape. The order summary report contained a physician order dated 06/24/25 for two (2) grams of reconstituted Fetroja (antibiotic) IV solution via IV every eight hours related to acute osteomyelitis of the left ankle and foot and osteomyelitis of the vertebra, sacral, and sacrococcygeal region until 07/03/25.Review of Resident #41's June 2025 medication administration record (MAR) revealed evidence to indicate staff changed the resident's IV tubing and PICC dressing and needleless connector on 06/22/25. The MAR further revealed evidence to indicate staff changed the resident's IV tubing on 06/23/25 and 06/24/25.Review of Resident #41's June 2025 treatment administration record (TAR) revealed evidence to indicate staff cleansed the skin tear to the right forearm with normal saline, applied gauze, and covered the area with retention tape on 06/23/25 and 06/24/25.During an observation on 06/23/25 at 9:27 A.M., Resident #41 was in bed and an undated dressing was observed on the resident's forearm. An IV was observed in the resident's upper right arm, also with an undated dressing. During an observation on 06/24/25 at 3:15 P.M., Resident #41 was in bed with a dressing on the resident's right forearm, with no date or initials. The resident's IV was running, and no date was observed on the IV dressing or tubing.During an interview on 06/24/25 at 3:26 P.M., Licensed Practical Nurse (LPN) #24 stated they changed IV dressings every Sunday. She stated there should be a date on Resident #41's dressings and the IV tubing.During an interview on 06/24/25 at 3:33 P.M., LPN #24 went into Resident #41's room to check the IV tubing and associated dressing, as well as the dressing on Resident #41's forearm. At 3:34 P.M., LPN #24 exited Resident #41's room and confirmed there was no date on the resident's IV dressing or tubing, nor was the dressing on Resident #41's forearm dated.During an interview on 06/25/25 at 12:01 P.M., LPN #22 stated the treatment for Resident #41's dressings should have been initialed and dated.During an interview on 06/25/25 at 1:43 P.M., Registered Nurse (RN) #12 stated IV lines should be dated and were changed every 24 hours, noting she was fairly certain that was the facility policy.During an interview on 06/25/25 at 2:13 P.M., LPN #23 confirmed she completed the treatment dressing for Resident #41 on 06/24/25. LPN #23 stated that when a dressing was changed, the nurse was to put their initials and date on the dressing.During an interview on 06/27/25 at 11:18 A.M., the Assistant Director of Nursing (ADON) stated the wound care nurse conducted routine checks daily to ensure the dressings were done daily, and she checked behind the wound care nurse and made sure everyone was checked daily. She stated she walked into the resident rooms, and she was not aware of the dressings and tubing not being dated until it was presented. She stated she did not have a set time to conduct these checks, noting it was sporadic. She stated anyone who was setting up or administering the IV tubing and dressing and the dressings should initial and date them.During an interview on 06/27/25 at 11:33 A.M., the Director of Nursing (DON) stated her expectation was for nurses to date Resident #41's IV dressing and tubing on their shift and should date and initial the dressing for the forearm if they performed the treatment. She stated they had numerous resources and corporate educators if staff had a question related to professional standards of practice.During an interview on 06/27/25 at 11:55 A.M., the Administrator stated her expectation was for staff to date all dressings and tubing at some point during the shift, ideally at the time of the tubing and dressing change, but at least prior to end of the shift.During an interview on 06/27/25 at 3:10 P.M., RN #25, a regional educator, stated for nurse competencies they pulled the policy and step-by-step instructions and completed the competencies according to the policy. RN #25 stated that it included dating dressings for treatments and IVs.Review of a facility policy titled, Quality of Care - Care Planning, dated 10/2022, revealed, each discipline is responsible for implementing and providing input (based on patient/resident representative feedback) on any interventions to assist the patient in achieving their goals and desired outcomes. The policy revealed the facility must monitor effects of their approaches to ensure they are implemented as intended and have the desired effect to achieve measurable objectives and resident's goals for care.Review of a facility policy titled, Infection Control - Dressings, Dry/Clean, revised in 08/2024, revealed, the purpose of this procedure is to provide guidelines for the application of dry, clean dressings. The policy noted that steps in the procedure included for staff to have available strips of tape adequate for securing dressing at the end of the procedure and add date, time and initials.Review of a facility policy titled, Venous Access Devices: Midline Catheters, revised in 08/2016, revealed a midline catheter is meant to provide a passage to introduce prescribed fluids or IV medication directly into the basilic, cephalic, or brachial vein distal to the shoulder. Dressings should be changed weekly and if the integrity of the dressing is compromised unless ordered sooner by Physician/clinician. The policy continued for staff to label the dressing with date/time and nurses initials.Review of a facility policy titled, Venous Access Devices: Peripheral IV Lines, dated 01/2018, revealed, a peripheral IV line is meant to provide a passage to introduce prescribed fluids or IV medication directly into the veins. The policy did not address IV dressing changes or the insertion of an IV.

