Every finding on record at Edgewood Manor of Greenfield

Based on medical record review, staff interview, and review of the facility policy, the facility failed to notify the resident and the resident's representative of a change in medical condition. This affected one (Resident #10) of three residents reviewed for notification of change in medical condition. The facility total census was 46 residents. Findings include: Review of the medical record for Resident #10 revealed an admission date of 08/24/25 with diagnoses including chronic obstructive pulmonary disease, diabetes, anxiety disorder, peripheral vascular disease, and vascular dementia. Review of the physician's note for Resident #10 dated 06/16/26 at 11:59 P.M. revealed the resident was readmitted with a non-pressure chronic ulcer due to peripheral artery disease after post-acute care and vascular surgery and debridement on 06/011/26 resulting in a wound vac treatment placement. Review of the nursing note for Resident #10 dated 06/15/26 at 5:02 P.M. revealed the resident returned from hospital a hospital stay with the left lower extremity wrapped with dressing. Review of the nursing notes for Resident #10 dated 06/15/26 to 06/23/25 revealed they did not include documentation of notification to the resident and/or the resident's representative of changes to the resident's wound. Interview on 06/23/26 at 9:12 A.M with the Director of Nursing, (DON) confirmed Assistant Director of Nursing (ADON) #30 notified her on 06/20/26 early in the morning after midnight that Licensed Practical Nurse, (LPN) # 54 had found fly maggots in Resident #10's dressing to the left leg. The DON stated the facility staff should have notified Resident #10 and/or the resident's representative of the change in the wound. Interview on 06/23/26 at 9:31 A.M with ADON #30 verified LPN #54 had contacted her in the early hours of 06/20/26 and reported the staff found fly maggots Resident #10's leg wound. ADON #30 verified the facility staff had not notified Resident #10 nor the resident's representative of the wound change observed on 06/19/26 Interview on 06/23/26 at 12:52 P.M. with LPN #54 confirmed early on 06/20/26 she discovered fly maggots in Resident #10's leg wound when she removed the wound vac dressing. LPN #54 stated she asked the Agency Nurse (AN) #80 and Certified Nursing Assistant (CNA) # 25 to observe the fly maggots under the dressings. LPN #54 stated Resident #10 had asked several times during the dressing change why so many staff were looking at her wounds. LPN #54 verified she did not tell the Resident #10 and she did not contact the family representative regarding the maggots to the wound. Interview on 06/23/26 at 1:14 P.M. with CNA #25 verified on 06/20/26 in the early hours PN #54 called her to Resident #10's room and she observed approximately 12 fly magots smaller than a grain of rice on the surface of the wound and five fly maggots under the wound vac treatment. CNA #25 stated Resident #10 asked several times why staff were looking at her wounds. CNA #25 verified neither she nor LPN #54 told Resident #10 of the fly maggots in her wounds. Review of facility policy titled Change in a Resident's Condition or Status dated 2001 revealed the facility should promptly notify the resident, his or her attending physician and the resident's representative of changes in the resident's medical condition or status.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to provide wound treatments as ordered by the physician and per professional standards of nursing practice. This affected three (Residents #10, #32 and #20) of three resident reviewed for wound care. The facility census was 46 residents. Findings include:1. Review of the medical record for Resident #32 revealed an admission date of 04/22/26 with diagnoses including fracture of the left femur, diabetes, and venous insufficiency. Review of the Minimum Data Set (MDS) assessment for Resident #32 dated 06/15/26 revealed the resident had intact cognition. Review of the physician's orders for Resident #32 dated June 2026 revealed an order to cleanse the left heel with wound cleanser, pat dry, apply Betadine and pad and kerlix once daily on day shift. Review of the nurse progress notes for Resident #32 dated 06/20/26 to 06/23/26 revealed the notes did not include documentation regarding why the resident's dressing to the left heel was not changed as ordered. Observation on 06/23/26 at 9:35 A.M. revealed the treatment to Resident 32's left heel was dated 06/20/26 with no time noted on the treatment. Interview on 06/23/26 at 9:35 A.M. with Assistant Director of Nursing (ADON) #30 verified Resident #32 had a treatment to the left heel ordered to be completed once daily. ADON #30 confirmed Resident #32's dressing was dated 06/20/26 indicating the treatment had not been completed daily as ordered. ADON #30 stated nurses should label wound treatments with the nurse's initials and the date and time of the treatment. 2. Review of the medical record for Resident #10 revealed an admission date of 08/24/25 with diagnoses including chronic obstructive pulmonary disease, diabetes, anxiety disorder, peripheral vascular disease, and vascular dementia. Review of physician's orders for Resident #10 revealed an order dated 06/19/26 for a daily dressing change wound treatment to the resident's left lower extremity. Observation on 06/23/26 at 4:20 P.M. of Resident #10 with Wound Nurse Practitioner (WNP) #70 revealed the dressing to the resident's left lower extremity was initialed by a nurse and dated 06/23/26, but there was no time noted on the treatment. Interview on 06/23/26 at 4:20 P.M. with WNP #70 verified the wound treatment to Resident #10's left lower extremity had no time noted on the treatment. WNP #70 stated it is nursing standard of practice for a nurse to label the wound dressing with the nurse's initials and the date and time of the treatment. 3. Review of the medical record for Resident #20 revealed the resident was admitted to the facility on [DATE] with diagnoses including diabetes, thrombosis of deep veins, and history of cardiac arrest. Review of the MDS assessment for Resident #20 dated 05/26/26 revealed the resident had severely impaired cognition and was dependent of staff for all care. Review of the physician's orders for Resident #20 dated June 2026 revealed an order to cleanse the left heel with wound cleanser, pat dry, apply Betadine, apply pad and Kerlix gauze once daily on day shift. Observation on 06/23/26 at 10:07 A.M. revealed Resident #20 had a treatment to the left heel dated 06/22/26 but the there was no time noted. Interview on 06/23/26 at 10:07 A.M. with Licensed Practical Nurse (LPN) # 9 verified Resident #20's wound dressing was not labeled with the time of the treatment. LPN #9 stated the time should be listed on the dressing as a nursing standard of practice for wound treatments. Interview on 06/23/26 at 3:35 P.M. with Regional Nurse (RN)#75 verified it was a standard of nursing practice for nurses to write the initials of the nurse performing the treatment and the date and time of the treatment on the dressing. Review of facility policy titled Wound Treatment Management dated 2025 revealed the facility would provide evidence based treatment as ordered by the physician in accordance with current standards of practice. This deficiency represents noncompliance investigated under Complaint Number 3049933.

