Every finding on record at Gardens of Mayfield Village

Based on observation, record review and interview the facility failed to honor Resident #24's food preferences and failed to ensure the food items served for meals were consistent with the planned four-week menu. This affected one resident (Resident #24) out of three residents reviewed for food preferences and had the potential to affect all the residents in the facility. The facility census was 55.Findings include:1. A review of Resident #24's clinical record revealed an admission date of 01/24/24 with diagnoses including chronic non-pressure ulcers to the left foot/heel, diabetes mellitus, malnutrition, morbid obesity, cognitive communication deficit, lumbar disc displacement, arthritis, cellulitis, atrial fibrillation (irregular heart rhythm), high cholesterol, macular degeneration of the right eye, and cataract.A review of Resident #24's physician orders dated 08/01/25 to 08/31/25 revealed a diet order dated 01/14/25 for a regular diet, regular texture, and thin liquids. A review of Resident #24's plan of care revised on 01/17/25 revealed Resident #24 had a nutritional problem or potential nutritional problem related to obesity as per Resident #24 preferred grilled cheese sandwiches for lunch and peanut butter and jelly for dinner. Interventions on the plan of care indicated to provide Resident #24 with meals according to the diet order.A review of Resident #24's daily meal ticket for breakfast revealed his Food Likes included two pieces of white toast, two scrambled eggs, cold cereal (Fruit Loops or Raisin Bran) and three servings of margarine. Instructions on the meal ticket included to provide the scrambled eggs with cheese, two pieces of white toast and Raisin Bran or Fruit Loops for breakfast, a grilled cheese sandwich for lunch and a peanut butter and jelly sandwich for dinner.An interview with Resident #24 on 08/26/25 at 3:15 P.M. revealed concerns about the meal service in the facility. Resident #24 stated he had very specific preferences for his breakfast meal in the facility. Resident #24 stated the kitchen staff do not read the meal tickets before placing the food items on his plate. Resident #24 stated on 08/24/25 he received two sausage links and one piece of bread with butter for breakfast. Resident #24 stated his meal ticket clearly indicated the food items he was supposed to receive for each meal in the facility were the same every day. Resident #24 stated he had complained to the Assistant Director of Nursing (ADON) #61 and had sent her a picture of the breakfast meal he was served on 08/24/25.A review of the facility's four-week menu cycle revealed the planned breakfast food items on 08/24/25 included breakfast casserole, cereal of choice, coffee cake, coffee/tea, 8 ounces of milk of choice and juice of choice was planned to be served to the residents.An interview 0n 08/26/25 at 10:47 A.M. with ADON #61 verified Resident #24 had complained about the food he received for breakfast on 08/24/25. ADON #61 verified Resident #61 did not receive the breakfast food items as indicated on his meal ticket.An interview with [NAME] #62 indicated Resident #24 had very specific foods that were to be served for each meal in the facility which did not change day to day. [NAME] #2 verified the food items Resident #24 received for breakfast on 08/24/25 was not what was listed on his meal ticket or what was planned on the menu for the breakfast meal.2. An observation on 08/26/25 at 8:30 A.M. of the breakfast meal service revealed the residents were served scrambled eggs or one to two hard cooked egg disc(s), one piece of raisin toast, oatmeal, one small orange, grape juice and milk.A review of the week number four on the four-week menu cycle revealed the food items planned to serve included an egg sandwich, cereal of choice, banana, coffee/tea, 8 ounces of milk of choice, juice of choice, margarine and jelly.An interview on 08/26/25 at 8:45 A.M. with the Kitchen Manager (KM) #63 verified the above findings and indicated the kitchen staff had replaced the banana with an orange because the banana was not delivered with the other food items on the most recent food order for the facility. KM #63 was unable to explain why the kitchen staff had not served the planned breakfast sandwich and verified the food items were available to serve the residents the breakfast meal food items as planned on the menu for 08/26/25.This deficiency represents non-compliance investigated under Complaint Number 2577029.

Based on record review and interview the facility failed to provide Resident #32's guardian with the results of the investigation of Resident #32's allegation of abuse in a timely manner. This affected one out of three residents reviewed for allegations of abuse. The facility census was 55.Findings include:A review of Resident #32's clinical record revealed an admission date of 05/24/24 with diagnoses including psychosis, malnutrition, severe dementia with agitation, cognitive communication deficit, drug induced dyskinesia (involuntary, uncontrolled muscle movements), mood disorder, bipolar disorder, and anxiety.Resident #32's dated 05/20/24 indicated Minimum Data Det (MDS) assessment indicated she had no behaviors including hallucinations, delusions or behavioral symptoms including physical and verbal aggression. The MDS assessment indicated Resident #32 exhibited refusal of care behavior almost daily.Resident #32's plan of care initiated on 09/18/24 revealed Resident #32 resided on the secured nursing unit due to decreased safety awareness, increased confusion, poor decision-making skills and previous history of elopement. Interventions on the plan of care included to encourage Resident #32 to attend activities of interest, maintain a consistent routine and monitor for exit seeking behavior.There was no documentation in Resident #32's clinical record to indicate an altercation had occurred between Resident #47 and Resident #32, Resident #32's allegation of abuse, or of contact with Resident #32's guardian regarding his concerns with Resident #32's allegation of abuse and other concerns. There was no documentation that Resident #32's guardian was notified of the results of the investigation of Resident #32's allegation of physical abuse.A review of a Self-Reported Incident (tracking number 263445) dated 07/30/25 revealed Resident #32 alleged Resident #47 had assaulted her in her room. An investigation was conducted with staff and resident interviews obtained which revealed no altercation had occurred. The investigation revealed Resident #47 was wandering aimlessly in the hallways of the secured unit and had entered Resident #32's room. When staff redirected Resident #47 away from Resident #32's room, Resident #47 began swinging his arms. The investigation concluded Resident #47 did not hit or assault Resident #32.An interview with Resident #32's guardian on 08/26/25 at 11:02 A.M. revealed he was visiting with Resident #32 on 07/30/25 when she alleged that Resident #47 had assaulted her in her room. Resident #32's guardian notified Assistant Director of Nursing (ADON) #61 and asked to have the facility notify him of the results when the investigation was completed.A review of Resident #32's guardian's progress notes indicated during his visit on 07/30/25 with Resident #32 she had alleged Resident #47 had assaulted her in her room several times. Resident #32's guardian notified the Administrator ADON #61 and Social Service Designee (SSD) #63 of the allegation of physical abuse. The progress note indicated the administrative staff would provide Resident #32's guardian with an update of the results of the investigation. Resident #32's guardian's progress notes indicated on 07/31/25 and 08/04/25 Resident #32's guardian sent an email to the SSD #63 asking for an update of the results of the investigation of Resident #32's allegation of physical abuse. Resident #32's guardian received one email from SSD #63 which revealed Resident #32 would receive her athletic shoes as requested on 08/04/25. There were no additional emails received from the facility to notify Resident #32's guardian of the results of Resident #32's physical assault allegation investigation.An interview with Administrator, SSD #63 and Resident #32's guardian on 08/26/25 at 11:02 A.M. verified they had not notified Resident #32's guardian of the results of the investigation of Resident #32's allegation of physical abuse. The Administrator and SSD #63 verified the above findings and proceeded to inform Resident #32's guardian of the results of Resident #32's physical abuse investigation.

Based on record review and interview the facility failed to maintain a complete accurate medical record for Resident #32. This affected one out of three residents reviewed for abuse. The facility census was 55.Findings include:A review of Resident #32's clinical record revealed an admission date of 05/24/24 with diagnoses including psychosis, malnutrition, severe dementia with agitation, cognitive communication deficit, drug induced dyskinesia (involuntary, uncontrolled muscle movements), mood disorder, bipolar disorder, and anxiety.Resident #32's dated 05/20/24 indicated Minimum Data Det (MDS) assessment indicated she had no behaviors including hallucinations, delusions or behavioral symptoms including physical and verbal aggression. The MDS assessment indicated Resident #32 exhibited refusal of care behavior almost daily.Resident #32's plan of care initiated on 09/18/24 revealed Resident #32 resided on the secured nursing unit due to decreased safety awareness, increased confusion, poor decision-making skills and previous history of elopement. Interventions on the plan of care included to encourage Resident #32 to attend activities of interest, maintain a consistent routine and monitor for exit seeking behavior.There was no documentation in Resident #32's clinical record to indicate an altercation had occurred between Resident #47 and Resident #32, Resident #32's allegation of abuse, or of contact with Resident #32's guardian regarding his concerns with Resident #32's allegation of abuse and other concerns. There was no documentation that Resident #32's guardian was notified of the results of the investigation of Resident #32's allegation of physical abuse.A review of a Self-Reported Incident (tracking number 263445) dated 07/30/25 indicated Resident #32 alleged Resident #47 had assaulted her in her room. An investigation was conducted with staff and resident interviews obtained which revealed no altercation had occurred. The investigation revealed Resident #47 was wandering aimlessly in the hallways of the secured unit and had entered Resident #32's room. When staff redirected Resident #47 away from Resident #32's room, Resident #47 began swinging his arms. The investigation concluded Resident #47 did not hit or assault Resident #32.An interview with Resident #32 on 08/25/25 at 2:30 P.M. revealed she stated a man had assaulted her in her room. Resident #32 pointed to Resident #47 and indicated this was the man who assaulted her physically in her room. Resident #32 was unable to state when this incident happened or addition details regarding the incident. Resident #32 stated she had informed the ADON #63 of the allegation of physical abuse.An interview with Resident #32's guardian on 08/26/25 at 11:02 A.M. revealed he was visiting with Resident #32 on 07/30/25 when she alleged that Resident #47 had assaulted her in her room. Resident #32's guardian notified Assistant Director of Nursing (ADON) #61 and asked to have the facility notify him of the results when the investigation was completed.A review of Resident #32's guardian's progress notes indicated during his visit on 07/30/25 with Resident #32 she had alleged Resident #47 had assaulted her in her room several times. Resident #32's guardian notified the Administrator ADON #61 and Social Service Designee (SSD) #63 of the allegation of physical abuse. The progress note indicated the administrative staff would provide Resident #32's guardian with an update of the results of the investigation. Resident #32's guardian's progress notes indicated on 07/31/25, 08/04/25 Resident #32's guardian sent an email to the SSD #63 asking for an update of the results of the investigation of Resident #32's allegation of physical abuse. Resident #32's guardian received one email from SSD #63 which revealed Resident #32 would receive her athletic shoes as requested on 08/04/25. There were no additional emails received from the facility to notify Resident #32's guardian of the results of Resident #32's physical assault allegation investigation.An interview with Administrator, SSD #63 and Resident #32's guardian on 08/26/25 at 11:02 A.M. verified the facility had not maintained an accurate, complete medical record for Resident #32.

Based on observation, interview and review of facility policy, the facility did not ensure a comfortable environment for Resident #24. This affected one resident (#24) of three residents interviewed for physical environment and had potential to affect an additional 24 residents (#7, #11, #13, #14, #19, #21, #23, 25, #28, #29, #31, #34, #35, #38, #40, #41, #44, #45, #47, #50, #53, #57, #58 and #59 residing on the second floor. The facility census was 63. Findings include:An interview on 07/22/25 at 10:00 A.M. with Maintenance Director (MD) #302 revealed he believed the highest ambient air temperature for the facility should be 71 degrees Fahrenheit (F) and as low as 65 degrees F. MD #302 also stated he was unaware of any resident concerns regarding ambient air temperatures. An interview on 07/22/25 at 11:06 A.M. with Resident #24 revealed the facility felt cold to him especially during the night and early morning. An observation was conducted with the Administrator on 07/22/25 at 11:23 A.M. on the 260's hall where the ambient air temperature was read at 63F using a facility thermometer. In the common area of the second floor at the nursing station, the ambient air temperature was 69F and the 200 hall common area had an ambient air temperature of 67 F which was below the regulatory required facility temperature range of 71 degrees F to 81 degrees F. The Administrator verified the temperatures at the time of the observation. The Administrator questioned the accuracy of the facility thermometer used to measure the temperatures. A second thermometer, purchased new by the facility, measured a second set of ambient air temperatures which were two degrees lower than the prior temperatures as stated above and this was verified by the Administrator at the time of the observation. Record review of the facility's environmental temperature policy dated 01/03/22 revealed the facility was to maintain an air temperature between 71 F to 81 F.This deficiency represents non-compliance investigated under Complaint Number 1311263 and 1311264 and is a recite to the annual survey completed 05/29/25.

Based on record review, observation, interview, and review of facility policy, the facility did not ensure Resident #63's urinary catheter device was properly secured. This affected one resident (#63) of two residents reviewed for urinary catheters. The census was 63.Findings include: Record review for Resident #63 revealed an admission date of 04/09/25 with diagnoses including unspecified dementia, and neuromuscular dysfunction of the bladder. Resident #63 had an active physician order and care plan dated 06/20/25 to maintain a securement device for the urinary catheter to prevent movement and urethral traction. This was to be monitored every shift, which was documented done as ordered on the first shift of 07/23/25. Further review of the care plan revealed no documented behaviors for Resident #63 removing his securement device.Review of the minimum data set (MDS) 3.0 assessment dated [DATE] identified Resident #63 to have moderate cognitive impairment and needing substantial assistance for toileting. Review of progress notes for Resident #63 for May 2025, June 2025 and July 2025 revealed no documented behaviors regarding Resident #63 removing the securement device. Observation of a catheter care procedure for Resident #63 on 07/23/25 at 3:02 P.M. by Certified Nurse Aide (CNA) #901 and the Director of Nursing (DON) revealed the resident did not have a catheter securement device in place to prevent motion of the lower tubing or bag from potentially tugging on the catheter insertion site.Interview with CNA #901 during the above-noted observation revealed she had seen a securement device on Resident #63 in the past, but she had provided personal care for him earlier in the day and did not see one on him.Interview with the DON at 3:40 P.M. on 07/23/25 confirmed Resident #63 had an order and care plan for a catheter securement device and none was in place during the catheter care. Interview with Licensed Practical Nurse #902 on 07/23/25 at 3:44 P.M. revealed she was Resident #63's nurse on this date. She did not check the resident for catheter securement placement today, however she recalled seeing it on him in the past.Interview with Consultant Registered Nurse (RN) #903 on 07/24/25 at 8:42 A.M. revealed RN #903 stated the facility applied a securement device to Resident #63's leg following the observed catheter care, however, he removed it. RN #903 stated the resident may have removed the device independently shortly prior to the catheter care observation. The surveyor confirmed with her at this time that Resident #63 had no notes or care plan indicating a behavior of removing catheter securement devices. Review of the facility's catheter care policy dated 09/2014 revealed staff were to ensure the catheter remained secured with a leg strap to reduce friction and movement at the insertion site.This deficiency is a recite to the annual survey completed 05/29/25.