Based on medical record review and staff interview, the facility failed to ensure wound care was documented accurately for one (#82) of three residents sampled for pressure ulcers. The census was 83. Findings include:Review of Resident #82's medical record revealed an admission date of 02/05/25. Diagnoses included multiple sclerosis, morbid obesity, hyperlipidemia, major depressive disorder, anxiety disorder, restless leg syndrome, essential hypertension, pulmonary embolism, constipation, neurogenic bowel, and neuromuscular dysfunction of the bladder. Review of an admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/11/25, revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS assessment indicated the resident was dependent on staff for toileting hygiene, rolling left to right, sitting to lying, lying to sitting on the side of the bed, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, and to walk 10 feet. The MDS assessment further indicated that the resident had an indwelling catheter, was always incontinent of bowel, had a stage II pressure ulcer (partial-thickness skin loss involving the dermis), and an unstageable pressure ulcer (obscured full-thickness skin and tissue loss) present on admission. Review of Resident #82's care plan report included a focus area, dated 02/05/225, that indicated the resident had a pressure ulcer/injury to the coccyx and right heel and was at risk for new development, worsening, recurrence related to community acquire, decreased functional ability, decreased sensory mobility, history of pressure ulcer/injury, history of skin breakdown, hypertension, impaired/decreased mobility, major depressive disorder, anxiety, hyperlipidemia incontinence, slow healing expected per wound nurse practitioner, and history of complicated wounds with a need for frequent debridement. Interventions directed staff to administer medications as ordered, administer nutritional interventions as ordered, administer treatments as ordered and monitor for effectiveness, assist as needed with mobility, turning and repositioning, assist as needed with toileting and hygiene, consult wound nurse practitioner, provide a particular wheelchair cushion, document non-compliance, and evaluate wound for size and depth. Interventions also directed staff to document progress on an ongoing basis, notify physician as indicated, provide an indwelling urinary catheter, provide a house supplement per physician orders, keep resident/responsible party updated on status, monitor for non-compliance, educate about risk with noncompliance, and monitor for signs of pain/discomfort. Administer pain medications and other interventions as needed, monitor for signs and symptoms of infections, monitor need for isolation precautions, notify clinician of worsening conditions, and obtain and monitor laboratory values/diagnostic tests as ordered. Review of Resident #82's February 2025 treatment administration record (TAR) revealed an order entry for Dakins (sodium hypochlorite 1/4 strength) external solution to be applied to the coccyx topically every day and night shift with a start date 02/19/25 and end date 03/06/25. The TAR revealed no evidence to indicate the treatment was completed on 02/25/25 for the day shift. The TAR also revealed an order entry for Dakin's external solution to be applied to right and left buttocks topically each day and night shift with a start date 02/13/25 and an end date of 02/19/25 at 1:22 P.M. The TAR revealed no evidence to indicate the treatment was completed on the evening shift on 02/14/25 and 02/15/25.During an interview on 06/27/25 at 12:42 P.M., Licensed Practical Nurse (LPN) #14 revealed she had been trained to complete treatments and then document their completion. She stated she completed Resident #82's treatments on 02/14/25 and 02/15/25 and must have hurriedly left the building and failed to document their completion. Review of Resident #82's March 2025 TAR revealed Dakin's (1/2 strength) external solution to be applied to the sacrum topically every day and night shift. Directions indicated to cleanse with Dakin's, pack with Dakin's moistened gauze, cover with abdominal pad (ABD), and secure with retention tape with a start date of 03/06/25 and an end date of 03/21/25 at 12:29 P.M. The TAR revealed no evidence to indicate the treatment was completed on the day shift on 03/07/25. During an interview on 06/27/25 at 10:43 A.M., LPN #13 revealed she had been trained to document when treatments were completed. She stated she performed Resident #82's treatment on 03/07/25 but failed to sign the treatment as completed. Review of Resident #82's April 2025 TAR revealed an order entry for Dakin's (1/2 strength) external solution to be applied to the coccyx topically every day and night shift. Directions indicated to cleanse the wound with Dakin's, pack with Dakin's moistened gauze, cover with ABD, and secure with tape with a start date of 04/03/25 at 7:00 P.M. and an end date of 04/17/25 at 7:05 P.M. The TAR revealed no evidence to indicate the treatment was completed on 04/03/25 on evening shift and 04/14/25 on day shift. During an interview on 06/27/25 at 12:50 P.M., Registered Nurse (RN) #6 revealed she had been trained to document completion after each treatment had been completed; however, she stated she forgot to sign after she completed Resident #82's treatment on 04/03/25 and 04/14/25. During an interview on 06/27/25 at 12:55 P.M., the Director of Nursing (DON) stated she expected wound care for Resident #82 to be completed and documented in the resident's electronic medical record after it was completed.During an interview on 06/27/25 at 1:37 P.M., the Administrator stated she expected wound care for Resident #82 to be completed as ordered and documented in the medical record when completed. This deficiency represents non-compliance identified under Complaint Number OH00165272 (iQIES Complaint Number 1372878).

Based on medical record review, staff interview, review of the transportation schedule, and review of the facility statement form the facility failed to ensure a resident had an adequate supply of oxygen when leaving the facility for a medical appointment. This affected one (#91) resident of three residents reviewed for respiratory care and services. The facility census was 90. Findings include: Medical record review for Resident #91 revealed an admitted [DATE]. Diagnoses included hemiplegia, hemiparesis following stroke, narcolepsy, type two diabetes mellitus, chronic heart failure, hypertension, pulmonary embolism, kidney failure and a history of covid. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #91 had significant cognitive impairment, required moderate to maximum assistance from staff for eating, toileting, transfers and bed mobility. Resident #91 had oxygen usage during the assessment period. Review of the plan of care revealed Resident #91 had shortness of breath related to acute respiratory failure. Interventions included to monitor breathing patterns and report abnormalities to the physician, position the resident with proper body alignment for optimal breathing pattern and the use of pain management as needed. Review of the physician orders for Resident #91 revealed an order dated 08/20/24 for oxygen at two to five liters per minute (l/m) via nasal cannula to keep oxygen saturation rate above ninety-two percent every day and night shift related to acute respiratory failure. Review of the facility's transportation schedule dated 11/08/24 revealed Resident #91 had an medical appointment at 10:15 A.M. and had a scheduled picked up for 9:30 A.M. Interview on 12/09/24 at 3:08 P.M. with Certified Nurse Assistant (CNA) #84 stated Resident #91 was sent to the medical appointment with an almost empty oxygen tank and without oxygen on. CNA #84 verified when Resident #91 returned from the appointment the resident did not have oxygen on and that oxygen tubing was on the back of the wheelchair, but there was no oxygen tank. CNA #84 stated Resident #91 did not appear to be short of breath and when the nurse checked Resident #91 oxygen saturation, it was in the nineties. Interview on 12/09/24 at 3:19 P.M. with CNA #34 stated she was assigned to the Resident #91 on 11/08/24. CNA #34 stated the nurse did not advise her of Resident #91's appointment and when transportation arrived Resident #91 was not ready. CNA #34 stated she rushed to get him ready for departure and noted that the portable oxygen tank was almost empty but in the rush to get Resident #91 ready the oxygen tank was not exchanged and should have been. Interview on 12/09/24 at 3:45 P.M. with the Assistant Director of Nursing (ADON) denied any knowledge of the incident. Interview on 12/09/24 at 5:26 P.M. with the facility transportation Driver #402 verified Resident #91 was picked up at the facility and dropped off at a physicians office on 11/08/24, where Resident #91's family member was waiting for the resident. Driver #402 verified Resident #91 had an oxygen tank on the wheelchair with oxygen tubing connected to the tank, but not to Resident #91. Driver #402 stated upon arrival to the appointment the family member advised that Resident #91 was to have oxygen on at all times. When leaving the appointment Driver #402 stated the family member was angry the oxygen tank was empty and took the oxygen tank. Driver #402 stated the incident was reported to the nurse caring for Resident #91 upon returning to the facility with Resident #91 after the appointment. Interview on 12/09/24 at 5:35 P.M. with facility Administrator verified no knowledge of the incident. Interview on 12/10/24 at 11:16 A.M. with Transportation Supervisor #403 verified Driver #402 notified her of the 11/08/24 incident with Resident #91 and the family member. Driver #402 wrote a statement regarding the incident and submitted the statement to the office. Transportation Supervisor #403 verified the facility nurse assigned to Resident #91 was informed of the incident. Review of the facility statement form dated 11/13/24 at 1:30 P.M. completed by Driver #402 revealed when Driver #402 arrived at the facility on 11/08/24 to pick up Resident #91 for a medical appointment, Resident #91 was not ready. CNA's #34 and #84 assisted getting Resident #91 and informed Driver #402 when Resident #91 was ready. The statement also contained information Resident #91 had no oxygen and the family member was angry Resident #91 was sent to an appointment with an empty oxygen tank, again. Additional interview on 12/11/24 at 3:00 P.M. with the Administrator verified the incident had occurred and the management team was not aware of Driver #402's statement or of the oxygen tank not being returned to the facility with Resident #91 after the medical appointment on 11/08/24. This deficiency represents non-compliance investigated under Complaint Number OH00159795.