Based on medical record review, staff interview. and review of the facility policy, the facility failed to document changes in a resident's medical condition in the medical record. This affected one (Resident #10) of three residents reviewed for documentation of a change in condition. The facility total census was 46 residents. Findings include: Review of the medical record for Resident #10 revealed an admission date of 08/24/25 with diagnoses including chronic obstructive pulmonary disease, diabetes, anxiety disorder, peripheral vascular disease, and vascular dementia. Review of the physician's note for Resident #10 dated 06/16/26 at 11:59 P.M. revealed the resident was readmitted with a non-pressure chronic ulcer due to peripheral artery disease after post-acute care and vascular surgery and debridement on 06/011/26 resulting in a wound vac treatment placement. Review of the nursing note for Resident #10 dated 06/15/26 at 5:02 P.M. revealed the resident returned from hospital a hospital stay with the left lower extremity wrapped with dressing. Review of the nursing notes for Resident #10 dated 06/15/26 to 06/23/25 revealed they did not include documentation of notification to the resident and/or the resident's representative of changes to the resident's wound. Interview on 06/23/26 at 9:12 A.M with the Director of Nursing, (DON) confirmed Assistant Director of Nursing (ADON) #30 notified her on 06/20/26 early in the morning after midnight that Licensed Practical Nurse, (LPN) # 54 had found fly maggots in Resident #10's dressing to the left leg. The DON stated ADON #30 told her Regional Nurse, (RN) # 75 had been contacted and had directed LPN #54 to not document the change in condition of the Resident #10 wounds. Interview on 06/23/26 at 9:31 A.M with ADON #30 verified LPN #54 had contacted her in the early hours of 06/20/26 and reported the staff found fly maggots Resident #10's leg wound. ADON #30 stated she contacted RN #75 who directed no documentation should be recorded in the medical record of the fly maggots to Resident #10's leg wound. ADON #30 verified any change of condition should be documented in the nursing notes timely and there should be documentation of notification provided to the resident and /or family representative and physician of the change in condition. Interview on 06/23/26 at 12:52 P.M. with LPN #54 confirmed early on 06/20/26 she discovered fly maggots in Resident #10's leg wound when she removed the wound vac dressing. LPN #54 stated she asked the Agency Nurse (AN) #80 and Certified Nursing Assistant (CNA) # 25 to observe the fly maggots under the dressings. LPN #54 stated on 06/20/26 ADON #30 had directed her per the direction of the RN #75 to not document the wound changes to Resident #10's wound in the nursing progress notes. LPN #54 verified the wound condition change and notifications should have been documented in the nursing progress notes. Interview on 06/23/26 at 1:14 P.M. with CNA #25 verified on 06/20/26 in the early hours LPN #54 called her to Resident #10's room and she observed approximately 12 fly maggots smaller than a grain of rice on the surface of the wound and five fly maggots under the wound vac treatment. Interview on 06/23/26 at 3:35 P.M. with RN #75 denied she had given directions to the ADON #30 for LPN #54 to not document on Resident #10's wound changes found on 06/20/26. RN #75 stated nursing documentation should be timely and accurate to what the nurse had observed, assessed and reported. Review of facility policy titled Change in a Resident's Condition or Status dated 2001 revealed the nurse should record in the resident's medical record information relative to changes in the resident's medical condition.

Based on medical record review, staff interview, and facility policy review, the facility failed to ensure resident dependent on staff for activities of daily living received a bath or shower as scheduled or requested. This affected one (Resident #32) out of four residents reviewed for bathing care. The facility census was 48.Findings include:Review of the medical record for Resident #32 revealed an admission date of 11/07/25. Diagnosis included nontraumatic intracerebral hemorrhage, dementia, anxiety disorder, and psychoactive substance abuse. Review of Resident #32's Medicare 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating a moderately impaired cognition for daily decision-making abilities. Resident #32 was noted to be dependent of staff for bathing, dressing and toileting hygiene. Review of the facility's current bathing schedule revealed Resident #32 was scheduled to receive a bath or shower twice a week on Wednesday and Saturday's nights. Review of the bathing task for Resident #32 from 03/01/26 through 05/24/26 revealed there was a 10-day span between 03/25/26 through 04/05/26 where no bath or shower was documented as being offered, received, or refused. Interview on 05/27/26 at 3:10 P.M. with the Director of Nursing verified there was a 10-day span where Resident #32 was not noted to have received or been offered a bath or shower. Resident #32 was noted to still be at the facility during this time. The DON claimed they were not sure why Resident #32 would not have received a bath or shower during that time frame. Review of the facility policy titled Shower/Tub Bath, revised on 02/2018 revealed that the purpose of this procedure is to provide cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Noted under Documentation section of this policy was the information to be documented when a bath or shower was completed which included the date and time the bath or shower was performed, name and title of the individual who assisted along with if the resident refused the bath or shower and any interventions taken.

Based on medical record review, observations, and staff interview, the facility failed to ensure call lights to request for help or assistance was within reach for all residents. This affected one (Resident #32) out of four residents reviewed for call lights. The facility census was 48.Findings include:Review of the medical record for Resident #32 revealed an admission date of 11/07/25. Diagnosis included nontraumatic intracerebral hemorrhage, dementia, anxiety disorder, and psychoactive substance abuse. Review of the plan of care dated 05/10/26 and revised 05/11/26 revealed Resident #32 was at risk for falls and had an actual fall with no injury. Interventions related to fall safety included keeping a call light in reach. Review of Resident #32's Medicare 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating a moderately impaired cognition for daily decision-making abilities. Resident #32 was noted to be dependent of staff for bathing, dressing and toileting hygiene. Observation on 05/26/26 at 4:00 P.M. of Resident #32's room revealed resident was out of room at that time. A push pad call light was noted to be on the floor under the room divider curtain and not within reach if needed. Observation on 05/27/26 at 9:36 A.M. revealed Resident #32 laying supine in bed with the bed in the lowest position, the left side of the bed up against the wall and the right side of the bed had a fall mat on the floor next to the bed. A touch pad call light was observed on the floor under the room divider curtain as observed the previous day. Interview on 05/27/26 at 9:39 A.M. with Licensed Practical Nurse (LPN) #2 verified Resident #32's call light was on the floor and not within reach. LPN #2 claimed call lights should be within reach at all times.

Based on resident and staff interview, review for the facility grievance log, and review of a facility policy, the facility failed to make prompt efforts to resolve dietary grievances. This had the potential to affect all 50 residents residing in the facility. The facility census was 50. Findings include: Review of the October 2024 grievance log revealed the facility received four grievances regarding dietary services and the quality of the food. The resolutions listed included to educate on tray line and availability and will cook the food longer. Review of the November 2024 grievance log revealed the facility received two grievances regarding dietary services, the quantity of food, and the quality of the food. The resolutions listed were the facility offered alternatives and adjusted portions. Review of the December 2024 grievance log revealed the facility received two grievances regarding dietary services and food. The resolution listed was the facility educated staff. Interview with Resident #9 on 01/21/25 at 9:25 A.M. revealed the food did not taste good at the facility. Interview with Resident #27 on 01/21/25 at 9:36 A.M. revealed the food at the facility was not good. Resident #27 stated he believed the issue was with how the food was prepared. Interview with Resident #28 on 01/21/25 at 10:09 A.M. revealed Resident #28 disliked the food at the facility. Interview with Resident #12 on 01/21/25 at 10:30 A.M. revealed the food did not taste good at the facility. Interview with Resident #29 on 01/21/25 at 11:15 A.M. revealed the food did not taste good at the facility, and reported the food was bland. Interview with Resident #21 on 01/21/25 at 2:32 P.M. revealed the food did not taste good at the facility. Interview with the Administrator on 01/23/25 at 11:03 A.M. verified the facility had received a large number of complaints about the food and dietary services. The Administrator reported the dietary department at the facility were contracted staff and the complaints about dietary services continued to occur because the facility could only discuss the residents' concerns with the dietary services contractor. The Administrator reported the facility did not have any proof of the education provided from the October and December 2024 grievances regarding the dietary services grievances was provided to dietary services staff. The Administrator stated she never tested the food at the facility for quality. Interview with Licensed Practical Nurse (LPN) #335 on 01/23/25 at 1:14 P.M. revealed residents complained of the food being too cold or they received small portions. LPN #335 stated the food complaints at the facility had been ongoing and LPN #335 felt the food did not appear appetizing. Review of the facility's undated policy titled, Resident and family concerns and grievances policy and procedure, revealed residents may voice a grievance to the facility staff in person, by phone or by written communication. The facility will follow up with residents within 72 hours of the filing of a grievance. The facility will make reasonable efforts to ensure that all grievances are adequately resolved within thirty calendar days from the day the grievance was received. This deficiency represents non-compliance investigated under Complaint Number OH00161251.