3. Review of Resident #8's medical records revealed an admission date of 02/13/25 with diagnoses including bilateral lower extremity ulcers and pressure ulcer of the left heel. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had intact cognition. Resident #8 required maximum (staff) assistance with bathing and personal hygiene. Review of care plan dated 04/23/25 revealed Resident #8 had a pressure ulcer to the left heel. Interventions included administer treatments as ordered. Review of physician orders for May 2025 revealed Resident #8 was ordered to cleanse left heel with normal saline, apply collagen (wound dressing used to promote healing), cover with an absorbent pad and wrap with gauze daily and as needed. Interview on 05/12/25 at 12:40 P.M. with Wound Nurse Practitioner (WNP) #189 revealed Resident #8 had a pressure ulcer to his left heel that was present on admission. WNP #189 stated she had not seen Resident #8 in approximately three weeks and stated another nurse practitioner had been following him. Observation of wound care with WNP #189 and Licensed Practical Nurse (LPN) #108 at time of interview, revealed LPN #108 had removed Resident #8's sock to his left foot and no dressing or wound care treatments were on. WNP #189 stated Resident #8 was supposed to have had collagen, an absorbent pad and a gauze to the area. Further observation revealed Resident #8's left heel had a large amount of dried crusted debris around the area. WNP #189 stated Resident #8's wound care was to be completed daily and also as needed. Review of the facility policy titled, Prevention of Pressure Ulcers/Injuries, revised July 2017, revealed the facility was to review the resident's care plan and identify risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. The facility was to evaluate, report and document potential changes of the skin and then review the interventions and strategies for effectiveness on an ongoing basis. This deficiency represents non-compliance investigated under Complaint Number OH00164012 and Complaint Number OH00161946. Based on observation, record review, facility policy review and interview, the facility failed to implement an adequate and effective pressure ulcer prevention program to promote healing and ensure Resident #39 and Resident #51, both of whom were cognitively impaired, dependent on staff for activities of daily living and incontinent of bowel and bladder, received timely and necessary pressure ulcer prevention care and treatment. The facility also failed to provide wound care as ordered for Resident #8. This affected three residents (#8, #39 and #51) of seven residents reviewed for pressure ulcers. Actual Harm for Resident #51 occurred on 04/23/25 when nursing staff identified a pressure wound (no staging was identified) on Resident #51's buttocks which was noted to occur from prolonged sitting in his chair without adequate repositioning and then failed to implement effective interventions and provide timely and necessary treatment to prevent further deterioration of the wound to a Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) pressure ulcer. Actual Harm for Resident #39 occurred on 05/05/25 after nursing staff failed to perform a weekly skin assessment to identify and implement effective interventions to prevent a compromised area on Resident #39's coccyx area from deteriorating to an Unstageable (full-thickness tissue loss with the base of the ulcer covered by slough (yellow, tan, gray, green or brown) or eschar (tan, brown or black) in the wound bed) pressure ulcer. The ulcer was subsequently classified as a Stage III pressure ulcer. Findings include: 1. Review of the medical record for Resident #51 revealed an admission date of 05/06/24 with diagnoses including epilepsy (seizures), cognitive communication deficit, need for assistance with personal care and history of encephalitis (inflammation of the brain). Review of the care plan dated 05/07/24 (and last updated on 04/29/25) for Resident #51 revealed the resident had the potential for skin impairment related to self-care deficit and bladder and bowel incontinence. There was no mention of the resident having a Stage III pressure ulcer that was facility acquired on 04/23/25. Interventions to prevent skin breakdown included to encourage turning and repositioning with rounds, use house barrier cream with each incontinence episode, pressure reduction cushion to the wheelchair, pressure reduction mattress to the bed (dated 04/18/24), encourage to float heels as tolerated and Prevalon boots to bilateral heels while in bed (03/11/25). The last intervention added to the care plan was on 04/29/25 for an albumin level (laboratory testing) to be obtained when clinically indicated. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 had severely impaired cognition. The assessment revealed the resident was dependent on staff for activities of daily living including rolling left to right in bed, transfers, and toileting. The MDS assessment revealed the resident had no pressure ulcers. Review of the MDS 3.0 assessment dated [DATE], for discharge return anticipated, revealed Resident #51 had one pressure ulcer Stage III that was present on previous admission or entry to the facility. Review of the Braden Scale (tool used to assess a resident's risk of developing pressure ulcers), dated 03/31/25 revealed Resident #51 was at high risk for developing pressure ulcers. Review of the nursing progress note dated 04/23/25 at 1:17 P.M. revealed a pressure wound was on Resident #51's buttocks. Licensed Practical Nurse (LPN) #114 stated she believed it may have resulted from prolonged sitting in his chair without adequate repositioning. She stated she updated the physician and received an order for Triad Wound Paste to be applied to the buttocks. LPN #114 stated she would be ordering a donut cushion to enhance comfort and reduce pressure while the resident was seated. Review of the weekly wound observation tool dated 04/23/25 for Resident #51 revealed the resident had a Stage I (non-open superficial reddening of the skin that may appear red, blue or purple which does not turn white when pressed on) pressure ulcer to the gluteal region and it was worsening. It was noted to measure 2.0 centimeters (cm) in length by (x) 2.5 cm in width with no depth. Review of the physician order dated 04/23/25 revealed an order to clean the buttocks with normal saline and apply Triad Cream daily. Review of the nursing progress note dated 04/28/25 at 2:38 P.M. by Registered Nurse (RN) #175, who was also the previous Director of Nursing (DON), revealed the area (unknown area) was assessed by the wound care practitioner on 04/28/25 and was classified as moisture associated skin damage (MASD). Review of the wound care practitioner's progress note dated 04/28/25 at 8:32 A.M. revealed she had seen Resident #51's right lateral ankle Stage III pressure. However, there was no assessment for the pressure ulcer to the resident's buttocks at this time. Review of the weekly wound observation tool dated 04/28/25 revealed the resident's buttocks was not assessed. Review of the nursing progress note dated 04/28/25 at 2:48 P.M. by RN #175, revealed Resident #51 was seen by the wound care practitioner on 04/28/25 and an area was noted to be MASD. The location of the are was not noted. The nursing progress note stated therapy was made aware for a pressure reducing assistive device, all parties were made aware, an order for albumin level was ordered and air mattress was in place. The same progress note was again made on 04/29/25 at 2:50 P.M. Review of the physician order dated 05/01/25 for Resident #51 revealed an order to recommend the resident was in a chair two to three hours max at a time, can tilt all the way back to offload weight from sacrum. Review of the weekly skin assessment dated [DATE] revealed Resident #51 had a Stage I pressure ulcer to the sacrum that measured 2 cm x 2.2 cm x 0 cm. Review of the weekly wound observation tool dated 05/05/25 revealed Resident #51 had a Stage III pressure ulcer to his right upper buttocks that was acquired on 05/05/25 and this was the first observation of the area. It was noted to have moderate drainage and measure 3.5 cm x 2.7 cm x 0.3 cm. Review of the wound care practitioner's progress note dated 05/05/25 revealed Resident #51 was seen for a new open area on the right buttock. Wound Nurse Practitioner #189 noted the resident had a Stage III pressure ulcer that was acquired in-house. It measured 3.5 cm x 2.7 x 0.3 cm. There was moderate drainage and had 80 percent (%) granulation tissue with 10% slough and 10% pink tissue. She provided a new order to clean the area with normal saline, apply medi-honey and calcium alginate (type of wound treatment) and cover with clean and dry dressing every day and as needed starting on 05/06/25. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #51 was at risk for developing pressure ulcers and had one or more pressure ulcers. The assessment reflected the resident had two pressure ulcers that were Stage III with one of them being present on admission or reentry. Observation on 05/13/25 at 10:57 A.M. of wound care to Resident #51 by the DON and RN #193 revealed Resident #51 did not have a dressing on his right buttock. The DON verified the dressing was not in place as ordered. The area to the right buttock measured 3 cm x 3 cm x 0.1 cm. Interview on 05/19/25 at 11:35 A.M. with the DON verified Resident #51's pressure ulcer to his buttocks was not properly assessed and treated since the pressure ulcer had been discovered on 04/23/25 until the wound nurse saw it on 05/05/25 (the area was the same and not new on 05/05/25). She verified Wound Nurse Practitioner #189 had not assessed the area to his buttocks until 05/05/25 and the nursing progress note on 04/28/25 and 04/29/25 were incorrect stating he had seen the wound nurse and the skin impairment was MASD. Attempted interview on 05/19/25 at 11:45 A.M. with Wound Nurse Practitioner #189 was unsuccessful. No return contact was made. Interview on 05/19/25 at 11:35 A.M. with the DON verified Resident #51's care plan was not updated related to the pressure ulcer to his buttocks nor were new interventions added. Observation on 05/19/25 at 12:50 P.M. of Resident #51 revealed he was in bed but did not have heel boots on as ordered. Licensed Practical Nurse (LPN) #106 verified staff had not placed his heel boots on when he was assisted to bed and the heel boots were on a stand next to the bed. Observation on 05/20/25 at 7:30 A.M. of Resident #51 revealed the resident's air mattress was alarming and alerting staff that it was not working correctly. The resident also did not have on his heel boots. On 05/20/25 at 8:14 A.M., the air mattress was still alarming. On 05/20/25 at 9:30 A.M. Resident #51's air mattress was still alarming and was noted to not be fully inflated. Registered Nurse (RN) #186 verified the resident's heel boots were not on and the air mattress was not functioning correctly. Interview on 05/20/25 at 12:08 P.M. with LPN #114 revealed she was the nurse who originally saw Resident #51's pressure ulcer to his buttocks. She stated she updated the DON, physician and Resident #51's mother related to the new open area. She stated she determined the open area was from the resident sitting for prolonged periods without being repositioned. Review of the facility policy titled, Prevention of Pressure Ulcers/Injuries, revised July 2017, revealed the facility was to review the resident's care plan and identify risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. The facility was to evaluate, report and document potential changes of the skin and then review the interventions and strategies for effectiveness on an ongoing basis.2. Review of Resident # 39's medical record revealed an admission date of 05/26/22 with diagnoses including unspecified dementia with severe anxiety, moderate protein - calorie malnutrition, adult failure to thrive, and palliative care. Review of Resident #39's Hospice Care Plan dated 08/14/23 revealed an air mattress was ordered to be placed on Resident #39's bed for pressure ulcer prevention. Review of the facility care plan dated 04/23/25 revealed the plan of care did not include an air mattress for pressure ulcer intervention. Review of Resident #39's Braden Scale dated 04/11/25 revealed the resident was at very high risk for pressure ulcer development. Review of Resident #39's weekly wound assessment dated [DATE] revealed there were no skin issues identified. The weekly wound assessment due on 04/25/25 was not completed. Review of Resident #39's care plan dated 04/23/25 revealed the resident was at risk for skin breakdown with an intervention for nursing as well as Hospice to visit and provide care, assistance, and evaluation. Review of Resident # 39's Hospice observation note dated 04/28/25 (for comprehensive assessment) by the RN revealed the resident's skin was intact. Review of Resident #39's progress note dated 04/29/25 revealed the nurse identified an area on the resident's sacrum documented as an in-facility acquired area. This was the first observation of the area, noting it was dry with no drainage, no odor, and measured 0.2 cm x 0.1 cm x 0 cm with no inflammation. The progress note did not identify what kind of wound it was. Treatment was noted to cleanse with normal saline and apply Triad Cream. There was no indication Resident #39's family was notified of the area identified. Review of Resident #39's weekly skin assessment dated [DATE] revealed the resident's skin was intact with no new or active pressure areas (However, this appeared to be inaccurate based on the 04/29/25 progress note). Review of Resident #39's Braden Scale dated 04/30/25 revealed Resident #39 was at a moderate risk for pressure ulcer development. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #39 had dementia, with anxiety, and was always incontinent with bowel and bladder. Resident #39 was totally dependent on staff for toileting hygiene, rolling and transfers. Resident #39 was at risk for developing pressure ulcers and no pressure ulcers were noted on the assessment. Review of Resident #39's Wound Nurse Practitioner (NP) initial assessment dated [DATE] revealed the resident had a Deep Tissue Pressure Injury (DTI) on the sacrum measuring 5.3 cm x 3.0 cm with an undetermined depth. The NP recommended a pressure reducing mattress and treatment for the injury. There was no evidence in Resident #39's medical record the pressure reducing mattress was implemented. Review of Wound Nurse Practitioner assessment dated [DATE] revealed Resident #39's wound was a Stage III pressure ulcer on the coccyx (contradicting the sacrum location on 05/05/25) with decreased size of 3.7 cm x 4 cm x 0.2 cm, clustered wound, base/tissue was 70% granulation tissue and 30% scabbed and crusted of the wound. The treatment was to clean with normal saline, pat dry, apply Triad, with a clean dry dressing. Review of a Hospice Nurse assessment dated [DATE] revealed the resident was observed in a Broda chair, pleasant, but confused, and skin was intact. Review of weekly skin assessment dated [DATE], completed by LPN #114, revealed an observation of a coccyx pressure ulcer which assessed the ulcer as being an unstageable wound with measurements of 5.1 cm x 3.5 cm with no depth. The treatment remained the same. Observation on 05/13/25 at 10:25 A.M. of Resident #39's coccyx area with LPN #114 revealed the resident did not have a dressing on her coccyx with no visible cream or ointment on the coccyx area at that time. The resident was not observed on a pressure reducing mattress. Review of Resident #39's medical record on 05/13/25 at 11:00 A.M. with LPN #114 revealed the wound treatment was documented as being completed and LPN # 114 verified she had not done the dressing but had signed it off as completed. A telephone interview on 05/15/25 at 10:58 A.M. with LPN #114 who completed the initial observation of Resident #39's pressure injury on 04/29/25 and the weekly skin assessment on 04/30/25 revealed LPN # 114 notified Resident #39's doctor of the pressure ulcer injury and tried a phone number for the Hospice company but stated that the phone number was not working. She stated she was instructed to give a guesstimate of the size of the wound by the previous Director of Nursing. LPN # 114's revealed the assessment of the wound on 04/29/25 was pink and non-blanchable, and the assessment dated [DATE] documented as skin intact was an error. LPN # 114 revealed she had not had any interaction or report given to the Hospice Nurse on 05/12/25 when the Hospice Nurse assessment indicated Resident #39's skin was intact when there was a Stage III pressure ulcer. A telephone interview on 05/15/25 at 11:12 A.M. with Hospice Registered Nurse #186 regarding her assessment of Resident #39 skin documentation dated 05/12/25 revealed Resident #39 was in her chair and the resident's skin was not assessed. Hospice RN #186 stated she was unaware the resident had a pressure ulcer. A telephone interview on 05/15/25 at 11:30 A.M. with Certified Nurse Practitioner (CNP) Wound Nurse #191 revealed Resident #39 was first assessed for a pressure wound on 05/05/25 as an unstageable deep tissue injury (DTI) area, and each time the resident was assessed, the resident was found without treatments in place. CNP Wound Nurse #191 revealed on 05/12/25 the resident's wound was observed as a Stage III pressure area that was opened with granulated tissue visible. CNP Wound Nurse #191 revealed she was unaware that Resident #39 was receiving hospice care. Interview on 05/14/25 at 2:25 P.M. with Regional Director of Clinical Services #166 revealed Resident #39 should have had an air mattress placed on the bed as soon as a skin issue was observed and it was not in place as it should be. A telephone interview with Hospice Registered Nurse #177 on 05/15/25 at 11:12 A.M. revealed Resident #39 was to have an air mattress on her bed according to the hospice care plan. Observation on 05/15/25 at 12:35 P.M. of Resident #39 with Regional Director of Clinical Services #166 revealed the air mattress was not in place but it was on the Hospice care plan dated 08/14/23 to be a preventive measure for pressure injuries. Interview on 05/19/25 at 1:25 P.M. with [NAME] President (VP) of Operations #172 verified Resident#39's wound assessment by CNP Wound Nurse #191 on 05/12/25 revealed the pressure area was a Stage III pressure area and was opened and Resident #39's weekly wound assessment dated [DATE] noted Resident #39 had an unstageable pressure area with measurements of 5.3 cm x 3.1 cm with undetermined depth. VP of Operations #172 could not identify what contributed to Resident #39's wound deterioration from a Stage III to an unstageable pressure ulcer. The review of the facility undated policy titled, Pressure Injury Prevention and Management, revealed the facility was committed to the prevention of pressure areas and develop evidence-based interventions for the prevention would include communication with disciplines that provide care and interventions for the residents. Interventions would include repositioning, relieving pressure devices as ordered, preventative skin orders, and treatments timely with notification to all parties involved in the resident's care.