Based on medical record review, observations, staff interview, policy review and review of the Standards of safe medication administration by a certified medication aide, the facility failed to ensure medications were administered by the staff member who prepared the medications. This affected one (#45) of four residents reviewed for medication administration. The facility census was 76. Finding include: Review of the medication record for Resident #45 revealed an admission on 09/06/23 with diagnoses including but not limited to hypoatremia, anemia, hypertensive orthostatic hypotension renal disease, dementia, and depression. Review of the quarterly Minimum Data Assessment (MDS) assessment dated [DATE] for Resident #45 revealed a brief interview for mental status revealing severe cognitive impairment. Resident #45 required moderate assistance with bed mobility, transfers, and toileting. Resident #45 required set up assistance for meals. Review of the plan of care for Resident #45 revealed the resident had impaired cognition and impaired decision making skills related to dementia. Interventions included administer medication as ordered, cue and reorient as needed and engage the resident is simple structured activities. Review of the physician orders for Resident #45 for the month of January 2024 revealed the resident was scheduled to receive Amlodipine five milligrams (mg) one tablet by mouth, fiber-lax 625 mg by mouth, vitamin B-12 micrograms (mcg) one tablet, digoxin 0.125 mg one tablet by mouth, omeprazole 20 mg tablet by mouth, vitamin D-3 1000 units one tablet by mouth, escitalopram 10 mg one tablet by mouth, sodium chloride one gram (gm) by mouth, questran four gm-one packet mixed with water and metoprolol tartrate 25 mg by mouth. Observation on 01/11/24 at 9:00 A.M. of Licensed Practical Nurse (LPN) #69 prepare the medications for Resident #45. LPN #69 prepared Amlodipine, fiber-lax, vitamin B-12, digoxin, omeprazole, vitamin D-3, escitalopram, sodium chloride, questran, and metoprolol tartrate and placed them in a medication administration cup. LPN #69 then handed the medication cup with medications to the Medication Aide (MA-C) #96 who was not present at the time of medication preparation. MA-C #96 then entered the room of Resident #45 and administered the medication to resident. Interview on 01/11/24 at 9:10 A.M. with LPN #69 verified that MA-C #96 did not prepare the medication for Resident #45. LPN #45 additionally verified she documented in the medical record that she administered the medication not the MA-C and stated MA-C trusted her to prepare the correct medications for administration. Interview on 01/11/24 at 9:12 A.M. with MA-C #96 verified she did not know what medications she was administering to Resident #45 and confirmed she did not prepare the medication following the guidelines for a MA-C (medication name, medication dose, medication expiration date and stored and supplied according to the administrative code). Interview on 01/11/24 at 10:30 A.M. with the Administrator verified LPN #69 did not follow the facility policy regarding the use of a medication aide. Further interview with the Administrator verified the LPN #69 should not have prepared and provided the medication for MA-C #96 to administer and additionally should not have signed that she administered the medication when she did not. Review of the standards of safe medication administration by a certified medication aide dated 02/01/2014 of the Ohio Revised Code states immediately after administering a medication the certified medication aide shall accurately document in the residents medical record the following information: the name of the medication and dosage administered, the route of the administration, the date and time of the administration and the name of the certified medication aide administering the medication. Review of the facility policy titled Administration Oral Medications dated 12/2021 stated the nurse/medication aide will cross check the following reference points to ensure accuracy from the physician orders, medication administration record, and label on drug container for accuracy. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, review of controlled substance records, staff interview, and review of facility policy, the facility failed to ensure a resident's narcotic medication administration was accurately documented in the medical record. This affected one (#81) of three residents reviewed for narcotic medication administration. The census was 78. Findings include: Review of Resident #81 closed medical record revealed an admitted [DATE]. Diagnoses included pubic fracture, dorsalgia, osteoarthritis, and femur fracture. Resident #81 was discharged from the facility on 11/03/23. Review of an admission Minimum data Set (MDS) assessment dated [DATE] revealed Resident #81 was cognitively intact and needed some help with activities of daily living (ADL's). Review of physician orders revealed an order dated 10/16/23 for take 0.5 to one Oxycodone hydrochloride five milligram (mg) tablet (narcotic pain medication) every six hours for pain up to seven days. Review of the facility's Controlled Drug Receipt/Record/Disposition Form revealed one tablet of Oxycodone hydrochloride five mg was documented as being withdrawn on 10/27/23 at 3:30 A.M. Oxycodone hydrochloride five mg was documented as being withdrawn on 10/22/23 at 9:00 A.M. and 10/23/23 at 3:00 A.M. Review of medication administration records (MAR's) revealed no documentation of Oxycodone hydrochloride five mg being administered on 10/17/23 at 3:30 A.M. Oxycodone hydrochloride five mg was documented as being administered on 10/17/23 at 6:25 A.M. Further review of MAR's revealed no documentation of Oxycodone hydrochloride five mg being administered on 10/22/23 at 9:00 A.M. and 10/23/23 at 3:00 A.M. During an interview on 12/06/23 at 10:30 A.M. the Director of Nursing (DON) confirmed the missing and inaccurate documentation in Resident #9's MAR of the Oxycodone medication. The DON had spoken with the nurse responsible for the missing and inaccurate documentation and reported the nurse forgot to log the Oxycodone hydrochloride five mg in the MAR after administering to Resident #9. The DON confirmed all medications administered to residents should be documented in the MAR accurately. Review of the facility;s policy titled Administration of Oral Medications dated revised December 2021 medications are charted as soon after the administration as possible. The nurse or medication aide will document medication administration, refusal, hold, or other necessary codes. This deficiency represents non-compliance investigated under Complaint Number OH00148080.