Based on observation, staff interview, review of menu spreadsheets, and review of a facility policy, the facility failed to ensure menus were followed during meal service. This affected all 50 residents residing in the facility. The facility census was 50. Findings include: Review of the menu spreadsheet dated 01/22/25 revealed residents on a regular diet were to receive one country fried steak with mushroom gravy, four ounces of carrots, four ounces of potatoes, and a square of cornbread, and residents on mechanical soft diets were to receive a four ounce scoop of ground country fried steak with mushroom gravy, four ounces of carrots, four ounces of potatoes, and a square of cornbread. Observation of meal service on 01/22/25 at 4:45 P.M. revealed [NAME] #406 served residents on regular diets one country fried steak, three ounces of gravy, four ounces of carrots, three ounces of potatoes, and a square of corn bread. [NAME] #406 served residents on mechanical soft diets three ounces of mechanically altered country fried steak, three ounces of gravy, four ounces of carrots, three ounces of potatoes, and a square of corn bread. Interview with [NAME] #406 on 01/22/25 at 4:45 P.M. verified residents on regular diets were served a three ounce scoop of potatoes and the menu spreadsheet indicated those residents should have received four ounces of potatoes. [NAME] #406 also confirmed residents on mechanical soft diets were served a three ounce scoop of potatoes and a three ounce scoop of mechanically altered country fried steak and the menu spreadsheet indicated those residents should have received four ounces of potatoes and four ounces of country fried steak. Review of the facility menus policy, dated October 2022, revealed menus were to be served as written. This deficiency represents non-compliance investigated under Complaint Number OH00161251.

Based on observation, staff interview, review of a dishwasher operation manual, and facility policy review, the facility failed to ensure food was served in a safe and sanitary manner, failed to ensure the kitchen was properly cleaned, and failed to ensure the dishwasher was appropriately functioning. This affected all 50 residents residing in the facility. The census was 50. Findings include: 1. Observation of the kitchen on 01/21/25 at 8:50 A.M. revealed staff were actively using the dishwasher. The dishwasher had a wash temperature of 111 degrees Fahrenheit (F) and a rinse temperature of 146 degrees F. Dietary Manager (DM) #410 was observed testing the chemical sanitizer in the dishwasher and the dishwasher tested at 200 parts per million (ppm). Interview with DM #410 on 01/21/25 at 8:50 P.M. verified the dishwasher had a wash temperature of 111 degrees F and a rinse temperature of 146 degrees F. DM #410 stated the dishwasher was a low temperature dishwasher, and the wash and rinse temperature should be above 120 degrees F. Review of the facility policy titled, Warewashing, revised February 2023, revealed all dishwasher water temperatures will be maintained in accordance with manufacturer recommendations for high or low temperature machines. Review of the dishwasher's operations manual dated May 2024 revealed the minimum wash and rinse temperature was 120 degrees F. 2. Observation of the kitchen on 01/22/25 at 4:45 P.M. revealed the ventilation cover on the ceiling above the facility's sink had a gray fuzzy substance built up on it. Interview with DM #410 on 01/22/25 at 4:45 P.M. verified the vent on the ceiling above the facility's sink had a gray fuzzy substance built up on it. 3. Observation of the meal tray line on 01/22/25 at 4:45 P.M. revealed [NAME] #406 was observed serving dinner to residents while wearing gloves. [NAME] #406 was observed to get gravy on her glove. [NAME] #406 proceeded to go to the dirty side of the dishwasher and use the overhead facet sprayer to spray the gravy off her glove using her other gloved hand to operate the facet. [NAME] #406 then returned to the tray line and continued to serve resident meals on the tray line without changing her gloves or washing her hands. Further observation of the meal tray line revealed [NAME] #406 grabbed a plate from a clean stack of plates that had a piece of lettuce on it from where it did not get completely cleaned in the dishwasher. [NAME] #406 proceeded to take off the piece of lettuce with her gloved hand, wiped the lettuce and her gloved hand on her shirt and continued to serve the meal on the soiled plate. [NAME] #406 also did not change her gloves after taking the lettuce off the plate or wiping it on her shirt. After the surveyor confirmed [NAME] #406 did not change her gloves or wash her hands during the observation, [NAME] #406 took the gloves off, washed her hands, and then proceeded to blow into a new pair of gloves with her mouth before putting them on and continuing to serve resident meals. Interview with [NAME] #406 on 01/22/25 at 4:45 P.M. verified she did not change her gloves after spraying off her glove using the facet on the dirty side of the dishwasher, and after removing lettuce from a soiled plate. [NAME] #406 verified that she blew into her new pair of gloves when she changed her gloves. [NAME] #406 also confirmed she continued to serve a resident's meal on a soiled plate after removing a piece of lettuce from the plate. Review of the facility policy titled, Warewashing, revised February 2023, revealed all dishware will be cleaned and sanitized after each use. Review of the facility's food preparation policy, revised February 2023, revealed all staff will practice proper hand washing techniques and glove use.

Based on observation, medical record review, and staff interview, the facility failed to maintain a clean, sanitary, and homelike environment. This had the potential to affected all 50 residents residing at the facility. The facility census was 50. Findings include: 1. Interview and observation with the Administrator on 01/23/25 at 9:25 A.M. confirmed the light over the nurses' station when walking onto the unit from the front door did not have a cover and had exposed florescent lighting. The light to the left of the main nurses' station when walking onto the unit was missing a light cover and had exposed florescent lighting. The [NAME] Court hallway had four missing light covers with exposed bulbs. The [NAME] hallway had exposed ceiling with no ceiling tiles outside of Resident room [ROOM NUMBER] and damage on the ceiling with no tiles cover outside of Resident room [ROOM NUMBER]. Their was also a light out over the seating areas of the resident living room. The [NAME] Court hallway had a total of four florescent lights out. The Administrator confirmed the findings at the time of the observations. 2. Medical record review for Resident #41 revealed he admitted to the facility on [DATE]. His diagnoses included complete traumatic amputation of one left lesser toe, essential primary hypertension, staphylococcal arthritis, diabetes mellitus (DM), and chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) assessment for Resident #41 dated 12/12/24 revealed he had mildly impaired cognition. Resident #41 was dependent on staff for toilet use, required moderate assistance from staff with bathing, lower body dressing, putting on shoes, and personal hygiene, and required set up assistance from staff with eating and oral hygiene. Observation on 01/21/25 at 12:50 P.M. revealed Resident # 41's room had a strong odor of urine, scattered debris all over the floor, and the floor appeared to be dirty. Interview on 01/21/25 at 1:53 P.M. with Licensed Practical Nurse (LPN) #238 confirmed the strong smell of urine in Resident #41's room, and confirmed the debris scattered all over the floor and appearance of the dirty floor. 3. Medical record review for Resident #28 revealed he admitted to the facility on [DATE]. His diagnoses included, DM, end stage renal disease, essential primary hypertension, peripheral vascular disease, gastro-esophageal reflux disease, heart failure, heart failure, atherosclerotic heart disease, congenital and hereditary, and insomnia. Review of MDS assessment dated [DATE] revealed Resident #28 was cognitively intact. Further review of the MDS assessment revealed he was dependent on staff for bathing, required set up assistance from staff for eating, required moderate assistance from staff with oral hygiene, upper body dressing, and personal hygiene, and required maximum assistance from staff with toile use and lower body dressing. Observation on 01/21/25 at 10:09 A.M. revealed Resident #28 had a brown and reddish substance splattered and scattered along the wall next to the resident's bed. Further observation revealed the floor appeared soiled and unkept. Interview and observation on 01/22/25 at 11:20 A.M. with LPN #238 confirmed the brown and reddish stains and splatters along Resident #28's wall beside his bed, and confirmed the floor appeared soiled and dirty.

Based on observation, staff interview, review of a resident list, and review of a food recipe, revealed the facility failed to prepare food in a palatable and attractive manner. This affected four (#1, #3, #6, and #42) of four residents who received mashed potatoes during meal observations. The facility census was 50. Findings include: Observation of meal service on 01/22/25 at 4:45 P.M. revealed [NAME] #406 served mashed potatoes as an alternate using a four ounce scoop. Further observation revealed [NAME] #406 went to scoop out a portion of mashed potatoes and part of the scoop was the dry potato mix. Interview with [NAME] #406 on 01/22/25 at 4:45 P.M. verified the mashed potatoes were not thoroughly mixed and residents were served dry mashed potato mix in their mashed potatoes. Review of the facility's undated mashed potato recipe revealed to mix the dry potato mix and water together, add margarine, and mix thoroughly. Review of the facility's undated list of residents that received mashed potatoes on 01/22/25 revealed four (#1, #3, #6 and #42) residents received the alternate mashed potatoes. This deficiency represents non-compliance investigated under Complaint Number OH00161251.