4. Review of Resident #60's medical records revealed an admission date of 01/21/25. Diagnoses included dementia, muscle weakness and need for personal care assistance. Review of care plan dated 04/23/25 revealed Resident #60 resided on the secured unit related to decreased safety awareness. Resident #60 was a smoker. Interventions included instruct resident on the facility policy on smoking and notify charge nurse if it is suspected resident had violated smoking policy and Resident #60 required supervision while smoking. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had intact cognition. Review of smoking assessment dated [DATE] revealed Resident #60 was safe to smoke with supervision. Review of progress note dated 04/30/25 timed 12:24 P.M. authored by Licensed Practical Nurse (LPN) #108 revealed Resident #60 had been suspected of smoking in his room. Observation on 05/15/25 at 8:24 A.M. revealed a strong odor of cigarette smoking outside of Resident #60's room. At time of observation Resident #60 was observed to have been exiting his room. Upon entering Resident #60's room the odor of cigarettes had been stronger and a cloud of smoke was observed in the room. Further observation revealed Resident #60's toilet had ashes inside. At time of observation Certified Nursing Assistant (CNA) #109 stated she had observed the odor of cigarettes in the hallway outside of Resident #60's room and stated she had informed the Unit Manager (UM) #200. At 8:38 A.M. UM #200 and LPN #193 entered Resident #60's room and had begun to search for smoking materials and Resident #60 had denied he had smoked in his room. At 8:44 A.M. Regional Registered Nurse (RRN) #166 had entered Resident #60's room and had begun to search Resident #60 and a lighter was found by RRN #166. RRN #166 stated residents were not permitted to have smoking materials on them and staff was to collect any materials after smoke breaks. 5. Review of Resident #53's medical record revealed an admission date of 01/24/24 and diagnoses including type two diabetes, morbid obesity, non-pressure chronic ulcer of left heel and midfoot, arthritis and atrial fibrillation. Review of a quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 was cognitively intact, required staff set-up for activities of daily living and did not reject care. Review of Resident #53's physician's orders as of 05/14/25 revealed an order dated 10/13/24 for leave of absence (LOA) without supervision every 24 hours as needed for LOA. Review of a progress note dated 05/01/25 at 6:19 P.M. and authored by Licensed Practical Nurse (LPN) #131 revealed Resident #53 was compliant with taking evening medications. No mood or behaviors were witnessed by or reported to this nurse. Review of a progress note dated 05/02/25 at 2:34 A.M. and authored by Registered Nurse (RN) #105 revealed Resident #53 went to LOA, he did not return, nurse tried to contact him by phone no answer, the facility checked two other contacts and they didn't know where he went. Review of a progress note dated 05/02/25 at 3:35 A.M. and authored by RN #105 revealed police called and let the facility know Resident #53 went to the hospital and they were keeping him, nurse would call for follow up. Review of a progress note dated 05/02/25 at 3:18 P.M. and authored by RN #171 revealed this nurse spoke with the Cleveland Clinic Staff at the Euclid Hospital Campus. Staff stated to this nurse, the resident was seen here in the emergency department at this campus last night, but the resident has not been admitted and here that person is no longer here at this campus. Resident #53 had not returned to the facility at this time. Nursing staff aware. Review of a progress note dated 05/02/25 at 9:52 P.M. revealed Resident #53 returned to the facility at 9:50 P.M. Review of the second floor LOA book revealed on 05/01/25, Resident #53 left at 2:30 P.M., did not mark a return date or time but double lines were drawn and a line was placed in the signature column on the form. Continued review of the LOA book revealed on 05/02/25, double lines were drawn instead of a time and Resident #53 was documented as returning at 9:00 P.M. and had the resident's signature. The LOA book did not indicate any expected time of return for Resident #53 for any date documented. Interview on 05/14/25 at 10:26 A.M. with LPN #131 revealed Resident #53 had an order for LOA so was allowed to sign himself out in the LOA book on the second floor. LPN #131 stated residents were supposed to write down the time they expected to come back, which Resident #53 did not do. If staff were not at the nurses' station where the LOA book was located at when he left staff were to look for Resident #53 and see if his car was gone. LPN #13 stated if residents put an expected time on the LOA log and that time passed, staff were to call the resident to determine their whereabouts. Interview on 05/14/25 at 11:22 A.M. with Regional Director of Operations (RDO) #196 revealed nursing staff were supposed to check the LOA books but would not provide a set time frame for how often staff were to check the LOA books. During the interview, RDO #196 was shown Resident #53's LOA logs where expected return dates/times were not provided which went against the facility's LOA policy but showed that Resident #53 came back to the facility on or before midnight most nights. Follow-up interview on 05/14/25 at 11:53 A.M. with RDO #196 and [NAME] President of Operations (VPO) #172 revealed Resident #53 refused to write his expected time of return as in the past, staff called his brother when he did not return to the facility and he did not like that. RDO #196 and VPO #172 stated staff were to contact a resident out on LOA prior to the midnight census, then the Director of Nursing (DON) would be text-messaged, which would drive the next steps to be taken. RDO #196 and VPO #172 did not provide more information regarding Resident #53's LOA and unknown whereabouts on 05/01/25 during the interview. Interview on 05/14/25 at 12:43 P.M. with Certified Nursing Assistant (CNA) #137 revealed he never saw Resident #53 leave or sign out. Interview on 05/14/25 at 1:03 P.M. with RN #171 revealed she was aware of Resident #53's hospitalization on 05/01/25 as the police had called the facility to let them know. RN #171 stated Resident #53 was allowed to come and go but had to be back to the facility by 12:00 A.M. RN #171 stated she had worked on 05/01/25 from 8:00 A.M. to 4:00 P.M. and was not aware Resident #53 had been gone as they did not check the LOA books until the morning when it would be discussed at the stand-up meeting. RN #171 stated Resident #53 would often not tell staff were he was going or how long he would be gone for his LOA. RN #171 stated on 05/02/25 she had called several hospitals to see where Resident #53 was at to try to find out where he went and stated overall the DON or on-call nurse should have been contacted regarding this issue. Interview was attempted with RN #105 on 05/14/25 at 1:13 P.M. but was not successful. Review of the facility policy, Signing Residents Out, revised August 2006 revealed a sign out register is located at each nurses' station. Registers must indicate the resident's expected time of return. The policy did not address when staff were to reach out to residents to determine their whearabouts following a LOA without returning to the facility. This deficiency represents noncompliance investigated under Complaint Number OH00161946. 3. Review of the medical record for Resident #25 revealed an admission date of 10/04/23. Diagnoses included but were not limited to unspecified dementia with behaviors, morbid obesity, hypertensive chronic kidney disease, nicotine dependence and delusional disorders. Review of the 10/17/23 care plan which was last updated on 04/18/25 for Resident #25 revealed Resident #25 was a current smoker in the facility. On 07/01/24, it was noted Resident #25 was to have gone against building smoking policy a few times. Interventions included Resident will use smoking materials safely and smoke safely in designated areas which were initiated on 04/18/25. Interventions listed were to complete smoking evaluation per facility guidelines and resident will follow facility smoking policy. Review of the 01/16/25 smoking safety assessment for Resident #25 revealed cognitive loss, resident able to light cigarette, requires facility to store lighter and cigarettes and required supervision while smoking. Review of the 04/09/25 quarterly Minimum Data Set (MDS) 3.0 for Resident #25 revealed severe cognitive impairment. Resident #25 was noted to require set up for activities of daily living. Observation on 05/12/25 at 1:28 P.M. revealed Resident #25 riding in the facility elevator. Resident #25 was observed to reach inside her shirt into her bra pulling out a cigarette. Interview at the time of the observation with Resident #25 when asked if she was supposed to have cigarettes in her possession revealed Resident #25 stated, yes, I paid for them. Resident #25 was then observed exiting the elevator near the receptionist office and went directly out to the smoking patio. At the receptionist area, Activities Director #132 was observed handing out cigarettes to residents and telling them to wait to go out to the smoking area, but residents were observed obtaining their smoking items, leaving and going out to the smoking area without supervision. Six residents were observed out on the smoking patio with no staff supervision. Observation on 05/12/25 at 1:40 P.M. with Regional Director of Clinical Services (RDCS) #166 confirmed six residents were out on the smoking patio without staff supervision. RDCS #166 confirmed Resident #25 was observed out on the smoking patio with a pack of cigarettes in her bra and a lighter in her possession. Additional residents identified out on the smoking patio unsupervised were Residents #3, #6, #7, #8, #25 and #35. Review of the current smoking safety assessments for Residents #3, #6, #7, #8, #25 and #35 revealed all of them required supervision for smoking. Interview on 05/12/25 at 4:28 P.M. with Activities Director #132 confirmed the smoking items are kept in a locked box inside a locked cabinet in the reception area. Activities Director #132 confirmed residents line up in the hallway and are to wait until a staff member is present to take them to the smoking area and light their cigarettes. Activities Director #132 also confirmed while passing out cigarettes this afternoon, residents were taking their cigarettes and going out to the smoking area and were using each other to light cigarettes without staff supervision. Review of the December 2016 revised facility policy called; Smoking Policy-Residents revealed any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member at all times while smoking. Residents are not permitted to keep cigarettes, pipes, tobacco and other smoking articles in their possession. Based on observation, record review, interview, and policy review, the facility failed to ensure Resident #21 and Resident #24's had interventions in place to prevent falls, safe smoking practices were in place for supervised smokers, and proper measures were taken to ensure Resident #53's safety on leave of absences. This affected 10 residents (#3, #6, #7, #8, #21, #24, #25, #35, #53, and #60) of 19 residents reviewed for accidents. The census was 59. Actual harm occurred on 04/29/25 when Resident #21, who was identified to have poor safety awareness in a motorized wheelchair (which had been provided by therapy) and had a history of falls between 03/05/25 and 04/28/25 from the motorized wheelchair, sustained a fall resulting in increased pain and transfer to the emergency room for evaluation. The resident was diagnosed with a closed fracture of the fibula as a result of the fall. Prior to the fall with fracture, the facility failed to properly/adequately assess the resident's safe use of the motorized wheelchair and failed to implement effective and individualized interventions to decrease the resident's risk of falls with injury. Findings include: 1. Review of Resident #21's medical record revealed an admission date of 06/25/25 with diagnoses of post traumatic seizure, acute respiratory failure, type two diabetes, unspecified asthma, repeated falls, and need for assistance for personal care. Review of the fall records for Resident #21 revealed the resident had been given a motorized wheelchair on 02/15/25 from the therapy department. There was no safety screen documented at the time of the resident receiving the chair. Review of Resident #21's falls since 02/15/25 revealed six of Resident #21's eight falls occurred from the motorized wheelchair without evidence of effective and/or individualized interventions being implemented to address the resident's safety in the wheelchair. This included falls on 03/05/25, 03/19/25, 04/08/25, 04/13/25, 04/28/25, and 04/29/25. Review of Resident #21's Therapy Screen sheets dated 03/05/25 revealed the resident had poor safety awareness. The therapy evaluation and treatment plan for 03/05/25 to 04/04/25 included a goal to increase strength and stability during gait and transfers. The resident had poor balance with standing and reaching. The therapy screen did not include a treatment plan to include the resident's motorized wheelchair. Review of Resident #21's care plan dated 03/25/25 revealed the resident had numerous falls with multiple interventions listed. However, the care plan was not updated since 03/25/25 and did not include the motorized wheelchair or interventions specific to the resident's care needs and/or safety/fall risk related to the use of the motorized wheelchair. Review of a therapy screen sheet dated 04/13/25 revealed Resident #21 had poor safety awareness in wheelchair; however, there was no evidence Resident #21's safety using the motorized wheelchair was assessed/evaluated or had any type of interventions/treatment associated with it. Review of Resident #21's progress note dated 04/29/25 at 2:17 P.M. revealed the resident was observed in front of his bed on the floor with complaint of leg pain. The doctor was called and ordered to transport to the emergency room for an x-ray. Review of Resident #21's hospital record dated 04/29/25 revealed the resident had a fall from a wheelchair and was diagnosed with close fracture of the left fibula on the distal end that did not require surgery. The resident was released with a walking boot for the closed fracture and was to follow-up with orthopedics on 05/15/25 at 10:00 A.M. Review of Resident #21's progress note dated 04/29/25 at 8:59 P.M. revealed the resident returned from the emergency room with a walking boot on the right foot with a diagnosis of closed fracture of the distal end of the fibula. The resident was encouraged to keep his chair in a locked position when transferring and to have his room moved closer to the nurses' station. The residents' room was at the end of the hall. Observation on 05/12/25 at 10:44 A.M. of Resident #21 revealed the resident had a walking brace on his left lower leg and a wheelchair in front of him. The resident had a motorized wheelchair in the corner of the room with no batteries on it to use. Resident #21 stated that he had fallen from the chair and his finger got stuck on the power button and he ran over his leg with the chair and the facility took the chair away. Interview on 05/13/25 at 3:25 P.M. with Regional Director of Clinical Services #166 confirmed the plan of care for Resident #21 was not updated with fall/safety interventions related to the use of a motorized wheelchair or following falls from the motorized wheelchair. Interview on 05/19/25 at 12:49 P.M. with Therapy Director #106 revealed Resident #21 was on therapy case load regularly and they worked on cognition and the resident's balance (which was poor). The director revealed Resident #21 had poor wheelchair safety and verified the resident was not assessed to use the motoroized wheelchair safely when a change was identified on 04/13/25. Interview on 05/21/25 at 8:00 A.M. with [NAME] President (VP) of Operations #172 revealed Resident #21 declined to move his room after the fall on 04/29/25 and confirmed the facility did not assess Resident #21 for motorized wheelchair safety before the fall with fracture on 04/29/25. VP of Operations #172 confirmed the resident had numerous falls from the motorized wheelchair without preventive (individualized and effective) interventions in place. A review of the facility undated policy titled, Fall intervention and Management Program revealed all residents were to be screened for fall risk and interventions put in place as needed. All falls were to be reviewed by the interdisciplinary team and intervention suggestions made with the best interest and safety of the resident. 2. Review of the medical record for Resident #24 revealed an admission date of 01/08/21 with diagnoses that include chronic congestive heart failure type 2 diabetes, severe protein- calorie malnutrition, frequent falls, dementia. Review of Resident #24's care plan dated 04/23/25 revealed the resident was at risk for falls related to decreased cognition, weakness and malnutrition and a perimeter mattress was ordered on 01/15/21 and added again on 04/23/25 for a fall intervention. Observation of Resident #24 on 05/12/25 at 11:00 P.M. revealed a frail man with loose fitting clothes and his breakfast in front of him untouched. There was a sign on the bathroom door stating to call for assistance posted. There were no other fall interventions visible. Observation on 05/15/25 at 11:17 A.M. with Regional Nurse #166 revealed Resident #24 did not have a perimeter mattress in place. Interview with Regional Nurse #166 at the time of the observation confirmed Resident #24's care plan had a perimeter mattress as an intervention from a fall on 4/23/25 and verified it was to be put in place on 01/15/21 as an intervention. A review of the facility undated policy titled, Fall Intervention and Management Program revealed all residents were to be screened for fall risk and interventions put in place as needed. All falls were to be reviewed by the interdisciplinary team and intervention suggestions made with the best interest and safety of the resident.

Based on record review, review of Centers for Disease Control and Prevention (CDC) guidance and interview the facility failed to ensure residents were screened for immunization, educated on the risk and benefit of receiving the COVID-19 vaccine, or were offered and received COVID-19 vaccinations as required. This affected five residents (#3, #8, #11, #21 and #60) of five reviewed for vaccinations. The facility census was 59. Findings include: 1. Review of Resident #3's medical records revealed an admission date of 05/17/24. Diagnoses included dementia, schizophrenia and muscle weakness. Review of Resident #3's immunization records revealed no documentation related to COVID-19 vaccinations, including consent/declination of the vaccination or education provided on the vaccine. Interview on 05/19/25 at 2:48 P.M. with [NAME] President of Operations (VPO) #172 and Regional Registered Nurse (RRN) #182 stated they were unable to locate the vaccination records, refusals or education for Residents #3, #8, #11, #21, and #60. VPO #172 and RRN #182 further confirmed no documented evidence was included in the residents electronic medical records. Review of the CDC guidance titled Staying Up to Date with COVID-19 Vaccines dated 01/07/25 revealed everyone over six months of age should receive the 2024 to 2025 COVID-19 vaccination to best protect from currently circulating stains. Review of the CDC guidance on COVID-19 dated 03/10/25 revealed the COVID-19 vaccination was recommended for prevention of severe health outcomes. 2. Review of Resident #8's medical records revealed an admission date of 02/13/25. Diagnoses included schizophrenia cognitive deficits and muscle weakness. Review of Resident #8's immunization records revealed no documentation related to COVID-19 vaccinations, including consent/declination of the vaccination or education provided on the vaccine. Interview on 05/19/25 at 2:48 P.M. with VPO #172 and RRN #182 stated they were unable to locate the vaccination records, refusals or education for Resident #8. VPO #172 and RRN #182 further confirmed no documented evidence was included in the residents electronic medical records. Review of the CDC guidance titled Staying Up to Date with COVID-19 Vaccines dated 01/07/25 revealed everyone over six months of age should receive the 2024 to 2025 COVID-19 vaccination to best protect from currently circulating stains. Review of the CDC guidance on COVID-19 dated 03/10/25 revealed the COVID-19 vaccination was recommended for prevention of severe health outcomes. 3. Review of Resident #11's medical records revealed an admission date of 03/02/17. Diagnoses included congestive heart failure, asthma and morbid obesity. Review of Resident #11's immunization records revealed no documentation related to COVID-19 vaccinations, including consent/declination of the vaccination or education provided on the vaccine. Interview on 05/19/25 at 2:48 P.M. with VPO #172 and RRN #182 stated they were unable to locate the vaccination records, refusals or education for Resident #11. VPO #172 and RRN #182 further confirmed no documented evidence was included in the residents electronic medical records. Review of the CDC guidance titled Staying Up to Date with COVID-19 Vaccines dated 01/07/25 revealed everyone over six months of age should receive the 2024 to 2025 COVID-19 vaccination to best protect from currently circulating stains. Review of the CDC guidance on COVID-19 dated 03/10/25 revealed the COVID-19 vaccination was recommended for prevention of severe health outcomes. 4. Review of Resident #21's medical records revealed an admission date of 06/25/24. Diagnoses included diabetes, respiratory failure and asthma. Review of Resident #21's immunization records revealed no documentation related to COVID-19 vaccinations, including consent/declination of the vaccination or education provided on the vaccine. Interview on 05/19/25 at 2:48 P.M. with VPO #172 and RRN #182 stated they were unable to locate the vaccination records, refusals or education for Resident #21. VPO #172 and RRN #182 further confirmed no documented evidence was included in the residents electronic medical records. Review of the CDC guidance titled Staying Up to Date with COVID-19 Vaccines dated 01/07/25 revealed everyone over six months of age should receive the 2024 to 2025 COVID-19 vaccination to best protect from currently circulating stains. Review of the CDC guidance on COVID-19 dated 03/10/25 revealed the COVID-19 vaccination was recommended for prevention of severe health outcomes. 5. Review of Resident #60's medical records revealed an admission date of 01/21/25. Diagnoses included dementia, chronic obstructive pulmonary disease (COPD) and cognitive deficits. Review of Resident #60's immunization records revealed no documentation related to COVID-19 vaccinations, including consent/declination of the vaccination or education provided on the vaccine. Interview on 05/19/25 at 2:48 P.M. with VPO #172 and RRN #182 stated they were unable to locate the vaccination records, refusals or education for Resident #60. VPO #172 and RRN #182 further confirmed no documented evidence was included in the residents electronic medical records. Review of the CDC guidance titled Staying Up to Date with COVID-19 Vaccines dated 01/07/25 revealed everyone over six months of age should receive the 2024 to 2025 COVID-19 vaccination to best protect from currently circulating stains. Review of the CDC guidance on COVID-19 dated 03/10/25 revealed the COVID-19 vaccination was recommended for prevention of severe health outcomes.