Based on medical record review, staff, resident and resident representative interviews and policy review, the facility failed to notify the resident's representative when their was a change of condition. This affected one (#1) of three reviewed for change of condition. The census was 71. Findings included: Medical record review for Resident #1 revealed an admitted [DATE]. Medical diagnoses included history of fractures and atrial fibrillation. Review of admission Minimum Data Set, dated dated dated [DATE] revealed she was cognitively intact. Her functional status was extensive assistance for bed mobility, transfers, and toilet use. She was independent for eating. She was occasionally incontinent for bowel and bladder. Review of physician progress note dated 09/26/23 revealed Resident #1 was being seen for red, painful, and warm thumb noted by the therapy department. Review of the progress note dated 09/26/23 revealed there wasn't any evidence Resident #1's Representative was notified of this skin condition. Interview with Resident #1 on 10/25/23 at 10:00 A.M. revealed she couldn't remember if she had a blister on her thumb. Interview with Resident #1's Representative on 10/25/23 at 1:19 P.M. revealed she was not contacted about Resident #'1's thumb on 09/26/23 and was quite surprised by the call. Interview with Assistant Director of Nursing (ADON) #9 on 10/26/23 at 2:15 P.M. revealed Resident #1 wasn't quite herself after she had COVID-19 on 09/09/23 and had periods of confusion and her cognitively status fluctuated. ADON #9 stated there were times they would call the resident's representative if the resident didn't seem alert and oriented. ADON #9 confirmed there wasn't any evidence in the chart the representative as contacted concerning her blister on her thumb. Review of the policy entitled Change in Condition dated 06/01/15 revealed the facility staff will report identified significant changes in resident's status. Documentation of the condition will be noted in the nurses charting or interdisciplinary charting as indicated. The resident's physicians/clinicians and responsible party will be notified of significant changes in resident's conditions. If a resident specified on admission they do want family members notified of a significant change the facility will respect that. If the resident is incapable of making decision, the responsible party will make any decisions that have to be made, but the resident should be up dated on his/her condition. This deficiency represents non-compliance investigated under Complaint Number OH00146641.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's code status was accurately documented. This affected one resident (#13) out of one resident reviewed for advanced directives. The facility census was 58. Findings include: Review of the medical record for Resident #13 revealed she was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly [NAME] Data Set (MDS) assessment dated [DATE] revealed Resident #13 had impaired cognition. Review of the physician orders for Resident #13 revealed an order dated 12/16/19 and discontinued 12/19/19, Do Not Resuscitate Comfort Care (DNRCC). An order dated 12/19/19 and discontinued on 04/02/21 revealed a code status of DNRCC. Further review of the physician orders revealed an order dated 04/02/21 and discontinued on 09/20/22 DNRCC-Arrest (A). An order dated 09/20/22 revealed the code status as DNRCC (Comfort Care). Review of Resident #13's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M.) during the time of survey. Review of the progress notes for Resident #13 revealed no information regarding request to change the code status on 12/19/19, 04/02/21, or on 09/20/22. Interview on 09/20/22 at 4:11 P.M., with the Licensed Practical Nurse (LPN) #270 confirmed the Advance Directive order was changed on 09/20/22 to a DNRCC (comfort care). LPN #270 confirmed the prior order in place for Resident #13 was a DNRCC-A which was the incorrect code status. Interview on 09/26/22 at 2:23 P.M., with the Director of Nursing (DON) verified the code status order was changed on 04/02/21 and the facility was not aware of why it was changed. The DON stated the facility identified the wrong order was in place on 09/20/22. Review of the facility policy titled Advanced Directives-Ohio DNR-Form and Policy, dated 08/2016 revealed once the form is completed, the admitting nurse or charge nurse shall obtain a physician's order indicating DNRCC or DNRCC-Arrest.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented as ordered. This affected one resident (#01) out of three residents reviewed. The facility census was 58. Findings Include: Review of the medical record for Resident #01 revealed an admitted [DATE]. Diagnosis included [CONDITION(S)] disease, non-[CONDITION(S)], non-pressure chronic ulcer of the left ankle, [CONDITION(S)], and disorientation. Review of the minimum data set (MDS) assessment dated on 08/28/22 revealed Resident #01 was severely cognitively impaired. The resident required extensive two-person physical assistance for transfer, dressing, and personal hygiene. Resident #01 required total dependence for toilet use and bathing. Review of the plan of care dated on 09/02/22 revealed Resident #01 was at risk for falls related to transient ischemic attacks (TIA), and a history of [CONDITION(S)]. Resident #01 was non-ambulatory but used a wheelchair. Interventions included an air mattress with bolsters, appropriate footwear, check frequently, extra low bed and to keep the bed in a low position, fall mats to both sides of the bed, provide frequent positioning, and avoid laying on the edge of the bed. Observation on 09/20/22 at 5:07 P.M. revealed Resident #01 was awake in his bed, there was no bolster located on the bed. There was only one fall mat next to the right side of the right side of the resident, but did not have a fall mat located on Resident #01's left side the side not by the wall. Interview on 09/20/22 at 5:15 P.M., with the Licensed Practical Nurse (LPN) #500 verified Resident #01 had no fall mat to the left side, and had no bolsters on his air mattress for fall prevention. Observation on 09/21/22 at 10:10 A.M., revealed Resident #01 was lying down in his room in bed and the fall mat to his left side was not laid down on the floor. Resident #01 had no bolsters on the air mattress. Interview on 09/21/22 at 10:12 A.M., with the Assistant Director of Nursing (ADON) #229 said hospice was supposed to bring a bolster for Resident #01's bed and had not brought one in. Review of policy titled Fall and Fall Risk Managing, revised date 08/2017 revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to decrease the resident risk from failing and to try to minimize complications from falling.