Based on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were encoded and transmitted within required timeframes. This affected five (#17, #5, #30, #27, and #11) of five residents reviewed for resident assessment. The facility census was 50. Findings include: 1. Review of the medical record for Resident #17 revealed an admitted [DATE]. Diagnoses included chronic kidney disease, hyperlipidemia, hypertension, and anemia. Review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the MDS was completed 08/13/24 but not submitted until 09/24/24. Interview on 01/22/25 at 3:22 P.M., MDS Coordinator (MDSC) #328 verified Resident #17's was submitted on 09/24/24. MDSC #328 stated the MDS assessment should have been submitted within seven days of completion. 2. Review of the medical record for Resident #5 revealed an admitted [DATE]. The resident discharged from the facility on 08/19/24. Diagnoses included metabolic encephalopathy, chronic obstructive pulmonary disease, hypertension, schizophrenia, hyperlipidemia, rheumatoid arthritis, gastro-esophageal reflux disease, epilepsy, and dementia. Review of Resident #5's MDS assessment dated [DATE] revealed the MDS assessment was completed on 09/09/24 and submitted 09/24/24. Interview on 01/22/25 at 3:23 P.M., MDSC #328 verified Resident #5's MDS assessment was not completed or submitted timely. MDSC #328 stated the MDS assessment should have been completed within seven days of the date of assessment and submitted within seven days of completion. 3. Review of the medical record for Resident #30 revealed an admitted [DATE]. The resident discharged from the facility on 08/30/24. Diagnoses included back pain, venous insufficiency, paroxysmal atrial fibrillation, and adult failure to thrive. Review of MDS assessments completed while Resident #30 revealed the most recent assessment completed was a quarterly MDS assessment on 08/20/24. There was no discharge MDS assessment completed for Resident #30. Interview on 01/22/25 at 3:24 P.M., MDSC #328 verified a discharge MDS assessment was not completed for Resident #30's discharge of 08/30/24. 4. Review of the medical record for Resident #27 revealed an admitted [DATE]. The resident discharged from the facility on 09/04/24. Diagnoses included congestive heart failure, Parkinson's disease, hypertension, and major depressive disorder. Review of Resident #27's admission MDS assessment dated [DATE] revealed the assessment was completed 08/30/24, however the assessment was submitted on 09/24/24. Interview on 01/22/25 at 3:25 P.M., MDSC #328 verified Resident #27's 08/27/24 admission MDS assessment was not submitted until 09/24/24. MDSC #328 stated assessments should be submitted within seven days of completion. 5. Review of the medical record for Resident #11 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus with diabetic neuropathy, vascular dementia, congestive heart failure, and major depressive disorder. Review of Resident #11's annual MDS assessment dated [DATE] revealed the MDS assessment was not completed until 09/06/24 and the assessment was submitted on 09/24/24. Interview on 01/22/25 at 3:26 P.M., MDSC #328 verified Resident #11's 08/09/24 MDS assessment was not completed nor submitted timely. MDSC #328 stated the MDS assessment should have been completed within seven days of the assessment date and submitted within seven days of completion.

Based on observation, resident and staff interview, and medical record review, the facility failed to develop care plans to address resident needs and interventions. This affected four (#12, #24, #39, and #42) of 24 residents reviewed for care planning. The facility census was 50. Findings include: 1. Review of Resident #12's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, type two diabetes mellitus with other specified complications, congestive heart failure, polyneuropathy, personal history of transient ischemic attack and cerebral infarction without residual deficits, congestive obstructive pulmonary disease, constipation, and centrilobular emphysema. Review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and was assessed to receive an anticoagulant medication. Review of Resident #12's physician order dated 06/06/24 revealed the resident received the anticoagulant Eliquis five (5) milligrams (mg) with instructions to give one tablet by mouth two times a day for atrial fibrillation. Review of Resident #12's comprehensive care plan from 06/06/24 to 01/22/25 revealed Resident #12 did not have a care plan to address the use of an anticoagulant. Interview with MDS Nurse #328 on 01/22/25 at 1:16 P.M. verified Resident #12 received a scheduled anticoagulant medication and did not have a care plan developed to address anticoagulant use. 2. Review of Resident #42's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including a wedge compression fracture of the first lumbar vertebra, atrial fibrillation, depression, presence of other vascular implants and grafts, hyperlipidemia, chronic obstructive pulmonary disease, and old myocardial infarction. Review of Resident #42's quarterly Minimum Data (MDS) assessment dated [DATE] revealed the resident was cognitively intact and was assessed to receive an anticoagulant medication. Review of Resident #42's physician order dated 09/05/24 revealed the resident received Eliquis 5 mg with instructions to give one tablet by mouth every morning and at bedtime for atrial fibrillation. Review of Resident #42's comprehensive care plan from 09/04/24 to 01/22/25 revealed Resident #42 did not have a care plan to address the use of an anticoagulant. Interview with MDS Nurse #328 on 01/22/25 at 1:16 P.M. verified Resident #42 received a scheduled anticoagulant medication and did not have a care plan developed to address anticoagulant use. 3. Review of Resident #39's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including end stage renal disease, insomnia, chronic kidney disease, chronic obstructive pulmonary disease, vascular dementia, hypertension, chronic respiratory failure and depression. Review of Resident #39's admission MDS assessment dated [DATE] revealed the resident was cognitively intact and was assessed as edentulous with no natural teeth. Interview and observation with Resident #39 on 01/21/25 at 11:30 A.M. confirmed the resident was edentulous and had dentures in place on his upper gums. Interview with MDS Nurse #328 on 01/22/25 at 1:16 P.M. verified Resident #39 did not have a care plan developed to address his dental needs, use of dentures, or edentulous status. 42731 4. Review of the medical record for Resident #24 revealed an admitted [DATE]. Diagnoses included congestive heart failure, hyperlipidemia, chronic respiratory failure, chronic obstructive pulmonary disease, major depressive disorder, hypertension, restless legs syndrome, type two diabetes, and cognitive communication deficit. Review of the comprehensive MDS assessment dated [DATE] revealed the resident had intact cognition. The resident had impaired range of motion on both lower extremities, was dependent on staff for toileting and bathing, and required substantial/maximal assistance for bed mobility. The resident expressed having little interest or pleasure in doing things more than half of the days during the assessment period. Review of the Care Area assessment dated [DATE] revealed Resident #24 triggered activities related to expressing having little interest or pleasure in doing things. The resident was noted to prefer self-initiated activities in her room. The resident was noted with a diagnosis of depression and required daily interaction with staff and other like residents. The resident was noted to be at risk for decline with her psychosocial status and for social isolation. It was noted activities would be addressed in the care plan. Review of Resident #24's medical record revealed there was no care plan developed to address activities. Interview on 01/22/25 at 4:23 P.M. with Activities Director (AD) #325 verified there was no activities care plan developed for Resident #24.

Based on observation, staff interview, review of a resident diet list, the facility failed to ensure mechanically altered meat was prepared in a form to meet resident needs. This affected 11 (#1, #4, #3, #6, #20, #23, #36, #42, #46, #47, and #202) of 11 residents that received mechanically altered diets. The facility census was 50. Findings include: Observation of meal service on 01/22/25 at 4:45 P.M. revealed a pan of mechanically altered country fried steak on the tray line. There were large chucks of the country fried steak in the pan that were larger than the size of a quarter. [NAME] #406 was observed to use a three ounce scoop to serve the mechanically altered country fried steak with chunks in it to residents that received mechanical diets. Interview with [NAME] #406 on 01/22/25 at 4:45 P.M. verified there were large chucks of mechanically altered pieces of country fried steak that were larger than the size of a quarter in the pan on the tray line. [NAME] #406 also verified she served residents that received mechanical soft diets the mechanically altered country fried steak with large chunks in it. [NAME] #406 confirmed the chunks of mechanically altered country fried steak were too large for residents on mechanical soft diets. Review of an undated list of residents that received mechanical soft diets revealed Resident #1, Resident #4, Resident #3, Resident #6, Resident #20, Resident #23, Resident #36, Resident #42, Resident #46, Resident #47, and Resident #202 received mechanical soft diets.