Based on personnel file review, interview, and review of facility policy, the facility did not ensure staff hired were free of disqualifying offenses. This affected two out of 11 personnel files reviewed for background checks and had the potential to affect all 59 residents in the facility. Findings include: Review of personnel files on 05/15/25 at 1:07 P.M. with Human Resource Manager #143 revealed the following areas of concern: Review of Certified Nursing Assistant (CNA) #125 personnel file revealed a date of hire of 11/06/24. Review of CNA #125's background report dated 12/03/24 revealed a charge dated 09/18/23 for aggravated robbery (2911.11) and aggravated assault (2903.12). The report revealed an additional charge on 10/25/24 for domestic violence (2919.25). All three charges occurred in the state of Ohio. Review of Maintenance Supervisor #138's personnel file revealed a date of hire of 01/28/25. Review of Maintenance Supervisor background report dated 02/18/25 revealed a charge dated 09/28/81 for aggravated robbery (2911.01) and a charge dated 05/17/1990 for drug abuse (2925.11). Both occurred in the state of Ohio. Interview with Human Resource Manager #143 verified the above findings at the time of discovery and confirmed the identified disqualifying offenses were disregarded. Human Resource Manager #143 provided a copy of Ohio Administrative Code Rule 3701-13-05 Disqualifying Offenses for Hiring of Direct Care Provider Employees which was used in determining CNA #125 and Maintenance Supervisor #138 should have been disqualified from employment at the facility. Review of the facility policy, Abuse, Neglect, Exploitation & Misappropriation of Resident Property Policy revised 11/01/19 revealed as part of the screening process the facility must conduct background checks in accordance with Ohio Law and the facility's policy and verify that the applicant is not excluded from any federally funded programs. This deficiency represents non-compliance investigated under Complaint Number OH00165671.

Based on personnel file review, interview, and review of facility policy, the facility failed to implement their abuse policy and procedure regarding checking potential applicants against the Ohio Nurse Aide Registry and ensuring all staff received a background check prior to employment This affected seven out of 11 personnel files reviewed for nurse aide registry checks and had the potential to affect all 59 residents in the facility. Findings include: 1. Review of the personnel files on 05/15/25 at 1:07 P.M. with Human Resource Manager #143 identified the following concerns: Review of the personnel file for Activity Director #132 revealed a hire date of 12/13/24. Further review of the personnel record did not reveal evidence a nurse aide registry search was completed. Review of the personnel file for Licensed Practical Nurse (LPN) #114 revealed a hire date 10/23/24. Review of the nurse aide registry check revealed it was not completed until 05/13/25. Review of the personnel file for Maintenance Supervisor #138 revealed a date of hire of 01/28/25. Review of the nurse aide registry check revealed it was not completed until 05/13/25. Review of the personnel file for Human Resource Manager #143 revealed a hire date of 04/24/25. Further review of the file revealed the nurse aide registry check was not completed until 05/12/25. Review of the personnel file for Business Office Manager #142 revealed a hire date of 02/24/25. Review of the nurse aide registry check revealed it was not completed until 05/13/25. Review of the personnel file for CNA #125 revealed a hire date of 11/06/24. Review of the nurse aide registry check revealed it was not completed until 12/28/25. Interview with Human Resource Manager #143 at the time of the discovery confirmed the identified findings and that she completed the nurse aide registry checks when they were unable to be located in the file during a review. Review of the Abuse, Neglect, Exploitation, & Misappropriation of Resident Property policy revised 11/01/2019 revealed screening is part of the procedure and prior to hiring a new employee, the facility would check with the Ohio nurse assistant registry and any other nurse assistant registries that the facility has reason to believe contain information on an individual, prior to using the individual as a nurse assistant. Review of Hiring Policy revised January 2008 revealed where appropriate, background investigations may be conducted on persons making application for employment with this facility and on current employees. 2. Record review of Licensed Practical Nurse (LPN) #114's personnel file revealed a date of hire 10/23/24. Further review of the personnel file revealed no evidence a background check was completed. Interview on 05/15/25 at 1:07 P.M. with Human Resource Manager #143 confirmed the personnel file for LPN #114 did not contain evidence a background check was completed. Review of the facility policy, Abuse, Neglect, Exploitation & Misappropriation of Resident Property Policy revised 11/01/19 revealed as part of the screening process the facility must conduct background checks in accordance with Ohio Law and the facility's policy and verify that the applicant is not excluded from any federally funded programs. This deficiency represents non-compliance investigated under Complaint Number OH00165671.

Based on observation, review of facility cleaning logs, and interviews, the facility failed to ensure the kitchen was maintained in a clean sanitary manner. This had the potential to affect all residents receiving food from the kitchen. The facility identified one resident (Resident #34) who received nothing by mouth. The facility census was 59. Findings include: During the initial kitchen tour completed on 05/12/25 from 8:35 A.M. to 9:00 A.M. with Dietary Manager #113 the following concerns were identified: - a one-gallon size Ziploc bag with a leftover ham portion which weighed approximately two pounds that was dated 04/28/25. -five-pound box of sliced mushrooms that had visible dark brown spots on the sliced mushrooms which were dated 04/24/25. -clear plastic container with red liquid inside that was thought to be fruit punch which was unlabeled and undated. -six-quart and three-quart clear plastic container with what appeared to be gravy inside that was unlabeled and undated. -six-quart clear plastic container with leftover cooked peas inside that was unlabeled and undated. -six-quart clear plastic container with what appeared to be mashed potatoes that was unlabeled and undated. -Observation of the reach in oven revealed it was heavily soiled with caked on blackened food on the bottom, the front and sides were also visibly soiled, and the handles were greasy upon touching the handles. -Observation of the six-burner gas cooktop revealed it was heavily soiled around the burners and soiled on the front of the oven below. -Observation of the dishwasher revealed the front of the dishwasher was soiled and had food debris on the front of it. -Observation of the sink near the oven revealed (two) eight-pound pork loins thawing in the sink without being covered in water -Observation of the kitchen floor revealed the tile was dirty and did not appear to have been swept or mopped. Interview at the time of the observations with Dietary Manager #113 revealed she just started two weeks ago, had two kitchen employees call off this morning and was waiting for their replacements to arrive. Dietary Manager #113 confirmed the above findings, stated she did not have kitchen cleaning logs to review, and had just created a kitchen cleaning schedule last week but had not implemented it yet. Dietary Manager #113 also confirmed she was aware the pork loins were not thawing in a safe manner. Observation on 05/14/25 at 1:28 P.M. with Regional Culinary Director #167 of the second-floor activity room refrigerator which was used for resident foods revealed: -an unopened 32-ounce med pas vanilla shake with a best by date of 03/16/25 -a 30-ounce container of grape jelly with a use by date of 03/28/25 -a 22-ounce container of strawberry syrup with a use by date of 03/22/25 -two undated and unlabeled leftover containers with visible mold in both containers -four (12-ounce) containers of juice with use by date of 09/05/24 -a six-ounce container of yogurt with a use by date of 12/06/24 Regional Culinary Director #167 confirmed the above findings at the time of observation. Observation on 05/14/25 at 1:42 P.M. with Regional Culinary Director #167 of Resident #34's (who has a diet order of nothing by mouth) personal room refrigerator revealed visible mold in the refrigerator, dried liquid spills, dark colored stains inside as well as the outside area around the refrigerator. Inside of the refrigerator the following concerns were found: -(four) unopened one-half cup containers of chocolate pudding with a use by date of 12/24 -(one) unopened 10-ounce bag of peanut butter chocolate chips with a use by date of 03/24 -(four) eight-ounce unopened containers of Isosource 1.5 enteral feeding with an expiration date of 09/23/25 Interview at the time of the observation with Regional Culinary Director #167 confirmed since Resident #34 had a physician diet order for nothing by mouth she was unsure why the refrigerator was in the room and confirmed the above items should have been disposed of and the enteral feedings should have been stored by the nursing staff. Observation on 05/21/25 at 2:00 P.M. in the kitchen revealed Dietary Aide #118, who had longer hair with short dread locks, not wearing a hair net. Dietary Aide #118 confirmed he was supposed to be wearing a hair net in the kitchen. Review of the undated facility policy called Sanitation/Infection Control revealed the Dietary Manager is responsible for supervising all sanitation and housekeeping procedures within the dietary department. Frozen food is to be thawed in the refrigerator not at room temperature. Leftover foods are placed in shallow containers, dated, labeled and chilled rapidly. These are used within 48 hours. A clean department is essential for good sanitation. The department includes the equipment, materials that are used, floors, and walls. To maintain high environmental sanitation standards, the following practices are suggestive but not all-inclusive. All work and storage areas are clean, well-lit and orderly. Walls, ceiling and floors are cleaned routinely and is a required task found on the cleaning schedule. All cooking equipment, door seals, and surfaces of grills, burners and ovens are wiped daily and thoroughly cleaned regularly. Light daily cleaning is required for steam table wells, refrigerator, range and grill, floor and mats, sink, garbage disposal, and ovens. Outside doors on steamers and freezers are wiped off, as are splashed on the equipment and walls. Review of the undated facility policy called Food Brought in by Visitors revealed if food is brought in, all perishable food in resident's rooms shall be in tightly closed containers, labeled and dated well. Review of the facility undated facility policy called; Hair Covering Policy revealed proper hair coverings will be worn at all times in the kitchen. All dietary staff are required to wear effective hair restraints that cover all exposed body hair including facial hair and hear hair.

Based on record review, facility policy and procedure review and interview the facility failed to ensure their Quality Assurance and Performance Improvement (QAPI) committee identified and followed through on concerns timely. This had the potential to affect all 59 residents in the facility. Findings include: Review of the facility QAPI minutes and Performance Improvement Plan (PIP) documentation revealed the following plans without continued corrective action, evidence the plan was revised when necessary or changed once identified to be ineffective: 1. Review of a QAPI plan dated 07/29/24 revealed an action plan related to late administration of medications. A root cause, responsible party and action steps were listed including an audit plan. No resolution date was listed and there was no additional information provided such as audits to verify the correction plan was completed. During the current annual survey, deficiencies were cited regarding medication administration and significant medication errors. 2. Review of a second QAPI plan dated 07/29/24 revealed an action plan related to the failure to complete wound assessments and weekly skin assessments timely. A root cause, responsible party and action steps were listed including an audit plan. A resolution date was listed as 07/29/24 for staff education and disciplinary action for the wound nurse but there was no additional information provided such as audits to verify the correction plan was completed. During the current annual survey, deficiencies were cited regarding pressure areas. 3. Review of a QAPI plan dated 11/15/24 revealed an action plan related to late administration of medications. A root cause, responsible party and action steps were listed including an audit plan. A resolution date was listed as 11/15/24 for staff education but there was no additional information provided such as audits to verify the correction plan was completed. During the current annual survey, deficiencies were cited regarding medication administration and significant medication errors. 4. Review of two QAPI plans dated 01/02/25 revealed two action plans related to residents' falls with fractures. A root cause, responsible party and action steps were listed including an audit plan. All steps except the audits had a resolution date of 01/02/25. No audits were available to verify the correction plan was completed. During the current annual survey, deficiencies were cited regarding falls with major injury. Interviews on 05/22/25 at 11:39 A.M. and 12:47 P.M. with Regional Director of Operations (RDO) #196, Registered Nurse (RN)/Vice President of Clinical Services (VPCS) #182 and [NAME] President of Operations (VPO) #172 revealed the facility's Administrator was responsible for implementing and overseeing any auditing put into place as part of quality assurance (QA). If audits were not working well, the QA team would need to meet again to discuss and alter the course of action. RDO #196 was unaware of the lack of follow-through including audits and oversight with the facility's self-identified concerns regarding medication administration, pressure areas and falls with major injury reviewed during the annual survey until this date [05/22/25] and reiterated the facility's Administrator was responsible for QA follow-up. VPO #172 confirmed there were no audits corresponding to the above QAPI plans available for surveyor review. Review of the facility policy, QAPI Program, revised April 2014, revealed the facility shall develop, implement and maintain an ongoing, facility-wide Quality Assurance and Assessment and Assurance Program to actively pursue quality of care and quality of life goals. Performance Improvement Projects (PIPs) are initiated when problems are identified and PIPs involve systematically gathering information to clarify issues and to intervene for improvements. Adverse events are traced, monitored and investigated as they occur and action plans are implemented to prevent recurrence of adverse events the facility would plan, conduct and document PIPs.

2. Review of Resident #9's medical records revealed an admission date of 04/09/25. Diagnoses included infection related to indwelling urethral catheter, neuromuscular bladder and need for personal care assistance. Review of care plan dated 04/14/25 revealed Resident #9 had an indwelling urinary catheter. Interventions included monitor for signs and symptoms urinary tract infection that included cloudiness, foul smelling urine and deepening of urine color. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had an indwelling urinary catheter. Review of physician orders for May 2025 revealed Resident #9 was on enhanced barrier precautions (EBP) related to indwelling medical device. Observation on 05/14/25 at 7:49 A.M. revealed Resident #9 was sleeping in bed and the urinary catheter bag was observed on the floor under Resident #9's bed. Sign was posted outside Resident #9's door that indicated Resident #9 was on enhanced barrier precautions, as well as an isolation bin that contained personal protective equipment (PPE), that included gown, gloves and face masks. Observation on 05/14/25 at 9:56 A.M. revealed Resident #9's urinary catheter remained on the floor. Observation on 05/14/25 at 10:00 A.M. with Certified Nursing Assistant (CNA) #109 confirmed Resident #9's catheter bag was on the floor. CNA #109 stated she had not provided Resident #9 with care since the start of her shift at 7:00 A.M. and stated urinary catheter bag should not be placed on the floor. Further observation of catheter care with CNA #109 for Resident #9 revealed catheter insertion site and tubing had black dried debris around it. CNA #109 stated she was unable to state when Resident #9 had last received catheter care and stated catheter care should be done at least every shift. CNA #109 had not donned PPE prior to entering Resident #9's room or during catheter care. Interview with CNA #109 at time of observation confirmed Resident #9 was on EBP and PPE should have been worn during catheter care. Review of facility policy titled Enhanced Barrier Precautions (EBP) dated 04/01/24 revealed residents with indwelling medical devices EBP were indicated. EBP included the use of gown and gloves during high contact resident care.Based on personnel file review, staff interview, and observation the facility failed to ensure pre-employment tuberculosis testing was completed timely for all staff, enhanced barrier infection control precautions were followed during Resident #9's catheter care, and hand hygiene was properly performed during Resident #165's medication administration. This had the potential to affect all 59 residents in the facility. Findings include: 1. Review of personnel file for CNA #191 revealed a hire date of 07/23/24. Further review of the personnel record revealed it did not contain evidence pre-employment tuberculosis testing had been completed. Review of the personnel record for LPN #161 revealed a hire date of 05/07/24. Further review of the personnel record revealed tuberculosis testing was not completed until 10/10/24 by an outside provider. Review of the personnel record for Activity Director #132 revealed a hire date of 12/13/24. Further review of the personnel record revealed tuberculosis testing was not completed until 12/18/24. Record review of Licensed Practical Nurse (LPN) #114's personnel file revealed a date of hire 10/23/24. Further review of the personnel record revealed tuberculosis testing was not completed until 12/26/24. Interview on 05/15/25 at 1:07 P.M. with Human Resource Manager #143 confirmed the identified findings. 3. Observation of medication administration on 05/12/25 at 8:55 A.M. revealed LPN # 114 began the medication pass without performing hand hygiene. The nurse went into Resident #165's to administer medication. LPN #114 placed gloves on her hands and administered pills in a cup to the resident, after the administration the nurse went out of the resident's room with gloves on, walked up the hall to the medication cart and retrieved Enoxaparin injection for the resident with the gloves still on. The nurse administered the injection to Resident #165 at 9:05 A.M. with the same gloves on. When the injection was completed, LPN #114 left the residents room and walked back up the hall to the medication cart then took the gloves off. The nurse did not complete hand hygiene. Interview at 9:10 A.M. on 05/12/25 with LPN #114 revealed the nurse was a new nurse and she stated that she didn't think about hand hygiene during or after the medication administration. Interview with Regional Director of Nursing Services #166 on 05/12/25 at 9:15 A.M. revealed the nurse should have performed hand hygiene before the medication administration, before the gloves were placed on the nurses' hands, and after the gloves were removed in Resident #165's room and hands cleaned before leaving the room. She stated infection control is a priority in the facility. Review of the facility policy titled Handwashing/ Hand Hygiene, dated August 2015, revealed the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel should follow the handwashing/ hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene is the final step after removing protective equipment.