Based on medical record review, observation, and staff and resident interview, the facility failed to ensure care planned interventions were implemented as ordered. This affected three residents (#01, #17, and #61) out of three residents reviewed for quality of care. The facility census was 58. Findings include 1. Medical record review for Resident #17 revealed an admission on 07/01/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had cognitive impairment. Resident #17 required extensive assistance for bed mobility, dressing, total assist for transfers and toilet use. Resident #17 was coded with functional impairment on bilateral upper extremities. Review of the plan of care for Resident #17 dated 09/05/22 revealed the resident had an activity of daily living self-care performance deficit related to impaired mobility, stroke, and contracture of the right hand and the right ankle. Interventions included range of motion as tolerated and a splint device to the right hand as tolerated. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient was to donn the right resting hand splint after the evening meal, remove at breakfast. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 09/19/22 1:52 P.M., with Resident #17 stated she had a contracture on her right hand due to a stroke and the staff was supposed to put a splint on but they had not placed the splint in a long time. Observation on 09/20/22 6:50 P.M. of Resident #17 revealed no splint in place at this time. Observation on 09/22/22 at 7:01 A.M. of Resident #17 revealed no splint in place as ordered. A follow-up interview on 09/20/22 at 7:01 A.M., with Resident #17 stated the staff had not put the splint on last night. Interview on 09/22/22 at 7:03 A.M. with Licensed Practical Nurse (LPN) #233 verified the splint was not in place as it should have been. LPN #233 verified they were going to have to look for the splint as it could not be located at the time of the interview. A request for a policy related to the application of splinting devices was requested during the survey and not provided for review. 2. Medical record review for Resident #61 revealed an admitted on 05/19/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE] revealed Resident #61 had intact cognition. Resident #61 was not assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care for Resident #61 dated 09/15/22 revealed Resident #61 was at risk for bleeding related to aspirin therapy and anticoagulant. Interventions included administer medication as ordered, gently provide oral hygiene, monitor for signs and symptoms of bleeding and obtain laboratory tests as indicated. Review of the active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission skin assessment dated [DATE] for Resident #61 revealed five areas of bruising on the left lower leg measuring 5.5 centimeters (cm) by 2.5 centimeters, right hand measuring 10.5 cm by 6.5 cm, right lower leg measuring 7.5 cm by 4 cm, left hand measuring 2.5 cm by 2.0 cm, and a right antecubital bruise measuring 2.5 cm by 2.0 cm. Review of the Nurse practitioner (NP) progress note dated 08/10/22 revealed no documentation of any bruising on the residents arms and hands. Review of the progress notes for Resident #61 dated 05/19/22 through 09/24/22 revealed no documentation of any bruising or physician notification. Review of the current electronic health record assessment tab for Resident #61 revealed no documentation of any measurements or monitoring of bruising. Review of the previous electronic health record assessment tab for Resident #61 revealed no documentation for any measurements or monitoring of bruising. Observation on 09/20/22 at 12:03 P.M. of Resident #61 sitting in the activity room. Bruising noted to both arms covering the majority of the lower forearms and hands. Bruises were deep purple in color and in various stages of healing. Interview on 09/20/22 at 12:03 P.M., with Resident #61 stated she has new bruises all the time related to her medication, one will heal and then another one will show up. Resident #61 stated staff had not measured them. Resident #61 verified that no one had abused her causing the bruises. Interview on 09/22/22 at 1:19 P.M., with the Director of Nursing (DON) said she spoke with the resident about the new bruising on her hand and was told by the resident that she hit her arm on the table when she was bringing her arm from her lap to the table. The DON verified no measurements were documented in the resident's medical record, the physician was not notified, and it was not measured. The DON said when a new skin issue was identified the staff would measure the area and notify the physician. Additionally, stated since we know the resident was on a blood thinner bruises were to be expected and they were not identified as injuries of unknown origin. A policy regarding anticoagulant monitoring was requested on 09/21/22 and 09/22/22 and not provided for review. 3. Review of the medical record for Resident #01 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed Resident #01 was severely cognitively impaired. The resident required extensive two-person physical assistance for transfer, dressing, and personal hygiene. Resident #01 required total dependence for toilet use and bathing. Review of the plan of care dated on 09/02/22 revealed Resident #01 was at risk for falls related to a recent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #01 was currently non-ambulatory and used a wheelchair for mobility. Interventions included air mattress with bolsters, appropriate clothing and foot wear, frequent reminders, remind to use the call light, frequent repositioning, avoid laying at edge of bed, encourage to use call light, and check frequently. Review of the interdisciplinary team (IDT) follow up note on 08/23/22 at 8:36 A.M. revealed Resident #01 had a skin tear to the left upper extremity. The resident had a bruise on the left arm and had thin skin. A skin tear was received during morning care when staff was turning the resident in bed. A new interventions of geri sleeves was added to help prevent further skin tears and bruising to his upper extremities. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 09/20/22 at 5:07 P.M. Resident #01 was lying in bed, awake and had no geri sleeves on. Interview on 09/20/22 at 5:15 P.M., with LPN #500 who verified Resident #01 had no geri sleeves on at the time. Observation on 09/21/22 at 10:10 A.M. Resident #01 was lying down in bed and had no geri sleeves on at the time. Interview on 09/21/22 at 10:12 A.M., with the Assistant Director of Nursing (ADON) #229 who stated Resident #01 should have had his geri sleeves on his arms. The ADON #229 said she had put them on last night before she left. Observation on 09/21/22 at 10:14 A.M. with the ADON #229 who picked up the geri sleeves laying in the chair and placed the geri sleeves on Resident #01. Interview on 09/27/22 at 6:00 P.M., with the Administrator who said they had no skin protection policy or skin protocol at the facility.

Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure call lights were within reach of the resident. This affected three residents (#17, #32, and #41) out of three residents reviewed for call light placement. The facility census was 58. Findings include: 1. Medical record review for Resident #41 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #41 had impaired cognition. Resident #41 required total assistance for bed mobility, transfers, and toilet use. Resident #41 required extensive assistance with eating. Review of the plan of care for Resident #41 dated 09/15/22 revealed the resident was at risk for self care deficits related to [CONDITION(S)] and dementia. She was alert and not consistent with making her needs known to staff. She received staff assistance with daily care needs. She was encouraged to use the call light for staff assistance with her activities of daily living. Interventions included activities of daily living varies and staff provided care accordingly, resident was non ambulatory and required staff assistance for mobility. Assist with activities of daily living but promote independence. Review of the plan of care for Resident #41 dated 09/15/22 revealed the resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She was alert with confusion. She had no recent falls and was still able to use the call light at times. Interventions included appropriate footwear, clear pathways, check frequently, frequent reminders, teach to lock wheelchair, and remind the resident to use the call light. Observation on 09/19/22 at 12:25 P.M. of Resident #41 resting in bed without the call light within reach. The call light was entangled in the bed frame and the call light activation section was laying on the floor out of the reach of the resident. Interview on 09/19/22 at 12:25 P.M., of Resident #41 verified she was not able to locate her call light. Interview on 09/19/22 on 12:29 P.M., with Licensed Practical Nurse (LPN) #213 verified the resident was able to use her call light and it was not within reach for the resident to activate if needed. LPN #213 verified the call light was on the floor and the clip that attached it to the bed linen was broken and needed replaced. 2. Medical record review for Resident #17 revealed an admission on 07/01/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed resident #17 had cognitive impairment. The resident required extensive assistance for bed mobility, dressing, total assistance for transfers and toilet use. Resident #17 was always incontinent of bowel and bladder. Review of the plan of care for Resident #17 dated 09/15/22 revealed Resident #17 was at risk for falls related to balance problems, incontinence, side effects of medications, unaware of safety needs and impaired mobility. Interventions included assist with transfers, mobility, repositioning, and toilet use as needed, may adjust as needs dictate, keep floors free from spills and clutter, adequate light and call light within reach and encourage resident to use while in room, and frequently used items within reach. Observation on 09/19/22 01:34 P.M. revealed resident sitting in her Geri recliner beside her bed and the call light was not available for the resident to use if needed. Interview on 09/19/22 at 1:37 P.M., with LPN #225 verified the call light was not within reach of the resident to use. LPN #225 located the call light in between the wall and the bed on the floor. LPN #225 verified the resident was able to activate the call light system if needed. 3. Review of the medical record for Resident #32 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated on 08/09/22 revealed Resident #32 was severely cognitively impaired. The resident required extensive two-person assistance for bed mobility, transfers, and toilet use. Resident #32 required one-person physical assistance for personal hygiene, and dressing. Review of the plan of care dated on 08/18/22 revealed Resident #32 was at risk for self-care deficit related to general decline and recent hospitalization . Interventions included assistance with ambulation, bathing, bed mobility, dressing, eating, personal hygiene, oral care, toilet use, and transfers. Observation on 09/19/22 at 1:50 P.M. revealed Resident #32 was alert with periods of confusion. Resident #32 was seated in the recliner with no call light within reach. The call light was approximately three to four feet away from the resident on the bed. Interview and observation on 09/19/22 at 1:51 P.M., with Housekeeper #293 who verified the call light was over on the bed. Housekeeper #293 found the call light near Resident #32's bed and gave it to the resident. Review of the policy titled Nurse Call System, revised date 08/2017 revealed the staff will ensure the call light was within reach when the resident was in their room or bathroom.

Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure medications were safely stored. This affected three residents (#47, #26, and #48) out of seven residents reviewed for medication storage. The facility census was 58. Findings include: 1. Medical record review for Resident #47 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had impaired cognition. Resident #47 required extensive assistance for bed mobility and toilet use. Observation on 09/19/22 at 8:15 A.M. revealed Resident #47 was resting in bed watching television. A tube of [MEDICATION(S)] cream two percent (%) was located on the bedside table. The tube was labeled with a prescription for use for Resident #47. Interview on 09/19/22 at 9:15 A.M., Resident #47 stated she received the cream four times a day for a rash she had and they must have left it in her room. Interview on 09/19/22 at 9:22 A.M. with the Licensed Practical Nurse (LPN) #225 verified the cream was for Resident #47 and should not have been left in the resident's room. 2. Medical record review for Resident #48 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed Resident #48 had impaired cognition. Resident #48 required extensive assistance for bed mobility. The resident was totally dependent for transfers, eating and toilet use. Observation on 09/19/22 at 8:15 A.M. revealed Resident #48 resting in her bed. On the bedside table was a thirty-millimeter medication cup filled to the top with a white creamy substance. Interview on 09/19/22 at 9:22 P.M., with the LPN #225 verified the white lotion without a label on Resident #48's bedside stand. LPN #225 said the resident received [MEDICATION(S)] Gel one percent to her shoulders, elbow and hand every eight hours for arthritis pain but LPN #225 could not confirm what the substance was in the medication cup but it should not be in a resident's room. 3. Medical record review for Resident #26 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had intact cognition. Resident #26 required extensive assistance for bed mobility and transfers. Resident #26 required total assistance for toilet use and supervision for eating. Observation on 09/20/22 10:54 A.M. revealed Resident #26 was resting in bed with his bedside table positioned across the front of the resident. On the bedside table in a pharmacy labeled bag was a bottle of artificial eye drops 1.4 percent with the resident's name on it. Interview on 09/20/22 at 10:54 A.M., Resident #26 stated the nurse brought the eye drops in this morning and forgot to take them out with her. Interview on 09/20/22 at 11:05 A.M., with LPN #287 verified the eye drops were for Resident #26 and should not have been left in the room unsecured and unattended. Review of facility policy titled Medication Storage, dated 12/21 revealed medication and biological's, including treatment items are securely stored in a locked cabinet that is inaccessible by residents and visitors. This deficiency substantiates Master Complaint Number OH 948.

Based on medical record review, interview, and policy review, the facility failed to submit an updated Pre-Admission Screenings and Resident Review (PASARR) following the addition of psychiatric diagnosis. This affected two Residents (#27, #35) out of two residents reviewed. The facility census was 58. Findings include 1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual minimum data set (MDS) assessment dated [DATE] revealed Resident #27 was cognitively intact. The resident was totally dependent on staff with transfers. She required extensive assistance from staff with bed mobility, dressing, personal hygiene, and toilet use. Review of the PASARR provided by the facility for Resident #27 dated 09/12/17 (resident transferred from another nursing facility), revealed no psychiatric diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #27 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of the medical record Resident #35 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed Resident #35 had mildly impaired cognition. Resident #35 was independent with bed mobility, dressing, transfers, eating, personal hygiene and toilet use. Review of Resident #35's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #35's PASARR dated 11/14/20 revealed Section D was marked as no indication of mental health disorders. Review of the facility policy titled PASARR (MI/MR) Identification Screen (OHIO), undated revealed any resident review that requires further evaluation will automatically be referred to the appropriate state agency the [NAME] 2.0 system. Once the determination is made by the state agency. They will send the results directly to the submitter. This will also be uploaded to the electronic health record.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure resident medications were handled in a sanitary manner to decrease the potential of infection. This affected one resident (#19) out of four residents observed for medication administration. The facility census was 58. Findings include: Review of the medical record for Resident #19 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had impaired cognition. Review of the active physicians orders for Resident #19 revealed orders for [MEDICATION(S)] suspension 50 micrograms (mcg) spray both nostrils one time a day for allergies, [MEDICATION(S)] (an antihistamine) solution 137 mcg one spray in each nostrils every 12 hours, [MEDICATION(S)] (a [MEDICATION(S)]) packet 17 grams (gm) one packet daily, [MEDICATION(S)] extended release 25 milligrams (mg) one tablet every day for hypertension, [MEDICATION(S)] (a supplement) 400 mg one tablet daily, [MEDICATION(S)] sulfate (iron supplement) 325 mg one tablet daily, multivitamin one tablet daily, [MEDICATION(S)] (an antidepressant) 25 mg one tablet daily, aspirin chewable 81 milligrams daily, [MEDICATION(S)] (a diuretic) 40 mg tablet daily, omeprazole (a medication to treat heartburn or reflux disease) 20 mg one tablet daily, [MEDICATION(S)] (an anxiolytic medication) 10 mg one tablet daily, tamsulosin ([CONDITION(S)] medication) 0.4 capsule one daily, senna plus (a medication for constipation) 8.6-50 one tablet one time a day, and cetirizine (antihistamine) 10 mg one tablet one time a day. Observation on 09/22/22 at 8:54 A.M. Licensed Practical Nurse (LPN) #225 prepared medications for Resident #19. Prior to the preparation LPN #225 had not performed any hand hygiene before removing the [MEDICATION(S)] suspension, [MEDICATION(S)] solution, [MEDICATION(S)] packet, [MEDICATION(S)] extended release, [MEDICATION(S)], [MEDICATION(S)] sulfate, multivitamin, [MEDICATION(S)], aspirin, [MEDICATION(S)], omeprazole, [MEDICATION(S)], tamsulosin, senna plus, and cetirizine from the medication cart. LPN #225 handled the medication cart keys, the medication cart drawers, and touched the individual medication boxes for each medication. LPN #225 used scissors to open the [MEDICATION(S)] package and poured water from a water pitcher on the cart into a cup then emptied the [MEDICATION(S)] package into the cup and stirred it with a spoon. LPN #225 tore open each individual package emptying the pill into the medication cup. While emptying the package for [MEDICATION(S)] the pill fell on to the medication cart surface. LPN #225 picked up the pill with her bare hands and placed the pill into the medication administration cup with the other opened medications. LPN #225 then picked up the last remaining packet and placed the packet into the medication cup with the other opened medication, advising the surveyor she needed to take the blood pressure before administering the medication. LPN #225 then administered medication to Resident #19 after taking the blood pressure and opening the last remaining individual medication package and emptying it into the medication administration cup with the other medications. Interview on 09/22/22 at 9:05 A.M., with LPN #225 verified she picked up the pill when it spilled onto the medication cart top surface using her bare hands and placed it into the medication cup with the other opened medication and had not performed hand hygiene prior to picking up the medication with her bare hands. LPN #225 verified she placed the [MEDICATION(S)] still in the package from the pharmacy into the medication administration cup touching other opened capsules and pills, and carried them into the room for administration to the resident. Interview on 09/23/22 at 4:09 P.M., with the Director of Nursing (DON) via electronic message verified medication should not be handled with bare hands and administered to a resident. Review of the facility policy titled Administration Oral Medications, dated 12/2021 revealed tablets and capsules are handled so that fingers do not touch them.