Based on observation, medical record review, staff interview, policy review, the facility failed to maintain proper signage and personal protective equipment for a resident with an indwelling medical device placed on enhanced barrier precautions. This affected one (#9) of five residents reviewed for infection control. The facility census was 50. Findings include: Review of Resident #9's medical record revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, mixed hyperlipidemia, tracheostomy status, cognitive communication deficit, disease of the pancreas, acquired absence of the larynx, dysphagia pharyngeal phase, obesity due to excess calories, epilepsy, chronic kidney disease, major depressive disorder, and type two diabetes mellitus with hypoglycemia. Review of the 12/23/24 quarterly Minimum Data Set (MDS) assessment revealed Resident #9 was cognitively intact and require tracheostomy care while a resident. Review of Resident #9's physician orders revealed an order dated 10/03/24 for enhanced barrier precautions related to a tracheostomy. Observation on 01/21/25 at various random times revealed Resident #9 had no sign on or near the door to the resident's room for enhanced barrier precautions and there was no personal protective equipment (PPE) outside the room. Observation on 01/22/25 at 3:20 P.M. revealed Resident #9 continued to have no sign on or near the resident's room door for enhanced barrier precautions. Interview with Licensed Practical Nurse (LPN) #333 on 01/22/25 at 3:25 P.M. verified there was no enhanced barrier precautions sign on or near Resident #9's room and no PPE available for use in Resident #9's room. Review of the 08/01/22 facility enhanced barrier precautions policy revealed enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDRO) to residents. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. PPE is available outside of the resident rooms.

Based on medical record review and staff interview, the facility failed notify the state mental health authority with a significant change Preadmission Screening and Resident Review (PASARR) for a resident with a change in their mental health condition. This affected two (#2 and #33) of three residents reviewed for PASARR. The facility census was 50. Findings include: 1. Review of Resident #33's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including major depressive disorder, hypothyroidism, personal history of traumatic brain injury, hypokalemia, other developmental disorders of speech and language, muscle weakness, and xerosis cutis. Review of Resident #33's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as severely cognitively impaired. Review of Resident #33's PASARR document dated 11/05/21 revealed Resident #33 had no diagnoses of mental disorders. Resident #33 did not have indications of serious mental illness. Resident #33's diagnosis of traumatic brain injury was marked on the PASARR and Resident #33 was noted to have indications of developmental disability. Review of Resident #33's notice of PASARR determination and right to a state hearing letter dated 11/08/21 revealed Resident #33 may require the level of services provided by the nursing facility and may continue to reside in the nursing facility for 180 days from the date of the determination. The nursing facility in conjunction with the local entitles shall initiate and continue discharge planning activities throughout the period of time specified on the determination notice. The last date of the specified period was listed on the letter as 05/07/22 and the deadline for an extension request was listed on the letter as 04/07/22. Review of Resident #33's medical record from 11/08/21 to 01/22/25 revealed there were no additional extensions or PASARRs determinations for Resident #33 past 05/07/22. Review of Resident #33's diagnosis list dated 01/22/25 revealed Resident #33 had a diagnosis of major depressive disorder with an onset date of 10/08/21 and schizoaffective disorder with an onset date of 08/04/23. Interview with Social Services Director (SSD) #322 on 01/22/25 at 1:16 P.M. verified Resident #33 received a new diagnosis of schizoaffective disorder on 08/04/23 and the facility did not complete a significant change PASARR or notification to the state mental health authority of Resident #33's new diagnosis. SSD #322 also verified Resident #33's major depressive disorder diagnosis with an onset date of 10/08/21 was not listed on the 11/05/21 PASARR. 42731 2. Review of the medical record for Resident #2 revealed an admitted [DATE]. Diagnoses included dementia, irritable bowel syndrome with diarrhea, gastro-esophageal reflux disease, paranoid schizophrenia (added 04/12/22), chronic pain syndrome, constipation, anemia, major depressive disorder, psychotic disorder with delusions, anxiety, and adult failure to thrive. Review of the quarterly MDS assessment dated [DATE] revealed Resident #2 had moderately impaired cognition. Review of Resident #2's PASARR dated 10/21/20 revealed section D, indications of serious mental illness, was coded as the resident did not have any indications of serious mental illness. There were no further PASARRs completed for Resident #2 in the medical record. Interview on 01/22/25 at 3:11 P.M., SSD #322 verified a new PASARR was not completed when Resident #2 received a new diagnosis of paranoid schizophrenia on 04/12/22.

Based on medical record review, staff interview, hospital documentation review, and review of a facility policy, the facility failed to ensure non-pressure wounds were properly assessed and treated in a timely manner. This affected one (#37) of one residents reviewed for wounds. The facility census was 50. Findings Include: Record review for Resident #37 revealed she was admitted to the facility on [DATE]. Diagnoses included, rheumatoid arthritis, essential primary hypertension, gastro-esophageal reflux disease (GERD), chronic pain syndrome, anxiety disorder, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was cognitively intact. Resident #37 was dependent on staff for bathing, toilet use, dressing, and personal hygiene, and required maximum assistance from staff with eating, and oral hygiene. Review of the hospital discharge report titled, Admission Continuity of Care, included in Resident #37's admission paperwork dated 11/30/24 revealed Resident #37 had a wound located on her left anterior ankle. Review of Resident #37's wound evaluation note dated 12/09/24 revealed the resident presented with a trauma injury wound on her left medical ankle. The wound measured 1.5 centimeters (cm) long by 1.0 cm wide by 0.3 cm deep. Further review of the wound evaluation document revealed necrotic tissue was removed from the wound to establish margins of viable tissue. A treatment order was given to apply leptospermum honey once daily for 30 days and apply a boarder gauze once daily for 30 days with replacement of kerlix if the dressing fell off. Review of a wound evaluation dated 01/20/25 revealed Resident #37's left ankle wound showed improvement as measured 0.5 cm long by 0.5 cm wide by 0.1 cm deep. Interview on 01/21/25 at 9:56 A.M. with Resident #37 stated she had the wound on her left ankle at the hospital, however, no one at the facility identified the wound or provided any treatment to the wound on her left ankle until several days after she admitted to the facility. Interview on 01/22/25 at 3:32 P.M. with MDS Nurse #328 confirmed the facility failed to identify the wound located on Resident #37's left ankle. MDS Nurse #328 confirmed the wound located on Resident #37's left ankle was present at the the time of admission and the facility did not provide treatment to the wound from the time of admission on 12/04/24 through the initial wound care assessment on 12/09/24. Interview on 01/22/25 at 4:15 P.M. with Assistant Director of Nursing (ADON) #308 confirmed the facility failed to treat Resident #37's wound to the left ankle until 12/09/24 when the wound physician as the resident. ADON #308 confirmed the facility failed to identify the wound on Resident #37's initial skin assessment. Interview on 01/22/25 at 4:28 P.M. with Licensed Practical Nurse (LPN) #335 confirmed she was the admission nurse for Resident #37 the day the resident was admitted to the facility. LPN #335 stated she was off work for a few days after Resident #37 was admitted to the facility, and when she returned to work, management told her she missed Resident #37's left ankle would on her initial assessment. Interview on 01/23/25 at 2:14 P.M. with Wound Physician (WP) #501 confirmed his first assessment for Resident #37 was on 12/09/24 and confirmed Resident #37's admitted was 12/04/24. WP #501 stated did not feel the delay in treatment caused further damage to Resident #37's left ankle wound. Review of the facility policy titled, Wound Care, dated October 2010, revealed the facility should verify a physician's order for the procedure, and as part of the preparation for wound care, the facility will review the resident's care plan to assess for any special needs of the resident.