Based on record review, observation and interview, the facility failed to ensure the elevators were working in a safe operation condition. This had the potential to affect all 59 residents residing in the facility. Findings include: Review of documentation for elevator concerns including invoices from the elevator service company dated from 11/08/24 to 05/13/25, incident with the fire department with elevator rescue and an employee in-service revealed the facility had been having elevator concerns to both elevators since 11/08/24. Review of the documentation revealed: -11/08/24 invoice-Elevator one was not responding, stuck on unknown floor and the doors closed. It was unoccupied. Elevator technician adjusted the light tray and elevator one was still in service. -12/09/24 invoice-Elevator preventative maintenance. -01/08/25 invoice-Elevator one and two, preventative entrapment, elevators not responding. Both elevators stuck on unknown floors. The doors were closed on both elevators. The elevators were unoccupied. Elevator technician emptied pit buckets on both cars and then checked operations. -01/24/25 invoice-Preventative maintenance. -02/14/25 invoice-Elevator one was not responding. The elevator was stuck in between floors. The doors were closed and the elevator was unoccupied. Elevator one was down for a light ray unit and the part was on order. -03/04/25 invoice-Elevator two was not responding at 1:09 P.M. It was stuck on the first floor with the doors closed and unoccupied. Elevator technician replaced switches to both door locks and car doors and repaired the car door track on elevator one. The pit was cleaned and emptied on elevator two. -03/04/25 invoice-Elevator one and two were not responding at 6:44 P.M. Both elevators were stuck on unknown floors, doors closed and unoccupied. The elevators were reset by the facility and running at the time of the elevator technician's arrival. The elevator technician run both cars and was unable to find an issue. They left both elevators in service. -03/06/25 invoice-Performed safety test on the elevators and there were no concerns. -03/10/25 invoice-Elevator two was not responding and stuck on the first floor with the doors closed and unoccupied. The low oil sensor had tripped. The elevator technician ran elevator two it tripped again. After trying again, elevator two was working. The elevator technician stated the valve may need replaced soon. -03/11/25 invoice-Elevator two was not responding. Elevator technician replaced the top and bottom boards and adjusted the valve. -03/14/25 invoice-Elevators one and two were not responding and stuck on the second floor with the doors closed and unoccupied. The elevator technician found a loose wire on a coil. -03/15/25 invoice -Elevator two was going up but not coming back to the first floor. The elevator was stuck on the first floor with the doors closed, though still in use. The elevator technician stated the car had a low oil timer and reset the car and it was left in service. -03/18/25 invoice-Elevators one and two were not responding. Both elevators were stuck on the first floor with the doors closed and unoccupied. Elevator technician reset the low oil and updated their office about the valve replacement (noted on 03/10/25). -03/19/25 invoice-Preventative maintenance. The elevator technician replaced the power board. -03/24/25 invoice-Elevator two was not responding. The photo eye was not working and had shut down the elevator and was stuck on the first floor with the doors closed. Elevator technician was unable to find any concerns. -04/09/25 invoice-Elevator two was not responding and stuck on an unknown floor with the doors closed and unoccupied. The elevator technician stated the motor read good. They updated the facility to contact an electrician about incoming power issues. -04/11/25 invoice-Elevator two was not responding and stuck on the first floor with the doors closed and unoccupied. Elevator technician stated the elevator was having low leg amp faults (indicating a voltage/connection problem). The elevator was taken completely out of service. -05/04/25 Fire Department Incident stated at 1:24 P.M. they were notified of possible entrapment in a stalled elevator car. The fire department arrived at the facility at 1:29 P.M. Upon arrival, the person had already been removed from the elevator car and the elevator was working properly. -05/06/25 invoice-Elevator two had motor and valve replacement. Elevator two was still out of service. -05/08/25 invoice-Performed preventative maintenance. -05/13/25 invoice-A call was placed to the elevator service company stating elevator one was not responding to first floor call and was stuck on the second floor, doors closed. -Review of elevator in-service, undated, revealed The elevator is currently in repair and should be completed shortly. In the meantime, please be aware of the following: Mindful to push the elevator back down to the first floor, remember resident and families are waiting for the elevator, your assistance is appreciated to expedite not only family and resident needs but also coworkers and supplies. Any questions, please contact your Administrator or Director of Nursing. Observation on 05/12/25 at 8:15 A.M. of the facility elevators revealed elevator two (bigger elevator) was out of service. Elevator one was working, however, when getting into the elevator there was a sign posted stating When exiting the elevator please send it back to the first floor, per maintenance. Interview on 05/12/25 at 9:59 A.M. with Licensed Practical Nurse (LPN) #114 stated elevator two was broken. She stated someone did come to look at it but it was still out of order. She stated elevator one did not work properly. LPN #114 stated when the elevator was used and taken to the second floor, whoever was exiting the elevator had to push the button one to send it back to the first floor or it would be stuck on the second floor. She stated if the one button was not pushed, residents had to wait long periods of time and then staff would have to call to the second floor for someone to go into the elevator and press button one so it would return to the first floor. Interview on 05/12/25 at 10:00 A.M. with the Director of Nursing (DON) revealed she was unaware of the concerns with elevator one. She stated she did not know staff/residents had to press one when they were exiting the second floor to ensure the elevator would return to the first floor. Interview on 05/12/25 at 10:34 A.M. with LPN #100 verified elevator one was not working properly. She stated it would be stuck on the second floor if the resident, visitor or staff member did not push the one button to return it to the first floor. She stated Resident #6 was unable to fit into elevator one because the size of his wheelchair. LPN #100 stated most of the activities were done on the second floor. Observation on 05/12/25 at 2:16 P.M. of elevator one. The button had been pushed and residents were waiting to go to the second floor. Approximately five minutes later, at 2:21 P.M., the elevator door opened and immediately shut not allowing residents to get off of the elevator onto the first floor. Interview on 05/12/25 at 2:48 P.M. with Regional Maintenance Director (RMD) #169 revealed the elevator company was here on 05/09/25 to fix elevator two. He stated they replaced the motor but it had not corrected the problem and had to order another part, a starter. He stated they were waiting for it to be installed later this week. He stated he was unaware of concerns with elevator one. Interview on 05/13/25 at 12:00 P.M. with Elevator Repair Supervisor #170 provided an email timeline for elevator two's repair. He also stated on 04/09/25 his service technician recommended an electrician which is the protocol when they get a power glitch in the building. He stated at that time the motor was fine and it lead the technician to believe it was the incoming power. He verified elevator two had been out of service since 04/11/25. He also stated he was not updated about elevator one's concern with not coming back to the first floor when called unless the one button inside the elevator was pushed on the second floor. He stated he believed the issue with elevator one was unrelated to the concerns of elevator two. Review of the email dated 05/13/25 from Elevator Repair Supervisor #170 revealed the last service call for elevator two was on 04/11/25. The pump motor was ordered on 04/15/25 and they fixed the elevator on 05/06/25. The elevator company scheduled an inspection on 05/09/25 with the state and it was noted the starter was not working. Interview on 05/13/25 at 1:39 P.M. with the Maintenance Director #138 verified he placed the elevator sign in elevator one related to pushing the button to go back to the first floor after arriving to the second floor. He also verified the staff in-service was done prior to 04/14/25 but was unable to give the exact date. He stated the facility did not call an electrician on 04/09/25 because the elevator technician had changed his mind about needing an electrician. He was unable to provide documentation stating this. He stated he could not recall staff or residents being stuck on the elevator. Maintenance Director #138 verified he had not called the elevator service company regarding elevator one's concern until today. Interview on 05/13/25 at 1:39 P.M. with RMD #169 revealed elevator one's opening was 35 inches. He stated Resident #11's motorized wheelchair was 30.5 inches. He stated the arm would need removed off of the chair for him to get into the elevator. Interview on 05/14/25 at 11:47 A.M. with Assistant Fire Chief #204 verified the fire department was called on 05/04/25 for an entrapment in elevator one. He stated when they arrived, the facility had gotten the elevator open. He was unsure if it was a resident or staff member who was entrapped on the elevator. Interview on 05/15/25 at 12:26 P.M. with RMD #169 stated on 05/04/25 there were no residents or staff entrapped on the elevator. A staff member had called the fire department because the elevator was stuck and she believed there was a resident or staff person in the elevator car. He stated the facility was able to send the elevator to the first floor and the doors opened before the fire department arrived. RMD #169 stated on 04/11/25 the elevator technician did not want to service elevator one because it was working and they did not want both elevators broke at the same time. He verified there was no documentation stating this. He stated he would provide a statement from the elevator technician. RMD #169 stated he believes elevator one issue was related to elevator two. He stated when elevator one is taken to the second floor and then someone on the first floor pushes the button, the elevator system believes elevator two is there and that is why elevator one does not return to the first floor without pushing the button. Interview on 05/15/25 at 2:50 P.M. with RMD #169 revealed the elevator technician refused to make a statement related to elevator one. However, he provided a statement from Elevator Repair Supervisor #170. Review of the emailed statement dated 05/15/25 at 2:57 P.M. from Elevator Repair Supervisor #170 revealed he had spoken to the normal routine elevator technician who serviced the building. He stated the dispatch problem with elevator one had been going on for quite some time and only when elevator two was out of service and the power was removed. Elevator Repair Supervisor #170 stated his technician stated he had attempted to correct elevator one's issue but both elevators shut down. He stated the technician instructed the building to put a sign in elevator one until elevator two was fixed so they would have a working elevator. Observation on 05/15/25 at 3:46 P.M. with RMD #169 of the elevators revealed the elevator technicians had left elevator two in between floors. RMD #169 stated elevator one should be able to be called to the first floor by the button on the first floor. This surveyor went to the second floor in elevator one and did not push the first floor button to return the elevator. RMD #169 pushed the up button on the first floor and elevator one did not return to the first floor verifying there was still an issue with elevator one. This deficiency represents non-compliance investigated under Complaint Number OH00161946 and Complaint Number OH00162143.

Based on observation, interview and record review, the facility failed to maintain a clean, sanitary and safe environment. This had the potential to affect all 59 residents residing in the facility. The facility census was 59. Findings include: Initial observation of the facility on 05/12/25 at 8:15 A.M. of the first floor revealed the bathroom on the first floor toilet paper holder was broken off. The Director of Nursing (DON) was present and verified the finding. On the second floor on the memory care unit there was noted to be strong odors of urine and bowel. The ice machine on the blue hall noted to have water leaking around it with towels and bath blankets laying on the floor to soak up the water that had leaked. Observation on 05/12/25 at 9:04 A.M. of Resident #45's room revealed the resident was not present in room. The bed linens were observed to have been heavily soiled and were odorous. The call light was observed across the room on the floor. On 05/12/25 at 9:18 A.M. returned to Resident #45's room with Licensed Practical Nurse (LPN) #108 and she verified the above findings. Observation on 05/12/25 at 10:05 A.M. revealed room [ROOM NUMBER], which was unoccupied, to have food debris and soiled depends in the room. Observation on 05/12/25 at 10:08 A.M. of Resident #9's room revealed his room to have debris on the floor and a bed pan underneath his bed that had not been cleaned of bowel and urine. Observation on 05/12/25 at 10:30 A.M. of Resident #35's room revealed his trash can beside his bed was full of dirty towels. Surrounding the trash can on the floor there was a dirty fitted bed sheet and bath blanket. There was also an empty urinal lying on the floor approximately two feet from the end of the bed. Resident #35 stated the staff on night shift had come in and assisted him with care but never returned to clean up his room. On 05/12/25 at 10:32 A.M. the Business Office Manager (BOM) #142 verified the findings as above. Observation on 05/12/25 at 10:31 A.M. of Resident #26's room revealed trash under his bed. Observation on 05/12/25 at 11:12 A.M. of Resident #17's room revealed the floor had food debris and there were paper towels on the floor. Observation on 05/14/25 at 7:30 A.M. of the first floor bathroom revealed there was no toilet paper and the trash was overflowing onto the floor. Interview on 05/15/25 at 9:39 A.M. with Housekeeper #174 revealed she had worked at the facility for one month. She stated there was not enough staff in housekeeping to ensure the facility was clean. She verified resident rooms were not being cleaned everyday. Observation on 05/20/25 at 12:32 P.M. of the 2nd floor nurse's station revealed the handrails to have food, band-aids, trash, paperclips, staples and straws in it. LPN #131 was present and verified the findings. She stated the housekeeping staff were not cleaning the resident rooms and common areas every day. Review of the facility policy titled, Cleaning and Disinfecting Residents' Rooms, revised August 2013, revealed housekeeping surfaces such as floors and tabletops would be cleaned on a regular basis as well as environmental surfaces. This deficiency represents non-compliance investigated under Complaint Number OH00164538, Complaint Number OH00162143, Complaint Number OH00162053 and Complaint Number OH00161946.

Based on observation and interview, the facility failed to maintain resident room water temperatures at a comfortable level. This affected five (Residents #7, #19, #27, #32 and #49) out of seven resident rooms tested for water temperatures. The facility census was 59. Findings include: Review of the last audit of water temperatures obtained by the facility was noted to be on 04/02/25 and 04/18/25. Temperatures were noted to be between 113.8 and 116.1. Observation on 05/14/25 at 9:20 A.M. of incontinence care to Resident #19 revealed she stated the water was cold. Certified Nursing Assistant (CNA) #135 stated he had let the water run for five minutes and Resident #19 wanted her water really hot. Observation on 05/14/25 at 9:44 A.M. and 9:45 A.M. of hot water temperatures revealed rooms [ROOM NUMBERS] were of required temperatures between 105 and 120 degrees Fahrenheit. On 05/14/25 at 9:50 A.M. observed water temperatures with CNA #125. room [ROOM NUMBER] (Residents #19 and #49) and room [ROOM NUMBER] (Resident #27) shared a bathroom. The water temperature was noted to be 88 degrees Fahrenheit after allowing the water to run for five minutes. room [ROOM NUMBER] (Resident #32) and room [ROOM NUMBER] (Resident #7) shared a bathroom. The water temperature was noted to be 96 degrees Fahrenheit after allowing the water to run for five minutes. CNA #125 verified the water temperatures and stated this was how the water usually felt while providing care.