Based on medical record review, staff and resident interview, and observation, the facility failed to provide a base line plan of care to the resident or the resident representative within the required timeframe. This affected one resident (#61) out of three reviewed for plan of care. The facility census was 58. Findings include: Review of the medical record for Resident #61 revealed an admitted on 05/19/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #61 had intact cognition. Resident #61 presented no behaviors during the assessment period. Resident #61 required extensive assistance for bed mobility, transfers, toilet use, and personnel hygiene. Resident #61 was incontinent of bladder and has an ostomy. Resident #61 had a stage three pressure ulcer. Review of the baseline plan of care for Resident #61 dated 05/19/22 revealed the plan of care was started on 05/19/22 and signed as completed on 06/08/22. The plan of care had no information regarding her care or services needed. Review of the progress notes dated 05/19/22 through 09/24/22 for Resident #61 had no documentation a baseline plan of care was provided to the resident or resident representative within the first 48 hours of her stay at the facility. Review of the Long Term Care Conference Summary dated 05/25/22 and locked 06/08/22 for Resident #61 revealed a team conference meeting was held with family, resident, nursing, dietary, social worker and activity director. The document had no evidence the plan of care being provided to the resident or the resident representative. Interview and observation on 09/20/22 at 12:03 P.M., with Resident #61 said she had not received a copy of the plan care from the facility. Resident #61 was dressed for the season and groomed. Interview on 09/22/22 at 2:10 P.M., with the Director of Nursing (DON) said the base line plan of care was initiated on 05/19/22 and signed completed by herself on 06/08/22, the DON verified there was no documentation the facility provided the resident with the document as required. A request for a policy related to the baseline plan of care was made during the annual survey and was not provided for review.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure a resident was provided privacy. This affected one resident (#01) out of three residents reviewed. The facility census was 58. Findings Included: Review of the medical record for Resident #01 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the minimum data set (MDS) dated on 08/28/22 revealed Resident #01 was severely cognitively impaired. The resident required extensive two-person physical assistance for transfer, dressing, and personal hygiene. Resident #01 required total dependence for toilet use and bathing. Observation on 09/20/22 at 5:07 P.M. Resident #01 was lying in the bed with the sheet pulled up exposing his adult brief. The resident was awake, had no Geri sleeves (protective sleeves) on or the bolster to the bed. Observation on 09/20/22 at 5:08 P.M. Resident #01 could be seen from the hallway in bed with his adult brief exposed. The residents door was open, and the privacy curtain was not pulled to provide privacy. Observation on 09/20/22 at 5:08 P.M. the Admissions Staff #505 was touring the facility with two unknown family members who viewed the room across the hall from Resident #01. Interview on 09/20/22 at 5:15 P.M., with Licensed Practical Nurse (LPN) #500 verified Resident #01 was uncovered in his room exposing his adult brief. Interview on 09/20/22 at 5:45 P.M the Admissions Staff #505 said she had not noticed Resident #01 was exposed in his room. The Admissions Staff #505 said she was in the hall with a new family who were touring the facility. Review of the policy titled Quality of Life and Dignity, revised date 08/2017 revealed staff to promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Residents are treated with dignity and respect at all times.

Based on medical record review, staff interview, and review of the bed hold form, the facility failed to provide notification of the facility's bed hold policy. This affected one resident (#09) out of one resident reviewed. The facility census was 58. Findings include Review of the medical record revealed Resident #09 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the discharge with return anticipated minimum data set (MDS) assessment dated [DATE] revealed Resident #09 was cognitively intact. The resident required supervision from staff with transfers, personal hygiene, toilet use, and bed mobility. Review of Resident #09's progress notes revealed she was transferred to the hospital on 08/16/22 following a fall at the facility. Resident #09 was readmitted to the facility on [DATE] following her hospital stay. Interview on 09/22/22 at 8:45 A.M., with the Administrator provided a paper titled Bed Holds & Leaves of Absence, dated 2018. The Administrator stated this letter was given to each individual when they discharged from the facility to the hospital. Review of the form titled Bed Holds & Leaves of Absence, dated 2018 revealed the letter contained no information regarding the number of bed hold days available or the cost of holding a bed if days were not available. A follow-up interview on 09/22/22 at 10:10 A.M., with the Administrator verified the facility provided each resident a copy of the bed hold policy at the time of discharge. The Administrator said the bed hold notification was a copy of a letter that was given to every resident at discharge. The letter had no specific information for the resident that discharged . The Administrator verified the letter does not provide information regarding the number of bed hold days available or cost of holding a bed if bed hold days were not available.