Based on observation, medical record review, and staff interview, the facility failed to ensure a resident was served food on a divided plate per the physician order. This affected one (#37) of one residents reviewed for assistive eating equipment and utensils. The facility census was 50. Findings include: Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included rheumatoid arthritis, essential primary hypertension, gastro-esophageal, chronic pain syndrome, anxiety disorder, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was cognitively intact. Resident #37 was dependent on staff for medication administration, bathing, toilet use, dressing, and personal hygiene, and required maximum assistance from staff with eating and oral hygiene. Review of Resident #37's diet order dated 12/12/24 revealed the resident was ordered a regular diet with regular texture and regular consistency. Review of Resident #37's physician order dated 01/07/25 revealed Resident #37 was to have a divided plate for all meals. Observation of the meal service on 01/22/25 at 4:45 P.M. revealed [NAME] #406 placed country fried steak, potatoes, corn bread, and carrots on a regular plate for Resident #37. Interview with [NAME] #406 on 01/22/25 at 4:45 P.M. verified Resident #37 was ordered a divided plate and Resident #37's meal was served on a regular plate. Review of the facility's assistive devices policy, dated October 2022, revealed assistive devices and utensils will be provided as identified in the individualized plan of care to maintain or improve a resident's ability to eat and drink independently.

Based on medical record review, staff interview, and policy review, the facility failed to timely administer pneumococcal vaccines. This affected two (#11 and #29) of five residents reviewed for vaccinations. The facility census was 50. Findings include: 1. Review of Resident #11's medical record revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, insomnia, hyperlipidemia, diabetes mellitus with diabetic neuropathy, peripheral vascular disease, mild cognitive impairment, vascular dementia, and hypothyroidism. Review of Resident #11's medical record on 01/23/25 revealed no documented evidence of the resident receiving a pneumococcal vaccine. 2. Review of Resident #29's medical record revealed an admitted [DATE]. Diagnoses included encounter for orthopedic aftercare, anxiety disorder, nausea, anemia, psychoactive substance abuse, tobacco use, spinal stenosis, chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebral infarction, cord compression, solitary pulmonary nodule, and chronic pain syndrome. Review of Resident #29's medical record on 01/23/25 revealed no documented evidence of the resident receiving a pneumococcal vaccine. Interview with Assistant Director of Nursing (ADON) #308 on 01/23/25 at 1:51 P.M. revealed Resident #11 and Resident #29 had not received a pneumococcal vaccine during either resident's stay in the facility, but they were suppose to receive it that day. ADON #308 verified the pneumococcal vaccine status should be checked on admission and yearly. Review of the facility pneumococcal vaccine policy, dated 10/01/23, revealed all residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series.

Based on observations and staff interview, the facility failed to provide a safe and functional environment for the residents. This had the potential to affect all 46 residents residing in the facility. Findings include: Observations of the facility on 05/01/24 at 9:45 A.M. revealed multiple rain gutters that were hanging unattached to the fascia board on the left side front of the building near resident room [ROOM NUMBER]. Gutter mounting nails had broken loose from the building due to extended weather conditions causing the wood to rot and an unstable attachment. A second area was located outside the main entrance above the business office. The gutter system had also become unattached to the fascia board causing the wood to rot. A third area was located at the back of the building near a resident courtyard, with the gutters hanging below the attachment points. Observation of room [ROOM NUMBER] on 05/01/24 at 10:30 A.M. revealed a large brown stain on the ceiling above the room window. Interview with the Administrator on 05/01/24 at 11:05 A.M. verified multiple areas of damaged and non-functional gutter system located around the entire facility. The Administrator stated there have been several estimates obtained to repair these areas in the past year. The Administrator stated they have been waiting on corporate to approve one of the estimates. This deficiency represents non-compliance investigated under Complaint Number OH00152896.

Based on record review, staff interview, review of facility policy, and review of the facility fall investigation, the facility failed to provide adequate amount of staff assistance for residents who the facility identified as being dependent for personal care. This affected one resident (#28) out of three residents reviewed for falls. The facility census was 56. Findings include: Record review for Resident #28 revealed an admitted [DATE]. Her diagnoses included, but not limited to, dementia, Parkinson's disease, contracture of left hand, diabetes mellitus, bilateral hearing loss, seizure disorder, acquired absence of left leg below knee (BKA), atrial fibrillation (A-fib), and dysphagia. Review of the five-day admission Minimum Data Set (MDS) assessment for Resident #28 dated on 01/03/23, revealed Resident #28 had severely impaired cognition. Resident #28 was totally dependent on staff and required the assistance of two persons for bed mobility, transfers, dressing, toilet use, personal hygiene, and eating. Review of the new admission fall risk assessment dated on 12/27/22, revealed Resident #28 was assessed at 16.0 which indicated resident was at high risk for falls and resident required hand on assistance to move from place to place. Review of care plan conference summary dated 01/03/23, revealed Director of Social Services, (DSS), Licensed Practical Nurse (LPN) #201, Activities #68 and resident's son attended the conference via phone. Notes indicated Resident #28 was nonverbal, required maximum assistance of two for Activities of daily living (ADLs), and was high fall risk due to impaired cognition. Further medical record review for Resident #28, revealed no baseline care plan was completed upon admission. Review of the nurse's progress notes dated 01/04/23 for Resident #28, revealed no documented evidence Resident #28 had a fall and/or was sent to the hospital. Review of the hospital notes dated 01/04/23 for Resident #28, revealed the resident was treated and released status post-acute fall from bed. Notes indicated the resident had an accidental, witnessed fall from her bed and struck the top of her head. Notes indicated the resident had no visible trauma to head or neck and examination and radiography tests were negative findings and without acute change. Notes additionally indicated the resident had a palpable hematoma on the top of her head and interventions were to be put in place to prevent future falls. Review of the nurse's progress notes dated 01/05/23 at 5:09 P.M., for Resident #28, revealed the writer attempted to reach resident's son to review the fall from last evening. Notes indicated messages were left for the Power-of-Attorney (POA). Review of the nurse's notes dated 01/05/23 at 5:12 P.M., for Resident #28, revealed the resident representative returned a call and was notified of the fall and the root cause analysis of the fall. Review of the internal facility fall investigation dated 01/05/23, revealed State tested Nurse's Aide (STNA) #200 rolled Resident #28 upon her right side at the edge of the bed to provide personal care (peri care) when STNA #200 turned to get something, and Resident #28 continued to roll and fell from the bed to the floor. Notes indicated the facility interviewed STNA #200 and determined the STNA failed to ensure two caregivers were present at the time for personal care for Resident #28. Notes indicated the resident was sent to the hospital, treated, and released with no significant injuries. Further review of the investigation revealed the facility determined the importance of utilizing two caregivers when required and the facility contacted the staffing agency to ensure the education was provided to the agency staff. Review of witness statement by STNA #200 dated 01/05/23, revealed the STNA was changing Resident #28 in her room when she fell on the floor. Notes indicated STNA #200 Turned resident on her right side, facing the wall, and turned to grab more wipes and the resident fell headfirst onto the floor. Notes indicated the resident was leaning forward and resident was more top heavy then STNA realized, and the resident fell due to the unbalanced distribution of weight. Notes indicated STNA #200 immediately notified the nurse who assessed resident and put her back in the bed. Notes indicate the resident was sent to the hospital. Notes indicated there was nothing obstructing her position that would have caused the fall, only her positioning itself. Review of the nurse's notes dated 01/10/23 at 10:00 A.M. for Resident #28, revealed the Interdisciplinary Team (IDT) met on 01/05/23 to review the resident's fall from the bed on 01/04/23 at 8:45 P.M. as resident received personal care. Notes indicated Resident #28 was sent to the emergency room for evaluation and returned. Notes indicated Resident #28 sustained a small hematoma to the top of her head measuring 2.5 centimeters (cm) by 3.0 cm. Notes indicated the physician was in to see the resident on 01/05/23, the family was updated, the care plan was reviewed and updated and monitoring in place. Interview on 01/10/23 at 2:43 P.M. with the Director of Nursing (DON) confirmed Resident #28 had a fall from her bed while care was being provided by one STNA (#200). The DON confirmed she could not say why only one STNA (#200) was providing care because Resident #28 required two caregivers with personal care. The DON confirmed STNA #200 turned away from Resident #28 to gather items for personal care when Resident #28 continued to roll forward from the bed onto the floor. The DON confirmed the facility did not document the fall that occurred during care on 01/04/23 because it was an internal investigation. Follow up interview on 01/10/23 at 3:05 P.M. with the DON, revealed she entered the IDT note for Resident #28 on 01/10/23 because while reviewing Resident#28's fall from 01/04/23, and during the surveyor reviewing the fall, the facility became aware they did not have any documentation of the fall in Resident #28's progress notes. Interview on 01/11/23 at 11:45 A.M. with STNA #200, revealed she was an agency aide working at the facility on 01/04/23 from 7:00 P.M. to 7:00 A.M. STNA #200 confirmed she had never worked with Resident #28 and didn't know how many staff were required to complete personal care for resident. STNA #200 indicated the usual form of communication on how to care for a resident, was to use Kardex system or by getting the information during walking rounds with previous shift. STNA #200 revealed she arrived late to her shift and did not complete the walking rounds with previous shift. STNA #200 confirmed she was not aware Resident #28 was required to be a two person assist. STNA #200 stated on 01/04/28 around 8:45 P.M. she was in middle of providing personal care (peri care) by herself when she rolled resident away from her, onto her right side (with her contracted left arm up in the air) and on the very edge of the bed. STNA #200 stated while Resident #28 was at the very edge of the bed, STNA #200 turned away from Resident #28 to get more wipes and Resident #28 continued rolling and fell directly from the bed and headfirst onto the floor. STNA #200 stated she got the nurse and the nurse assessed Resident #28 and staff placed Resident#28 back into the bed. STNA #200 stated Resident #28 was sent to the hospital for evaluation and treatment and returned from the hospital on 01/05/23 between 2:00 A.M. and 3:00 A.M. Interview on 01/11/23 at 2:56 P.M. with Licensed Practical Nurse (LPN) #201, indicated she was the supervisor on duty for the night shift (7:00 P.M. to 7:00 A.M.) on 01/04/23. LPN #201 confirmed she did not know that Resident #28 required two caregivers for personal care. LPN #201 stated this information was usually provided on the Kardex and stated she was unaware of Resident #28 having a Kardex available for staff to advise on how to provide care. LPN #201 stated she heard STNA #200 yell Resident #28 was on the floor. LPN #201 stated she observed Resident #28 on the floor, and she assessed a large knot on the top of Resident #28's head. LPN #201 stated Resident #28 was placed back in bed and then sent to the hospital for evaluation. LPN #201 confirmed she provided education to STNA #200 regarding never turning your back on a resident during personal care and proper position the resident in bed. LPN #201 confirmed Resident #28 returned from the hospital on 01/05/23 between 2:00 A.M. and 3:00 A.M. with no injuries. Review of the undated, handwritten Kardex (resident information document to care for residents) revealed Resident #28 required a two person assist for bed mobility, transfers, and transfer assist required a full body lift with two STNAs. Kardex indicated resident was to have a right-side assist bar and the left side of bed was to be against wall in a low position. Review of the facility policy titled, Fall and Fall Risk, Managing, dated March 2018, based on previous evaluations and current data, the staff will identify interventions related to the residents specific risk and causes to try to prevent the resident from falling and to minimize complications from falling. This deficiency represents non-compliance investigated under Complaint Number OH00139089. This deficiency represents ongoing noncompliance from the survey dated 12/14/22.