Based on record review, facility policy review, review of Centers for Disease Control and Prevention (CDC) guidance and interview the facility failed to ensure residents were were offered, screened, educated and received influenza and pnuemociccal vaccinations as required. This affected five residents (#3, #8, #11, #21 and #60) of five reviewed for vaccinations with the potential to affect all 59 residents residing in the facility. Findings include: 1. Review of Resident #3's medical records revealed an admission date of 05/17/24. Diagnoses included dementia, schizophrenia and muscle weakness. Review of Resident #3's immunization records revealed no documentation related to influenza or pnuemociccal vaccinations, consent/declination of the vaccination or education provided on the vaccines. Interview on 05/19/25 at 2:48 P.M. with [NAME] President of Operations (VPO) #172 and Regional Registered Nurse (RRN) #182 revealed they were unable to locate the vaccination records, refusals or education for Residents #3. VPO #172 and RRN #182 further confirmed no documented evidence was included in the residents electronic medical records. Review of facility policy titled Influenza Vaccine revised 08/16 revealed for residents who had received the vaccine the date of the vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the residents medical records. A residents refusal of the vaccination will be documented and placed in the residents medical records. Review of facility policy titled Pneumococcal Vaccine revised 08/16 revealed prior to or upon admission residents will be assessed for eligibility to receive the pnuemociccal vaccinations and will be offered the vaccine series within thirty days of admission unless contraindicated. Residents who had received the vaccine the date of the vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the residents medical records. Review online Centers for Disease Control and Prevention (CDC) information/guidance for pneumococcal vaccination dated 10/26/24 revealed the following: CDC recommends pneumococcal vaccination for children younger than 5 years and adults 50 years or older. CDC also recommends pneumococcal vaccination for children and adults at increased risk for pneumococcal disease. Follow the recommended immunization schedule to ensure that your patients get the pneumococcal vaccines that they need. The CDC guidance provides additional information for the types of risk associated with pneumococcal disease for vaccination of those individuals between the ages of 5 and 49 and also provides guidance on the type of pneumococcal vaccination/schedule for administration based on an assessment of the resident. 2. Review of Resident #8's medical records revealed an admission date of 02/13/25. Diagnoses included schizophrenia cognitive deficits and muscle weakness. Review of Resident #8's immunization records revealed no documentation related to influenza or pnuemociccal vaccinations, consent/declination of the vaccination or education provided on the vaccines. Interview on 05/19/25 at 2:48 P.M. with VPO #172 and RRN #182 revealed they were unable to locate the vaccination records, refusals or education for Residents #8. VPO #172 and RRN #182 further confirmed no documented evidence was included in the residents electronic medical records. Review of facility policy titled Influenza Vaccine revised 08/16 revealed for residents who had received the vaccine the date of the vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the residents medical records. A residents refusal of the vaccination will be documented and placed in the residents medical records. Review of facility policy titled Pneumococcal Vaccine revised 08/16 revealed prior to or upon admission residents will be assessed for eligibility to receive the pnuemociccal vaccinations and will be offered the vaccine series within thirty days of admission unless contraindicated. Residents who had received the vaccine the date of the vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the residents medical records. Review online Centers for Disease Control and Prevention (CDC) information/guidance for pneumococcal vaccination dated 10/26/24 revealed the following: CDC recommends pneumococcal vaccination for children younger than 5 years and adults 50 years or older. CDC also recommends pneumococcal vaccination for children and adults at increased risk for pneumococcal disease. Follow the recommended immunization schedule to ensure that your patients get the pneumococcal vaccines that they need. The CDC guidance provides additional information for the types of risk associated with pneumococcal disease for vaccination of those individuals between the ages of 5 and 49 and also provides guidance on the type of pneumococcal vaccination/schedule for administration based on an assessment of the resident. 3. Review of Resident #11's medical records revealed an admission date of 03/02/17. Diagnoses included congestive heart failure, asthma and morbid obesity. Review of Resident #11's immunization records revealed no documentation related to influenza or pnuemociccal vaccinations, consent/declination of the vaccination or education provided on the vaccines. Interview on 05/19/25 at 2:48 P.M. with VPO #172 and RRN #182 revealed they were unable to locate the vaccination records, refusals or education for Residents #11. VPO #172 and RRN #182 further confirmed no documented evidence was included in the residents electronic medical records. Review of facility policy titled Influenza Vaccine revised 08/16 revealed for residents who had received the vaccine the date of the vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the residents medical records. A residents refusal of the vaccination will be documented and placed in the residents medical records. Review of facility policy titled Pneumococcal Vaccine revised 08/16 revealed prior to or upon admission residents will be assessed for eligibility to receive the pnuemociccal vaccinations and will be offered the vaccine series within thirty days of admission unless contraindicated. Residents who had received the vaccine the date of the vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the residents medical records. Review online Centers for Disease Control and Prevention (CDC) information/guidance for pneumococcal vaccination dated 10/26/24 revealed the following: CDC recommends pneumococcal vaccination for children younger than 5 years and adults 50 years or older. CDC also recommends pneumococcal vaccination for children and adults at increased risk for pneumococcal disease. Follow the recommended immunization schedule to ensure that your patients get the pneumococcal vaccines that they need. The CDC guidance provides additional information for the types of risk associated with pneumococcal disease for vaccination of those individuals between the ages of 5 and 49 and also provides guidance on the type of pneumococcal vaccination/schedule for administration based on an assessment of the resident. 4. Review of Resident #21's medical records revealed an admission date of 06/25/24. Diagnoses included diabetes, respiratory failure and asthma. Review of Resident #21's immunization records revealed no documentation related to influenza or pnuemociccal vaccinations, consent/declination of the vaccination or education provided on the vaccines. Interview on 05/19/25 at 2:48 P.M. with VPO #172 and RRN #182 revealed they were unable to locate the vaccination records, refusals or education for Residents #21. VPO #172 and RRN #182 further confirmed no documented evidence was included in the residents electronic medical records. Review of facility policy titled Influenza Vaccine revised 08/16 revealed for residents who had received the vaccine the date of the vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the residents medical records. A residents refusal of the vaccination will be documented and placed in the residents medical records. Review of facility policy titled Pneumococcal Vaccine revised 08/16 revealed prior to or upon admission residents will be assessed for eligibility to receive the pnuemociccal vaccinations and will be offered the vaccine series within thirty days of admission unless contraindicated. Residents who had received the vaccine the date of the vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the residents medical records. Review online Centers for Disease Control and Prevention (CDC) information/guidance for pneumococcal vaccination dated 10/26/24 revealed the following: CDC recommends pneumococcal vaccination for children younger than 5 years and adults 50 years or older. CDC also recommends pneumococcal vaccination for children and adults at increased risk for pneumococcal disease. Follow the recommended immunization schedule to ensure that your patients get the pneumococcal vaccines that they need. The CDC guidance provides additional information for the types of risk associated with pneumococcal disease for vaccination of those individuals between the ages of 5 and 49 and also provides guidance on the type of pneumococcal vaccination/schedule for administration based on an assessment of the resident. 5. Review of Resident #60's medical records revealed an admission date of 01/21/25. Diagnoses included dementia, chronic obstructive pulmonary disease (COPD) and cognitive deficits. Review of Resident #60's immunization records revealed no documentation related to influenza or pnuemociccal vaccinations, consent/declination of the vaccination or education provided on the vaccines. Interview on 05/19/25 at 2:48 P.M. with VPO #172 and RRN #182 revealed they were unable to locate the vaccination records, refusals or education for Residents #60. VPO #172 and RRN #182 further confirmed no documented evidence was included in the residents electronic medical records. Review online Centers for Disease Control and Prevention (CDC) information/guidance for pneumococcal vaccination dated 10/26/24 revealed the following: CDC recommends pneumococcal vaccination for children younger than 5 years and adults 50 years or older. CDC also recommends pneumococcal vaccination for children and adults at increased risk for pneumococcal disease. Follow the recommended immunization schedule to ensure that your patients get the pneumococcal vaccines that they need. The CDC guidance provides additional information for the types of risk associated with pneumococcal disease for vaccination of those individuals between the ages of 5 and 49 and also provides guidance on the type of pneumococcal vaccination/schedule for administration based on an assessment of the resident.

Based on record review, observation and interview, the facility failed to ensure dependent residents were assisted with activities of daily living. This affected four (Residents #21, #24, #39 and #51) of nine reviewed for activities of daily living for dependent residents. The facility census was 59. Findings include: 1. Review of the medical record for Resident #51 revealed an admission date of 05/06/24 with diagnoses including epilepsy, cognitive communication deficit and need for assistance with personal care. Review of the care plan dated 07/09/24 for Resident #51 revealed he was at increased risk for malnutrition related to medications, seizures, weakness, dysphagia, mechanically altered diet and pocketing food. Interventions included for staff to assist with all meals. Review of the nursing readmission assessment dated [DATE] for Resident #51 revealed he was totally dependent on staff for eating. Observation on 05/19/25 at 12:00 P.M. of Resident #51 revealed his meal tray for lunch was delivered to his room. It was placed on his tray table across the room from his bed. Observation on 05/19/25 at 12:45 P.M. of Resident #51 revealed his meal tray for lunch was still sitting on his tray table untouched. Interview on 05/19/25 at 12:50 P.M. with Licensed Practical Nurse (LPN) #188 verified Resident #51's tray arrived at 12:00 P.M. She stated herself and one aide were on the floor to assist the two residents who needed assist with meals. She stated she was in the dining room as well. She verified staff had not assisted him with his meal. Observation on 05/20/25 at 8:00 A.M. of Resident #51 revealed his meal tray for breakfast was delivered to his room and was placed on his tray table. He was noted to still be in bed. Observation on 05/20/25 at 9:30 A.M. with Registered Nurse (RN) #186 revealed Resident #51's meal tray for breakfast was still sitting on his tray table untouched and the resident was in bed. She verified Resident #51 should have been up in his wheel chair and assisted with breakfast when the tray came at 8:00 A.M.2. Review of the medical record for Resident #21 revealed and admission date of 6/25/24 with diagnosis of post traumatic seizures, acute respiratory failure, need assistance with personal care, repeated falls, depression, osteoarthritis. Review of Resident #21's physician orders dated 06/25/24 revealed his showers were to be on Monday and Thursday on day shift or as needed. There was a bulletin posted by the resident's bed that indicated those are shower days. Review of the care plan dated 03/11/25 revealed the resident had a self-care deficit with the goals for the resident to be cleaned and well-groomed while requiring assistance of one. Resident #21's care plan did not indicate he refused care. Review of Resident #21's quarterly Minimum Data Set (MDS) assessment dated [DATE] under section E revealed the resident needed assistance with bathing. Review of the shower sheets for the last 30 days from 04/01/25 to 05/01/25 revealed on 04/03/25, 04/07/25, and 04/14/25 Resident #21 refused his showers. The resident missed nine out of the 12 showers scheduled to be given. Review of the plan of care record documented by certified nursing assistants (CNA) from 04/01/25 to 05/01/25 revealed the resident only had one shower on 04/17/25 with a signed shower sheet indicating he refused the shower. Observation of Resident #21 on 05/12/25 at 9:45 A.M. revealed the resident looked unkept. He was unshaven and had spots of dried food on his shirt. When the resident if he gets baths when he wants them, he stated it depends on what you call a bath. He revealed he gets washed up sometime with staff but wants showers twice a week like when he first got to the facility. The resident had dirty long nails that he wanted trimmed. Resident #21 revealed he washes up in the sink most of the time. Interview with Regional Nurse #166 on 05/13/25 at 2:25 P.M. confirmed there was no documentation the resident refused care and showers were not completed for the nine days missing out of the month. Review of facility process titled Shower/Tub Bath, dated 05/19/25, revealed facility promoted cleanliness, comfort for the resident, and observe the skin. When the bath is completed, the medical record should be updated with the date and time the bathing occurred. The name and title of person assisting the resident and any skin issues identified be reported to the nurse. These were to be completed two times a week or more per the resident's preference. 3. Review of the medical record for Resident #24 revealed an admission date of 01/03/17 with diagnoses of chronic heart failure, dementia, type 2 diabetes, muscle weakness, alcohol abuse, chronic kidney disease. Review of Resident #24's care plan dated 02/06/25 revealed the resident had a self-care deficit related to cognitive and physical deficits and requires assistance with activities of daily living. Review of Resident #24's CNA documentation on 04/24/25 revealed the resident required extensive assistance with bathing as needed. Review of Resident #24's shower sheets that were available for the last 30 days 04/01/25 to 05/01/25 revealed the resident had only two documented showers on a shower sheet and three in the electronic medical record. Observation of Resident #24 on 05/12/25 at 9:24 A.M. revealed the resident lying in bed with long, dirty fingernails, and the resident was unshaven. Observation of a shower schedule on the bulletin board in the resident's room revealed his showers were to be 7:00 A.M. to 7:00 P.M. on Monday and Thursdays. On 05/13/25 at 8:45 A.M. Resident #24 was observed with long dirty fingernails and an unkept appearance. When asking the resident if he wanted to shave and take a shower, he stated he wanted his nails cut and clean clothes on. The resident had a dark blue sweatshirt with a brown striped shirt underneath. Resident #24 had on plaid blue pajama like pants on and dirty yellow grip socks. Interview with Regional Director of Nursing #166 on 05/13/25 at 1:45 P.M. confirmed the resident did not have showers at least two times a week and did look unkept. She instructed a CNA to assist the resident in the shower and provide nail care. Observation of Resident #24 on 05/14/25 at 10:39 A.M. revealed the resident in the same clothes as the day before with his nails still long and dirty. The resident had a dark blue sweatshirt with a brown striped shirt underneath. Resident #24 had on plaid blue pajama like pants on and dirty yellow grip socks. Interview on 05/15/25 at 10:29 A.M. with Registered Nurse (RN) #193 confirmed Resident #24 did have long fingernails and was unshaven. She also stated the point of care documentation the CNA's are to do does not reflect an accurate picture of the resident's documented showers, and they were expected to provide signed shower sheets. Review of facility process titled Shower/Tub Bath dated 05/19/25 revealed the facility promoted cleanliness, comfort for the resident, and observe the skin. When the bath was completed, the medical record should be updated with the date and time the bathing occurred. The name and title of person assisting the resident and any skin issues identified be reported to the nurse. These were to be completed two times a week or more per the resident's preference. 4. Review of the medical record for Resident #39 revealed an admission date of 5/22/22 with diagnoses of unspecified dementia with severe anxiety, moderate protein calorie malnutrition, history of falls, palliative care, and hyperlipidemia. Review of Resident #39's care plan dated 02/06/25 revealed the resident required total assistance with activities of daily living and bathing with a severe physical and cognitive decline. Review of the medical record on 05/14/25 at 3:25 P.M. revealed Resident #39 was charted as able to perform bathing on her own, and CNA # 183 documented she was totally dependent on staff. Observation of Resident #39 on 05/12/25 at 11:58 A.M. revealed the resident was in a tilt back chair with a green sweater with dried food on it. Her nails were long and appeared to have dried food or dirt under them. Observation of Resident #39 on 5/13/25 at 9:26 A.M. with CNA #183 confirmed the resident needed washed up and she believed the Hospice aide would come and give her a bath but was not able to say when that occurred. Interview with Regional Director of Nursing #166 on 05/14/25 at 8:16 A.M. revealed there were no paper shower sheets for Resident #39 or any documentation in the medical record to verify showers were completed. She stated the resident was given a bed bath every day by the staff but could not provide documentation. Interview on 05/14/25 at 9:10 A.M. with Regional Director of Nursing #166 revealed that there was no hospice documentation available to indicate if Resident #39 was provided care by a hospice that may have performed bathing for the resident. Review of facility process titled Shower/Tub Bath dated 05/19/25 revealed the facility promoted cleanliness, comfort for the resident, and observe the skin. When the bath was completed, the medical record should be updated with the date and time the bathing occurred. The name and title of person assisting the resident and any skin issues identified be reported to the nurse. These were to be completed two times a week or more per the resident's preference.