Based on observation, medical record review, staff, resident, and resident representative interview, and policy review, the facility failed to ensure a safe, clean, and comfortable environment. This affected three residents (#21, #27, and #220) out of three residents reviewed. The facility census was 58. Findings include 1. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE]. Diagnoses included [NAME]-Chiari Syndrome, [CONDITION(S)], [CONDITION(S)], presence of cerebrospinal fluid drainage, dysphagia dysphonia, seizures, moderate protein calorie malnutrition, pressure ulcer of sacral region, [CONDITION(S)], and [CONDITION(S)]. Review of the quarterly [NAME] data set (MDS) assessment dated [DATE] revealed Resident #21 had impaired cognition. The resident was totally dependent on staff with transfers, eating and toilet use. Resident #21 required extensive assistance from staff with bed mobility, dressing, and personal hygiene. Interview on 09/19/22 at 11:58 A.M., with Resident #21's representative revealed he has observed Resident #21's wheelchair cushion to be dirty and soiled. The resident representative lifted up the wheelchair cushion and it was visibly soiled with a cracked brown dried substance. Interview on 09/19/22 at 12:17 P.M., with the Licensed Practical Nurse (LPN) #270 verified the cracked, dry, brown substance was on Resident #21's wheelchair cushion. LPN #270 stated the night state tested nurse aides are assigned cleaning the wheelchairs and cushion during the third shift. Review of the facility policy titled Wheelchair - Broda Chair - Gerichair Policy, dated 12/12 stated Wheelchairs and Geri-chairs are cleaned weekly and prn (as needed). 2. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, end stage renal disease, austro-[CONDITION(S)] reflux disease, acquired absence of right leg below the knee, major depressive disorder, [CONDITION(S)], [CONDITION(S)] Disease, and [CONDITION(S)]. Review of the annual MDS assessment dated [DATE] revealed Resident #27 was cognitively intact. The resident was totally dependent on staff with transfers. She required extensive assistance from staff with bed mobility, dressing, personal hygiene, and toilet use. Resident #27 was independent with eating and able to feed herself. Observation on 09/20/22 at 11:45 A.M., revealed Resident #27's floor had food containers, napkins, straw covers, and various trash under her bed and around her trash can. The carpet appeared soiled with debris. Observation on 09/21/22 at 12:13 P.M. Resident #27 was lying in bed with various trash all over the carpet including napkins, straw covers, and food containers. The carpet appeared soiled with debris strewn about. Interview on 09/21/22 at 12:16 P.M., with the Registered Dietician (RD) # 500 who verified the trash and debris were strewn across Resident #27's room. RD #500 verified the empty food containers under Resident #27's bed and the large stains on the carpet. 3. Review of the medical record for Resident #220 revealed an admitted [DATE]. Diagnosis included perforation of intestine, peritoneal abscess, gastroesophageal reflux disease, and intestines obstruction. Review of the MDS dated [DATE] revealed that Resident #220 was unfinished due to the recent admission. Resident #220 used a walker to ambulate at the facility. Review of the plan of care dated on 09/08/22 revealed Resident #220 was at risk for activity of daily living self-care performance deficit related to impaired mobility and pain. Interventions included assistance required for dressing, bathing, and transfers. Observation and interview on 09/19/22 at 2:04 P.M. with Resident #220 said she had taken a shower earlier in the day to leave the facility. There were towels on the floor in her way which made it difficult to ambulate with the walker. Observation on 09/19/22 at 2:05 P.M. Resident #220 had two-bathroom towels thrown on the floor in the middle of the bathroom near the shower floor. There was trash spilling out of the can. Used paper towels were near the trash can and a used plastic gloves laying near the bathroom trash can. Review of the facility policy titled Environmental Services Nurse's Department, undated revealed It is the policy of this skilled nursing facility to provide guidelines specific for cleaning duties to provide an optimum environment for the staff, residents, and visitors. Resident's rooms are cleaned on a weekly basis. Review of policy titled Management of Soiled Linen revised date 11/2017 revealed place soiled linen, linen with blood or body fluids into designated containers.

Based on medical record review, staff interviews, and physician interview, the facility failed to administer a [CONDITION(S)] machine (delivers an inhale and an exhale pressure and helps to open the lungs with this air pressure) as physician ordered. This affected one (#32) of three residents reviewed for respiratory concerns. The facility identified ten residents with respiratory concerns. The facility census was 67. Findings include: Review of the medical record for Resident #32 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the discharge Minimum Data Set (MDS) assessment for Resident #32, dated 05/28/21, revealed the resident required extensive assistance for dressing and hygiene and had shortness of breath (SOB) with exertion and at rest. Review of the hospital discharge instructions, dated 05/27/21, revealed to apply [CONDITION(S)] 'as directed'. There were no specific instructions for use of [CONDITION(S)]. Review of the plan of care for Resident #32, dated 05/27/21, revealed the resident was at risk for a potential in alteration of respiratory status related to [CONDITION(S)] (CHF) and [CONDITION(S)]. Interventions included administering respiratory treatments as ordered, observing for increased confusion or changes in mental status, and assessing lung sounds, vital signs, oxygen saturation, characteristics of respirations, and skin color every shift. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M., revealed Resident #32 was scheduled to have her [CONDITION(S)] machine at HS. The nurse noted the facility was awaiting arrival. Interview on 06/25/21 at 12:00 P.M. with the Director of Nursing (DON) confirmed the local company in which the facility received their oxygen supplies from. The DON verified a [CONDITION(S)] machine for a resident should be received within six hours of admission. The DON believed the resident's [CONDITION(S)] machine arrived at the facility on 05/28/21 in the early morning. Interview on 06/25/21 at 12:50 P.M. with Licensed Practical Nurse (LPN) #40 confirmed he worked when Resident #32 arrived at the facility. He confirmed he was on shift during the day on 05/27/21 and 05/28/21. LPN #40 stated the ordering of the [CONDITION(S)] machine would be the job of the night shift nurse as Resident #32 arrived at the facility on 05/27/21 at 6:00 P.M. LPN #40 was unaware if the [CONDITION(S)] machine was ordered by the oncoming nurse. Phone interview on 07/02/21 at 10:30 A.M. with Physician #500 confirmed Resident #32 arrived at the facility on 05/27/21 at about 6:00 P.M. and discharged later in the evening on 05/28/21. Physician #500 stated that she was not the doctor who verified the orders for Resident #32 but did see her on the morning of 05/28/21. The Physician assessed the resident that morning on 05/28/21 and noted no concerns. Physician #500 was not aware the facility did not have a [CONDITION(S)] machine for Resident #32 for the evening of 05/27/21 into the morning of 05/28/21. The hospital paperwork and facility order sheets confirmed Resident #32 was to receive a [CONDITION(S)] at night. Phone interview on 07/02/21 at 11:30 A.M. with RN #62 confirmed the [CONDITION(S)] was an order written [MEDICAL RECORD OR PHYSICIAN ORDER] .M. stating the facility was awaiting arrival of the [CONDITION(S)]. This deficiency substantiates Complaint Number OH 492.