Based on medical record review, review of the fall investigation, observation, staff, resident, and family interview, review of the fall list, and policy review, the facility failed to ensure appropriate interventions were implemented and maintained to ensure residents remained free from burns. This resulted in Immediate Jeopardy and serious life-threatening harm and/or injuries when Resident #45, whose bed had been positioned adjacent to an electric baseboard wall heater, rolled out of the bed, and sustained second degree burns (this type of burn affects both the epidermis and the second layer of skin the dermis and pain can be severe) to her back and right shoulder from the electric baseboard wall heater. This affected one resident (#45) of five residents reviewed for falls. The facility census was 51. On 12/02/22 at 3:30 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Clinical Services (RDCS) #400 were notified Immediate Jeopardy began on 10/23/22 when the facility failed to ensure Resident #45's bed was positioned in such a way that the resident did not sustain injuries from the electric baseboard wall heater after a fall and failed to subsequently ensure the resident's bed remained in a position to decrease the likelihood of the same action, situation, and/or practice from occurring in the future, and to prevent further potential injury from subsequent falls. On 10/23/22, Resident #45 sustained blisters and/or second degree burns to the lower back, the upper right shoulder, and one on her head. A subsequent wound evaluation and management referral, by the resident's physician, was conducted on 11/14/22 which resulted in a surgical procedure to remove the thick adherent eschar and devitalized (necrotic/dead) tissue from the resident's wounds. The Immediate Jeopardy was removed on 12/03/22 when the facility implemented the following corrective actions: On 12/02/22 at 4:19 P.M., the Administrator/Designee repositioned Resident #45's bed perpendicular to the baseboard wall heater on the opposite wall with the floor mat in place. On 12/02/22 at 5:20 P.M., the DON/Designee completed a head-to-toe assessment on Resident #45 with no new concerns noted. On 12/02/22 at 8:00 P.M., the DON/Designee completed a review of all in-house residents and identified three residents (#02, #24, and #45) with a Brief Interview for Mental Status (BIMS) assessment score of less than 12, Activities of Daily (ADL) score over 6, and those with risk for falls who could be at risk for injury related to the proximity of the residents ' bed to the baseboard wall heater. On 12/02/22 at 8:55 P.M., the Administrator/Designee completed facility rounds and the bed of one additional resident (#24), identified as being at risk, was evaluated and the residents ' bed was moved to an acceptable proximity away from the baseboard wall heater. On 12/02/22 at 10:15 P.M., the DON notified Resident #45's responsible party of the residents ' bed location change due to safety concerns. On 12/02/22 by 10:50 P.M., the DON/Designee had completed head to toe assessments on three residents (#02, #24, and #45), who had met the criteria for being at risk, with no additional concerns identified. On 12/02/22 at 11:45 P.M., all staff were educated by the Administrator/Designee via the One Call System, telephone call, or in person education regarding the proximity of the residents to the baseboard wall heaters and the staff response to residents at risk for injury due to the proximity of the baseboard wall heaters. They were all educated not to place floor mats next to the baseboard wall heaters. Newly hired employees will be educated during the facility general orientation and the agency staff will be educated on the first day of working an assignment at the facility. Prior to moving any existing resident into a bed located next to the baseboard wall heater (Rooms one through 26, and 34), the resident will be assessed for safety utilizing the fall risk assessment, BIMS assessment score, and the ADL criteria. All newly admitted residents will be placed in a bed by the door, away from the baseboard wall heater until risk factor assessments are completed. The Administrator/Designee will conduct facility rounds five times a week for two weeks, then three times a week for one week, then one time a week for one week to ensure residents at risk for injury are maintained at a proper proximity away from the baseboard wall heaters. Although the Immediate Jeopardy was removed on 12/03/22, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE]. Diagnoses included dementia without behavioral disturbances, repeated falls, difficulty walking, unsteadiness on feet, mild cognitive impairment, conversion disorder with seizures or convulsions, and a history of falling. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 03. The resident was dependent upon two staff members for bed mobility, transfers, and toilet use and required extensive assistance from one staff member for eating. The resident had no falls since the prior assessment. Review of the care plan dated 06/15/22 revealed Resident #45 was at high risk for falls related to confusion, deconditioning, gait and balance problems, incontinence, being unaware of safety needs, and vision and hearing problems. Interventions in place at the time of the fall on 10/23/22 included ensure resident's call light was within reach, follow facility fall protocols, investigate each fall to determine root cause, keep wheelchair away from the bed at bedtime, low bed, and maintain a clear pathway free from obstacles. Interventions added to the care plan on 10/26/22 included Dycem to the bed and rearrange the residents' room to ensure safety of the resident. Review of the care plan dated 10/26/22 revealed Resident #45 had an actual impairment to skin integrity of the lower back, head, right and left gluteal folds related to burns. Interventions included bariatric bed for safety, follow facility protocols for treatment of injury, and treatment as ordered. Review of the care plan revealed no documentation of Resident #45's bed being placed against the wall. Review of the fall risk assessment dated [DATE] revealed this resident was at high risk for falls evidenced by an assessment score of 17. Where a score of 0-5 was Low Risk, 6-15 Moderate Risk, 16 and above High Risk. Review of the fall risk assessment dated [DATE] revealed Resident #45 remained at high risk for falls evidenced by an assessment score of 21. Review of the physician orders dated 07/30/22 and discontinued on 12/02/22 revealed an order for a mat to the floor on the right side of the bed, and to check placement every shift. Review of the nurse progress notes dated 10/23/22 and timed 1:21 A.M., revealed the nurse was called to the room of Resident #45 by the State tested Nursing Assistant (STNA) #100 after being found on the floor between the bed and the window. The resident was immediately assessed for injury and cognition. Vital signs were assessed, and neuro-checks were initiated immediately. A bruise was observed to the right upper shoulder and the resident complained of pain to the head. The primary care physician and the hospice staff were notified with no new orders. As needed pain medication was administered with no other complaints voiced or noted. The immediate intervention was to place Dycem under the bed pad to prevent sliding. Review of the nurse progress note dated 10/23/22 and timed 6:02 A.M. revealed Resident #45 had blisters on the lower back, the upper right shoulder, and one on her head. The primary care physician was notified, and new orders were obtained to cleanse the