Based on record review and interview, the facility failed to ensure comprehension assessments were accurately completed. This affected five (Residents #34, #39, #51, #59 and #69) out of 40 residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 59. Findings include: 1. Review of the medical record for Resident #51 revealed an admission date of 05/06/24 with diagnoses including epilepsy (seizures), cognitive communication deficit, need for assistance with personal care and history of encephalitis (inflammation of the brain). Review of the census for Resident #51 revealed he was admitted to the hospital from [DATE] through 03/06/25. Review of the nursing readmission assessment dated [DATE] for Resident #51 revealed he had no skin issues noted. Review of the weekly skin assessment on 03/12/25 for Resident #51 revealed his skin was intact. Review of the MDS 3.0 assessment for Resident #51 dated 03/31/25, discharge return anticipated, revealed section M stated he had a Stage III pressure ulcer (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) present on admission. Interview on 05/19/25 at 11:30 A.M. with the Director of Nursing (DON) verified Resident #51's MDS from 03/31/25 was incorrect as his Stage III pressure ulcer to his buttocks was not present on admission. 2. Review of the medical record for Resident #59 revealed an admission date of 12/02/24 with diagnoses including rheumatoid arthritis, chronic obstructive pulmonary disease, heart disease and history of falling. Review of the nursing progress note dated 02/22/25 revealed Resident #59 was independent for bed mobility, transfers, eating, toileting, hygiene and walking. Review of the nursing progress note dated 02/24/25 revealed Resident #59 needed supervision for bed mobility and was independent for transfers, eating, hygiene and toileting. Review of the quarterly MDS 3.0 assessment for Resident #59 dated 03/11/25 revealed on section GG he needed set-up assistance for eating and was dependent on staff for toileting, showers, rolling and transfers. The assessment stated he did not walk. Interview on 05/22/25 at 9:06 A.M. with the [NAME] President of Operations (VPO) #172 verified Resident #59's MDS assessment on 03/11/25 was incorrect as he was not dependent on staff for activities of daily living. 3. Review of the medical record for Resident #69 revealed an admission date of 06/13/24 with diagnoses including diabetes mellitus and cognitive communication deficit. Review of the Medication Administration Record for December 2024 revealed Resident #69 received Insulin Glargine (medication for high blood sugar) from 12/11/24 through 12/31/24 every day upon rising. Review of the quarterly MDS 3.0 assessment for Resident #69 dated 12/21/24 revealed on section N question N350 for how many days of insulin injections were received during the last seven days, the question was answered only one. Interview on 05/20/25 at 2:20 P.M. with the [NAME] President of Clinical Services #182 verified Resident #69's MDS assessment on 12/21/24 was incorrect as she received seven insulin injections from 12/15/24 through 12/21/24.4. Review of the medical record for Resident #34 revealed and admission date of 07/29/22. Diagnoses included but were not limited to osteonecrosis, gastrostomy, history of malignant neoplasm of other sites of lip, oral cavity and pharynx and nicotine dependence. Review of the 05/09/25 quarterly Minimum Data Set (MDS) 3.0 for Resident #34 revealed a Brief Interview for Mental Status (BIMS) of 0 which indicated severe cognitive impairment and was independent for activities of daily living. Resident #34 was not noted to have significant weight changes and was using a feeding tube for over 51% of his nutrition needs and was receiving fluid intake of over 501 cubic centimeters (cc) of fluid via the enteral tube daily. Review of the 02/05/25 quarterly Minimum Data Set (MDS) 3.0 for Resident #34 revealed he revealed a Brief Interview for Mental Status (BIMS) of 0 which indicated severe cognitive impairment and was independent for activities of daily living. Resident #34 was noted to have significant weight loss and was using a feeding tube for over 51% of his nutrition needs and was receiving fluid intake of over 501 cubic centimeters (cc) of fluid via the enteral tube daily. Review of the 02/06/25 BIMS assessment for Resident #34 revealed it was in progress, not completed and had a score of 11 which indicated moderate cognitive impairment. Review of the 05/08/25 BIMS assessment for Resident #34 revealed a score of 0 which indicated severe cognitive impairment. Interview on 05/13/25 at 2:25 P.M. with Licensed Practical Nurse (LPN) #131 confirmed Resident #34 refuses his enteral feeding and drinks them orally. LPN #131 stated the nurse take the enteral feeding into Resident #34's room and he consumes it orally at his leisure. LPN #131 also stated Resident #34 is non-compliant with his nothing by mouth (NPO) status and consumes foods orally without a diet order. LPN #131 stated she had reported it to the previous Director of Nursing (DON) about five months ago and continued to document his refusals of enteral feeding. Interview on 05/13/25 at 3:33 P.M. with Regional Director of Clinical Services #166 confirmed she was unaware Resident #34 was refusing his enteral feeding and was consuming it orally, and was unaware staff were leaving the enteral feeding bottles in Resident #34's room. Observation on 05/14/25 at 11:07 A.M. with LPN #131 revealed she attempted to provide an enteral feeding flush for Resident #34. Resident #34 was observed to be making hand gestures pushing away and was attempting to speak but surveyor was unable to understand what Resident #34 was saying. Interview with LPN #131 following the observation revealed she was able to understand Resident #34. Resident #34 did not want the enteral flush and did not want to be bothered. Interview on 05/15/25 at 6:13 A.M. with Certified Nursing Assistant #123 revealed Resident #34 will frequently refuse care, will use his call light and will answer yes and no questions and will point to things to get his needs made known. Interview on 05/15/25 at 6:38 A.M. with Registered Nurse (RN) #153 revealed Resident #34 will not allow staff to administer his enteral feeding or flushes. Resident #34 will ask for his enteral feeding and does not want staff assistance. RN #153 confirmed she did not know how much Resident #34 was consuming of his enteral tube feeding whether via the percutaneous endoscopic gastrostomy (PEG) tube or orally and stated he usually drinks it orally. Phone interview on 05/15/25 at 9:14 A.M. with Registered Dietitian (RD) #181 revealed Resident #34 is NPO and uses a PEG tube. RD #181 stated she was unaware Resident #34 was refusing his enteral feeding or consuming his enteral feeding orally. RD #181 confirmed she had marked section K on the quarterly assessment for 02/05/25 and 05/09/25 for Resident #34 as receiving over 51% of his nutrition and 501 cc or more for hydration via the PEG tube. Interview on 05/15/25 at 9:47 A.M. with Director of Rehab #151 revealed Resident #34 refuses to participate in the BIMS assessment and therefore is coded as a 0. Interview on 05/20/25 at 1:57 P.M. with [NAME] President of Operations (VPO) #172 confirmed Social Worker (SW) #192 stated the answers for the BIMS assessment on the MDS were all no's and confirmed she did not write a progress note to explain. VPO #172 confirmed SW #192 should have checked Resident #34 was not assessed due to refusals on the MDS and should not have entered a BIMS of 0. VPO #172 also confirmed Resident #34 was not consuming >51% of his nutrition via the feeding tube or receiving at least 501 cc of fluid from enteral tube flushes due to resident refusals and confirmed the facility did not have a physician order for Resident #34 to consume nutrition orally. 5. Review of medical record for Resident # 39 revealed and admission date of 5/25/22 with diagnoses including unspecified dementia with severe anxiety, history of falling, moderate protein-calorie malnutrition, adult failure to thrive, encounter for palliative care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #39 section M indicated that there were no pressure ulcer/sores documented, the assessment noted that there were no interventions in place to prevent the ulcer/sores. Review of Nursing Weekly Wound Observation Tool dated 4/28/25 revealed that Resident #39 was identified with a pressure wound classified as an unstageable pressure which indicates that the wound is closed and unable to determine the depth of the wound at this time with measurement of 0.2 x 0.1 centimeters. Review of Braden Scale Prediction Pressure Sore Tool dated 4/11/25 for Resident #39 revealed the resident was at very high risk for a pressure sore. Review of physician's orders for Resident #39 revealed wound treatments were in place dated 4/29/25 to clean area with normal saline, pat dry and apply Triad Cream. Interview on 05/14/25 at 8:16 A.M. with Regional Director of Clinical Services #166 verified Resident #39 was totally dependent on care and the MDS dated [DATE] was not accurate and Resident #39 did have an identified pressure area during the look back period of the assessment. Review of the facilities policy titled Minimum Data Set (MDS) Policy not dated, outlines how the long-term facility collects, uses, and reports resident assessment date. It ensures standardized and comprehensive assessments are conducted using the plan of care and documentation to ensure the best practices are maintained.

Based on record review, policy review, and interview, the facility did not ensure Resident #26 was assessed to self-administer medications. This affected one resident (Resident #36) of two residents reviewed for self-administering medications. Facility census was 59. Findings include: Record review for Resident #26 revealed an admission date of 04/25/17 with diagnoses of legal blindness, acquired absence of one eye, and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact and had severe vision impairment. Review of the physician orders revealed Resident #26 self-administered, without supervision, Calcium-Vitamin D tablet 600-400 mg twice a day, Ammonium Lactate 12% Lotion topically to bilateral legs twice a day, and Omega-3 1000 mg soft gel once daily. Physician orders also contained an order Resident #26 was able to have medications at bedside with a start date of 11/30/21. Review of Medication Self-Administration Safety Screen assessment dated [DATE] determined Resident #26 may self-administer medications unsupervised however there had not been an updated assessment completed since that time. Interview on 05/19/25 at 9:40 A.M. with [NAME] President of Clinical Operations revealed an initial self-administration assessment was to be completed and then annually thereafter and confirmed Resident #26 did not have an updated self-administration assessment completed. Review of the Administering Medications Policy revised December 2012 revealed residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.

Based on observation, record review, policy review and interview, the facility failed to develop and implement a comprehensive and individualized nutrition program to monitor, ensure nutritional recommendations were implemented and prevent weight loss for Resident #27 who was admitted to the facility with a new gastrostomy tube/enteral feedings. This affected one resident (#27) of five residents who were identified as receiving parenteral nutrition in the facility. The facility census was 74. Actual Harm occurred on 03/01/24 when Resident #27, who received parenteral nutrition (nutrition given via a feeding tube inserted into the abdomen due to an inability to take in adequate nutrients orally) was identified to have a severe weight loss. On 01/26/24 the resident's admission weight was documented to be 145 pounds. On 02/29/24 the resident weighed 139.2 pounds and on 03/01/24 the resident weighed 115.8 pounds reflecting a 23.4 pound/16.8 percent (%) significant weight loss. In addition to a lack of intervention(s) to prevent the weight loss, at the time the weight loss was identified the facility failed to obtain a re-weight, failed to notify the registered dietitian, and failed to notify the physician. Findings include: Review of the medical record for Resident #27 revealed the resident was admitted to the facility on [DATE] with diagnoses including alcohol dependence with withdrawal, viral hepatitis B, viral hepatitis C, moderate protein calorie malnutrition and dysphagia (difficulty swallowing). Record review revealed the resident had a gastrostomy tube inserted during the hospitalization prior to his admission and received parenteral nutrition/hydration via the gastrostomy tube. A review of the hospital referral for Resident #27 dated 01/18/24 revealed the resident's weight was 61 kilos and 236 grams (135 pounds). Review of the medical record for Resident #27 revealed an admission weight dated 01/26/24 taken by a mechanical lift scale (a scale used to lift resident to obtain a weight due to inability to stand) was 145 pounds. Admission physician orders included an order for the enteral feeding, Isosource 1.5 calorie oral liquid (a nutritional supplement) to be administered via the feeding tube at 50 milliliters (ml) per hour continuously . Resident #27 had an admission diet order to have nothing by mouth. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating mild cognitive impairment. The assessment revealed Resident #27 received 51% or more of his total calories through parenteral or tube feeding means. Review of the admission care plan dated 02/05/24 revealed Resident #27 had potential risk for issues related to nutrition, low body mass index (BMI) and receiving nothing by mouth (NPO) status with a feeding tube. Interventions included providing tube (enteral) feed order as prescribed and monitoring weights (no frequency provided and no physician order for when to obtain weights for the resident). The care plan indicated nursing to notify the physician of any significant changes including a 3% weight change in one week, a 5% or more change in one month, or a 10% or more change in six months. An admission nutrition assessment dated [DATE] revealed the resident had a weight of 145 pounds with a body mass index (BMI) of 20 which was considered underweight for advanced age. Registered Dietician /Licensed Dietitian Nutritionist (RD/LDN) #310 recommended to increase the tube feeding for Resident #27 from Isosource 1.5 at 50 ml per hour continuous (1800 calories) via feeding tube to 70 ml per hour continuous (2520 calories) via the feeding tube. Review of the medical record revealed Resident #27's weight on 02/09/24 taken by a wheelchair scale (a scale with a ramp attached in which a person is weighed while seated in a wheelchair) was 141.5 pounds. Review of the medical record revealed Resident #27's weight on 02/29/24 taken by a wheelchair scale was 139.2 pounds. A review of the Medication Administration Record (MAR) for February 2024 revealed Resident #27 received Isosource 1.5 at 50 ml/hour continuously throughout the entire month. Record review revealed the recommendation to increase the Isosource to 70 ml/hour continuous via feeding tube dated 02/05/24 was not completed. Review of the medical record revealed Resident #27's weight on 03/01/24 taken by a sit-down scale (a scale with a chair attached so a person can be seated for their weight due to an inability to stand) was 115.8 pounds. This represented a 16.8% weight loss. There was no documented evidence Resident #27 was reweighed at this time to verify the weight and no documented evidence the dietitian and physician were notified of the weight loss. Review of the medical record revealed Resident #27's weight was obtained on 03/08/24 using a sit-down scale which was 117.6 pounds. There was no documented evidence the dietitian and physician were notified of the resident's weight on this date. Review of the medical record revealed Resident #27's weight on 03/19/24 taken by a sit-down scale was 116.5pounds. There was no documented evidence the dietitian and physician were notified of the resident's weight on this date. A nutrition progress note dated 03/19/24 revealed Resident #27 was reviewed related to a significant weight change and request to change tube feed to nocturnal (nighttime feeding). The weight in the assessment was documented to be 118 pounds with a BMI of 16 (underweight for advanced age). The recommendation by RD/LDN #310 was to provide 240 ml bolus of Isosource 1.5 (1080 calories) and Isosource 1.5 at 80 ml/hour continuous from 6:00 P.M. until 6:00 A.M. (1440 calories) for a total caloric intake of 2520 calories. Review of the medical record revealed Resident #27's weight on 03/26/24 taken by a sit-down scale was 115.8 pounds. There was no documented evidence the dietitian and physician were notified of the resident's weight on this date. A review of the MAR dated March 2024 revealed Resident #27 received Isosource 1.5 at 50 ml/hour continuous via the feeding tube from 03/01/24 until 03/19/24 when RD/LDN #310's recommendations to provide 240 ml bolus of Isosource 1.5 (1080 calories) and Isosource 1.5 at 80 ml/hour continuous from 6:00 P.M. until 6:00 A.M. (1440 calories) for a total caloric intake of 2520 calories were implemented. Review of the medical record revealed Resident #27's weight on 04/05/24 taken by a sit-down scale was 116.2 pounds. There was no documented evidence the dietitian and physician were notified of the resident's weight on this date. Review of the medical record revealed no documented evidence Resident #27 was weighed for six weeks, between 04/06/24 and 05/20/24. Review of the medical record revealed Resident #27's weight on 05/21/24 taken by a stand-up scale was 111.5 pounds. There was no documented evidence the dietitian and physician were notified of the resident's weight on this date. Review of the medical record revealed Resident #27's weight on 06/05/24 taken by a stand-up scale was 110.8 pounds. This reflected a 34.2 pound weight loss since admission (a 23.6% weight loss). There was no documented evidence that the dietitian and physician were notified of the resident's weight. A review of physician progress notes for Resident #27 dated 02/20/24, 03/05/24, 03/12/24, 03/19/24, 03/27/24, 04/04/24, 04/16/24, 04/30/24, 05/05/24 and 05/07/24 revealed no documented evidence the physician was notified, aware of or addressed the resident's weight loss at the time of these visits. There was no documentation within the notes addressing Resident #27 weight loss. On 06/25/24 at 11:00 A.M. an interview with RD/LDN #310 verified Resident #27's weight loss of 34.2 pounds since admission to the facility. RD/LDN #310 also verified Resident #27 did not receive the recommended Isosource 1.5 at 70 ml/hour continuous via feeding tube as recommended from 02/05/24 through 03/19/24. On 06/25/24 at 1:00 P.M. an interview with the Director of Nursing (DON) verified Resident #27 did not receive the recommended Isosource 1.5 at 70 ml/hour continuous via feeding tube as recommended from 02/05/24 through 03/19/24. On 07/01/24 at 2:15 P.M. an observation of the scale Resident #27 had been weighed on revealed a Brecknel ramp scale that could be used as a stand-up scale or a wheelchair scale. A sticker on the back of the scale revealed a calibration service date of 08/01/23 with a return service date of 08/01/24. Regional Director of Clinical Services (RDCS) #313 verified the date on the scale at the time of the observation. This was the same scale used during the weights obtained above. On 07/01/24 at 2:20 P.M. an observation of the DON weighing Resident #27 revealed the resident's wheelchair weight was 37 pounds. The DON then placed Resident #27 in the wheelchair and wheeled him up the ramp on the scale. The weight of Resident #27 in the wheelchair was 147 pounds. The net weight for Resident #27 was 110 pounds representing a 35-pound weight loss since admission. The DON and RDCS #313 verified the weights at the time of the observation. On 07/01/24 at 3:00 P.M. an interview with the RDCS #313 verified there was no documented evidence within the physician progress notes for Resident #27 to indicate physician notification of weight loss. RDCS #313 also verified the physician did not address Resident #27's weight loss. Interview on 07/02/24 at 1:15 P.M. with Medical Doctor #315 revealed he was unaware of Resident #27's weight loss. Interview on 07/02/24 at 2:05 P.M. with Nurse Practitioner #316 revealed neither she nor Medical Doctor #315 were notified of Resident #27's weight loss. A review of the policy titled, Weight Assessment and Intervention, dated September 2008, revealed the following: Under the section titled weight assessment, subsection one, nursing staff would measure resident weights on admission, the next day, and weekly for two weeks. Under the section titled weight assessment, subsection three, any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. When the weight was verified, nursing would immediately notify the dietician. Under the section titled weight assessment, subsection six, the threshold for significant unplanned and undesired weight loss at six months was severe if it was greater then 10%. Under the section titled care planning subsection one care planning for weight loss or impaired nutrition would be a multidisciplinary effort and would iclude the physician, nursing staff, the dietician, the consultant pharmacist and the resident or the resident's legal surrogate. This deficiency represents non-compliance investigated under Complaint Number OH00154554.