areas with normal saline, apply Silvadene (a burn ointment) one percent cream, and cover with a non-adherent dressing and secure daily. Review of the nurse progress note dated 10/23/22 and timed 6:05 A.M. revealed Resident #45's bed was repositioned in the room away from the wall heater and would update maintenance. Review of the initial wound evaluation and management summary progress note dated 11/14/22 revealed at the request of the referring provider, Medical Doctor (MD) #999, a thorough wound care assessment and evaluation was performed. Examination revealed there was a partial thickness wound burn of the left back present which measured 5.0 centimeters (cm) long by 1.5 cm wide by 0.1 cm deep which was covered with a dried fibrinous exudate (scab). Examination also revealed there was a full thickness burn of the right back present which measured 3.0 cm long by 2.5 cm wide by 0.1 cm deep which was covered 100 percent with thick adherent devitalized tissue. A procedure was conducted to remove the thick adherent eschar and devitalized tissue. The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine (a numbing agent). Then with a clean surgical technique, curette, 15 blade was used to surgically excise (remove) devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 0.1 cm and healthy bleeding tissue was observed. As a result of the procedure, the nonviable tissue in the wound bed decreased from 100 percent to 90 percent. Review of the facility fall investigation undated revealed the Interdisciplinary Team (IDT) met to review the fall from the bed which occurred on 10/23/22. Review of the clinical record and discussion with staff to investigate the root cause analysis was completed. Resident #45 reported pain at a score of two. The resident stated at the time of the fall she was attempting to get out of the bed to go to the restroom. The resident was incontinent of urine and was assisted to the bathroom where she voided (urinated). Staff stated the resident was restless. The Hospice staff were notified, and a larger bed was ordered related to restlessness to provide additional comfort. Staff to assist with toileting needs to prevent additional falls related to toilet use. Environmental factors reviewed during the investigation included the heater and the bed next to wall with the bed moved away from the wall immediately. Injuries documented on the fall investigation included blisters at first, ultimately burns. Review of the facility provided list of falls dated 09/01/22 through 12/02/22 revealed Resident #45 had additional falls from the bed which occurred on 10/07/22, 11/15/22, and 11/21/22. Observation on 12/02/22 at 10:50 A.M. revealed Resident #45 was in bed with the bed positioned near the electric baseboard wall heater. A fall mat was located on the left side of the bed between the bed and the electric wall heater. The fall mat was angled in such a way that the top corner of the mat was under the bed and the bottom corner was less than a finger width away from the electric baseboard wall heater. Upon touching the bottom of the electric baseboard wall heater, it was noted to be extremely hot to the point it caused discomfort. Observation and interview with Assistant Director of Nursing (ADON) #500 and Maintenance Director #700 on 12/02/22 at 10:57 A.M. revealed the distance of the edge of the residents ' bed from the wall heater, measured with a tape measure by the Maintenance Director #700, only measured 25 inches apart. ADON #500 and Maintenance Director #700 verified Resident #45's bed was positioned in such a way that if the resident fell on the left side of the bed, there was a likelihood the resident would be close enough to the electric baseboard wall heater to sustain further burns. ADON #500 and Maintenance Director #700 also verified the floor mat was positioned less than a finger width away from the electric baseboard wall heater. ADON #500 and Maintenance Director #700 verified the electric coils located in the electric baseboard wall heater were placed in such a way a resident's skin could potentially come in contact with the coils. A follow-up interview with ADON #500 on 12/02/22 at 1:30 P.M., revealed Resident #45's bed had been positioned against the wall since the employee began working at the facility in December 2021. ADON #500 stated the bed had been placed in this position by request of the residents' family and, at times, was observed to be located 12 to 14 inches away from the wall and electric baseboard wall heater due to staff moving the bed out to provide care for the resident. ADON #500 verified Resident #45 had a fall on 10/23/22 which resulted in second degree burns to the residents back and shoulder caused by the heat from the electric baseboard wall heater, and the electrical baseboard wall heater had to be replaced due to being broken during the fall. ADON #500 stated staff had been instructed to move the residents' bed away from the wall heater immediately to prevent the risk of further burn injuries. Observation and follow-up interview with Maintenance Director #700 on 12/02/22 at 3:00 P.M., revealed the surface temperature of the heating coils located on the electric baseboard wall heater, taken with a digital thermometer by Maintenance Director #700, measured 265 degrees Fahrenheit (F) in Resident #45's room. Observation and follow-up interview with ADON #500 on 12/02/22 at 4:45 P.M., revealed there was a red, burned area to the right side of Resident #45's lower back where treatment continued with Silvadene cream and a bandage. There was an area of scarring present on the left side of Resident #45's back which was a direct result of the burn incurred from the electric baseboard wall heater. Interview with Resident #45 at the time of the observation revealed the burned area to the lower right side of the residents back continued to be painful. Interview on 12/02/22 at 5:15 P.M. with the son of Resident #45, revealed he and other family members had requested the residents ' bed be placed against the wall due to the history of falls. He stated the bed was supposed to be directly against the wall, but staff often left it moved out after providing care for Resident #45. He stated had the bed been directly against the wall as requested, the resident would not have been able to fall onto the side of the bed located next to the electric baseboard wall heater and sustain burns. Telephone interview with Licensed Practical Nurse (LPN) #200 on 12/06/22 at 11:36 A.M., revealed the employee was working in the facility during the night shift on 10/23/22. LPN #200 stated the residents ' bed was placed extremely close to the wall and the electric baseboard wall heater. LPN #200 stated an STNA heard the resident call out and found the resident lying on the floor and came to get help. LPN #200 stated two nurses responded and found Resident #45 lying on the floor beside between the bed and the baseboard wall heater. LPN #200 stated the resident was not lying directly on the wall heater when the employee arrived at the room but suspected the resident had fallen on the heater due to it being broken. LPN #200 stated the resident was assessed initially with only a discolored area, thought to be a bruise, observed on the right shoulder but was later found to have developed blisters because of burns incurred from the baseboard wall heater during the fall. Review of the facility policy titled Falls - Clinical Management, revised 03/2018 revealed the staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out. This deficiency represents non-compliance investigated under Complaint Number OH00137129.