Based on observation, record review, interview and facility policy review, the facility failed to provide comprehensive, individualized and necessary diabetic ulcer (wound that commonly appears on the feet as a complication of diabetes often from lack of sensation or blood flow) assessment and care for Resident #151. This affected one resident (#151) out of three residents reviewed for diabetic/vascular/ pressure related wound care. The facility identified six residents (#111, #150, #151, #154, #162, and #163) with pressure/ vascular/ diabetic wounds. Actual harm occurred on 05/08/24 when the facility failed to adequately assess and implement diabetic ulcer wound care for Resident #151, a new admission who had intact cognition and was dependent on staff with activities of daily living (ADL) including bed mobility and transfers. On 05/08/24, Resident #151 was admitted to the facility with a diabetic ulcer to his right plantar foot that measured 0.5 centimeter (cm) in length, 0.5 cm in width, and had no depth. The facility failed to re-evaluate, measure, and document Resident #151's wound again until 05/20/24 at which time it had increased in size measuring 3.5 cm in length, 1.5 cm in width, and 0.2 cm in depth with 100 percent granulation (new tissue during healing process). The facility did not complete another wound evaluation until 06/03/24 and failed to complete daily treatments as ordered resulting in Resident #151's diabetic ulcer deteriorating and containing 40 percent slough (dead tissue) to the wound bed. Findings include: Review of the medical record revealed Resident #151 had an admitted [DATE] with diagnoses including paranoid schizophrenia, diabetes, cauda equina syndrome (compressed nerve roots at the bottom of the spinal cord), and hypertension. Review of clinical census revealed no documented evidence Resident #151 was out of the building on 06/01/24. Review of the May 2024 Treatment Administration Record (TAR) revealed Resident #151 had an order to cleanse the right plantar foot with normal saline, pat dry, apply silver alginate (highly absorbent, and antimicrobial dressing) to wound bed, cover with an abdominal (ABD) pad, and wrap with Kerlix gauze and an Ace wrap every night shift. The TAR was blank for 05/29/24, indicating no documented evidence that the treatment was completed. Review of the Nursing Admit/ Readmit No Care Plan- V2 dated 05/08/24 and completed by Licensed practical Nurse (LPN) #613 revealed Resident #151 had a vascular ulcer to his right plantar foot that measured 0.5 cm in length, 0.5 cm in width, and had no depth. Review of the medical record including nursing notes, Wound- Weekly Observation Tool assessments, and Wound Nurse Practitioner (NP) #612 consults revealed there was no documentation since his admission on 05/08/24 until 05/20/24 that Resident #151 was evaluated, including measurements of the wounds and/ or description of the wound (if any changes). Review of the care plan dated 05/09/24 revealed Resident #151 had actual impaired skin integrity related to a vascular wound to his right plantar foot. Interventions included encourage the resident to float heels as tolerated, encourage turn and reposition every two hours, and weekly treatment documentation to include measurement of each area of skin breakdown, exudate (drainage), and changes in observation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #151 had intact cognition. He was dependent on staff assistance with rolling left to right (bed mobility), transfers, and toileting. He was at risk of developing pressure ulcers. He had two venous/arterial ulcers. Review of Wound NP #612's progress note dated 05/20/24 revealed the initial consult evaluation revealed Resident #151 had a diabetic ulcer to his right plantar foot. The wound measured 3.5 cm in length, 1.5 cm in width and 0.2cm in depth. The wound bed contained 100 percent granulation tissue and there was no documented evidence of slough. She ordered to cleanse with normal saline, pat dry, apply silver alginate to the wound bed, cover with an ABD pad, and wrap with Kerlix gauze daily and as needed. Review of the Wound- Weekly Observation Tool dated 05/20/24 and completed by LPN/ Assistant Director of Nursing (ADON)/ Wound Nurse #609 revealed Resident #151's right plantar diabetic ulcer had 100 percent granulating tissue present. The wound measured 3.5 cm in length, 1.5 cm in width, and 0.2 cm in depth. Wound NP #612 ordered to continue the same treatment. Review of the medical record including nursing notes, Wound- Weekly Observation Tool assessments, and Wound NP #612 consults revealed there was no documented evidence between 05/21/24 and 06/03/24 that Resident #151's wounds were evaluated, including measurements of the wounds and/or description of the wound (if any changes). Review of the Resident Out/ In Log dated from 05/30/24 to 06/03/24 revealed Resident #151 on 06/01/24 had signed out of the facility at 11:00 A.M. but signed back in that he returned on the same day, 06/01/24 at 8:00 P.M. There was no further documented evidence that Resident #151 left the facility and per documentation was present in the facility at the time his treatment was scheduled on 06/01/24 (night). Review of the June 2024 TAR revealed Resident #151 had the same treatment order to his right plantar diabetic ulcer: cleanse with normal saline, pat dry, apply silver alginate to wound bed, cover with an ABD pad, wrap with Kerlix gauze and an Ace wrap every night shift. The documentation indicated on 06/01/24 that Resident #151 was out of the facility and on 06/02/24 the treatment was not completed as the wound care team was coming in. Review of the Wound- Weekly Observation Tool dated 06/03/24 and completed by LPN/ ADON/ Wound Nurse #609 revealed Resident #151's right plantar diabetic ulcer had 60 percent granulated tissue and 40 percent slough. The wound measured 1.0 cm in length, 2.6 cm in width and unable to determine depth due to slough. Wound NP #612 ordered to change the treatment due to the slough present to cleanse with 0.125 percent Dankins (diluted bleach) solution, pat dry, apply silver alginate to wound, cover with an ABD pad and wrap with Kerlix gauze daily and as needed. Review of Wound NP #612's progress note dated 06/03/24 revealed Resident #151 had a diabetic ulcer to his right plantar foot that measured 1.0 cm in length, 2.6 cm in width, and depth was unable to be determined as the wound bed contained 40 percent slough. There was moderate serosanguineous drainage, and the peri wound was dry and callused. She changed the treatment to cleanse the wound with 0.125 percent Dakins solution and continued silver alginate to the wound bed for autolytic debridement. Interview on 6/03/24 at 11:41 A.M. with Resident #151 revealed he was upset and frustrated as the dressing on his right foot had not been changed for several days and that he had a physician order to have his dressing changed daily. He revealed since he was admitted to the facility the nurses failed to complete his dressing on several occasions and that his wound was going to get worse because of the lack of care he was receiving. He revealed he had a fear he would need his foot amputated if not properly cared for. He also revealed he was not out of the facility on 06/01/24 at the time his wound dressing was scheduled for. Observation at the time of the interview revealed he had a sock that covered a dressing wrapped with Kerlix gauze to his right foot. The Director of Nursing (DON) assisted in pulling his sock down and identified that the date on the dressing was 05/31/24. She verified his dressing was to be completed daily and had not been completed on 06/01/24 and 06/02/24. Observation on 06/03/24 at 2:51 P.M. of wound care completed by Wound NP #612 and LPN/ ADON/ Wound Nurse #609 verified the date on the old dressing removed to his right foot was dated 05/31/24 and both verified his treatment was ordered to be done daily. LPN/ ADON/ Wound Nurse #609 cleansed the wound with normal saline. Wound NP #612 attempted to inspect the wound but stated the wound contained dried dressing that had adhered to the center of the wound bed. LPN/ ADON/ Wound Nurse #609 again proceeded to cleanse the wound and pick out the adhered pieces of dressing in the wound bed. Wound NP #612 proceeded to evaluate the wound and described it as 1.0 cm in length, 2.6 cm in width, and unable to determine depth as the wound contained 40 percent slough (dead tissue) and 60 percent granulation with moderate amount of drainage. Interview on 06/03/24 at 3:00 P.M. with Wound NP #612 revealed on her initial consult on 05/20/24 his diabetic ulcer had 100 percent granulation tissue but now, 06/03/24 she verified his wound now contained 40 percent slough. Interview on 06/03/24 at 3:46 P.M. with LPN/ ADON/ Wound Nurse #609 revealed on 06/01/24 Resident #151's treatment was not completed because he was out of the facility and on 06/02/24 his dressing was not changed because the wound team was consulting (the next day). LPN/ ADON/ Wound Nurse #609 verified per the census Resident #151 was not out of the facility on 06/01/24 at the time the dressing was due to be changed, and the nurse should have completed the dressing change on 06/02/24 as the Wound NP #612 was not scheduled to come in until the next day, 06/03/24. She stated, I do not have any excuse why it was not done since Friday (05/31/24). She revealed that there was a wound assessment completed on admission, 05/08/24, but verified there was no other documented evidence measurements and/or assessment of his wound were completed until 05/20/24. She verified there were no other assessment/measurements completed from 05/20/24 until today, 06/03/24. She revealed Wound NP #612 was the only one that assessed, and measured the wounds and that she took her assessments/measurements and input the findings into the resident's medical record. She revealed she was unsure why Wound NP #612 had not seen Resident #151 from 05/08/24 to 05/20/24 and that she thought he had refused her services and/or was not in his room on her last wound round on 05/30/24 and was not seen. She verified that she did not assess and measure the wound if the resident refused and/or was not in the building at the time the Wound NP #612 until the next scheduled Wound NP #612 visit. Interview on 06/03/24 at 4:43 P.M. with Regional Nurse #600 revealed all wounds including diabetic ulcers were to be evaluated, measured, and documented at least weekly in the medical record. She verified even if a resident was not seen by Wound NP #612, the nurse at the facility was to complete the evaluation, measurements, and documentation at least every seven days. Review of the undated Wound Report Non-Pressure and unsigned revealed a form with seven residents on it including Resident #151. The form revealed Resident #151 had a diabetic ulcer to right plantar foot that measured 1.0 cm in length, 2.6 cm in width and no depth. The area was unchanged and had moderate serosanguinous drainage. (this form was presented to the surveyor on 06/04/24 at 12:10 P.M. after the concern was brought to the attention of the facility of Resident #151's ulcer not having documentation in his medical record of being assessed at least weekly). Review of the undated facility policy labeled, Wound and Skin Care revealed if an ulcer was present then the resident would be placed on a wound program which would include the area to be measured and tracked weekly and as needed until resolved. The treatment wound be initiated as ordered by the physician. The policy revealed documentation of the ulcer would include measurements in centimeters of the wound and the amount, type, color and odor of the drainage. The policy revealed all wounds would be assessed weekly and the ineffectiveness or progress of healing would be reported to the physician as needed. This deficiency represents non-compliance investigated under Complaint Number OH00153870.

Based on observation, record review, facility policy review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of an in-house acquired pressure ulcer for Resident #49. This affected one resident (#49) of three residents reviewed who were at risk for pressure ulcers. The facility census was 58. Actual Harm occurred on 03/26/24 when Resident #49, who was cognitively impaired and dependent on staff for mobility was found to have a Stage III (Full thickness tissue loss. Subcutaneous fat may be visible and bone, tendon or muscles is not exposed. Slough may be present) pressure ulcer to the left buttock measuring 0.8 centimeters (cm) length by 1.5 cm width with 0.3 cm depth and serosanguineous drainage. The resident reported pain to the area. There was no evidence interventions, including turning and repositioning were provided to prevent the development of the ulcer or evidence the ulcer was found prior to being a Stage III. Findings include: Review of Resident #49's medical records revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included malnutrition, muscle weakness and need for personal care assistance. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had impaired cognition. The assessment revealed the resident was dependent on staff for toileting, bathing personal hygiene and mobility. There were no identified areas of skin impairment on the assessment. Review of a re-admission skin assessment dated [DATE] revealed the resident had no skin impairments There were no further documented skin assessments completed. Review of care plan dated 03/20/24 revealed Resident #49 was at risk for skin breakdown due to decreased mobility. Interventions included to encourage and assist Resident #49 to turn and reposition as tolerated and as needed, pressure reducing mattress and pressure reducing cushion to wheelchair. Staff to identify signs and symptoms of skin breakdown and notify appropriate staff. Review of Resident #49's progress note authored by Licensed Practical Nurse (LPN) #330 dated 03/26/24 revealed during wound care visit Resident #49 had complaints of pain in buttocks. Upon assessment with Wound Nurse Practitioner (WNP) #369 a Stage III pressure ulcer was noted on the buttock. Review of wound progress note dated 03/26/24 revealed a Stage III pressure ulcer to the left buttock that measured 0.8 centimeters (cm) length by 1.5 cm width and 0.3 cm depth. The area had a small amount of serosanguineous drainage. Review of the nursing progress notes revealed no documentation related to staff providing turning and repositioning interventions for the resident or evidence of the resident refusing turning and repositioning. Telephone interview on 04/01/24 at 12:55 P.M. with Resident #49's family revealed Resident #49 had a wound to her bottom that was a result of staff not turning and repositioning her often. On 04/01/24 at 1:53 P.M. observation revealed LPN #330 and WNP #369 were performing wound care for Resident #49. LPN #330 stated they had just completed the wound care of Resident #49's left leg and stated she also had a wound to her buttocks. Interview with WNP #369 revealed she was made aware Resident #49 had a wound to her buttocks on 03/26/24. WNP #369 stated she had assessed Resident #49's buttocks at that time and the wound was classified as a Stage III pressure ulcer. LPN #330 stated the area had not been reported previously. Observation of Resident #49's buttock wound revealed a foam dressing dated 03/31/24. LPN #330 removed the dressing and observation revealed an open area to Resident #49's buttocks that had a moderate amount of thick yellowish colored drainage. Interview with Resident #49 at time of observation revealed staff had not assisted her with turning and repositioning often. No additional information was provided by LPN #330 or WNP #369 related to turning and repositioning for the resident. Review of facility policy titled Prevention of Pressure Ulcers/Injuries revised 07/2017 revealed staff were to assist with repositioning residents at risk for pressure ulcers at least every two hours, inspect the skin on a daily basis when performing personal care and report and document potential changes in the skin. This deficiency represents non-compliance investigated under Complaint Number OH00152534 and OH00515990.

Based on observation, record review and interview, the facility failed to implement and re-evaluate care plan interventions to prevent a fall for Resident #13. This resulted in Actual Harm of a head laceration that required staples. This affected one resident (Resident #13) of three residents reviewed for accidents. Findings include: Review of the medical record for Resident #13 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 required extensive assistance with transferring and total dependence on staff for locomotion on unit. The assessment revealed Resident #13 was severely cognitively impaired for daily decision making. Review of the care plan last updated 10/17/13 revealed Resident #13 was at risk for falls due to poor safety awareness. An intervention initiated on 08/08/12 was for the resident not to be left unattended in her room while she was up in the broda chair. A new intervention initiated on 07/23/13 was to remove the resident from the dining area after the meal. A new intervention initiated on 10/02/13 was when up and out of bed, the resident was to be placed in a common area where she could be closely monitored by staff. A progress note dated 10/11/13 at 7:00 P.M. revealed Resident #13 had a fall in the dining room. An intervention initiated on 10/11/13 stated to continue to remove from dining room at the end of her meal. A progress note dated 10/16/13 at 2:04 P.M. revealed Resident #13 was found on the floor in the doorway. The resident was assessed, was bleeding in the back of the head and was transferred to the emergency room and received three staples to the left scalp. Review of a facility investigation report revealed on 11/05/13 at 12:20 P.M., Resident #13 was observed by staff attempting to ambulate, lost her balance, fell to the floor and hit her head before staff had the opportunity to redirect. A witness statement dated 11/05/13 stated the staff member witnessed a nurse running to the resident's room to catch the resident in the room from falling. Interview on 11/20/13 at 3:01 P.M. with Care Delivery Director #1 verified staff were removing other residents from the dining room on 10/11/13 and were unable to remove Resident #13 from the dining room prior to her falling. She confirmed the 10/16/13 fall took place in the hallway outside of the resident's room. She confirmed that on 11/05/13, Resident #13 was in her wheelchair in her room prior to the fall. Staff had just provided care for the resident and were in the immediate area but were not able to reach her before she fell . Observation on 11/20/13 at 3:28 P.M. and on 11/21/13 at 1:48 P.M. revealed Resident #13 was in a Broda wheelchair in the hallway next her bedroom with no staff in the immediate area. These observations were confirmed with another surveyor. Interview on 11/21/13 at 1:50 P.M. with Care Delivery Director #1 verified that despite the intervention written on 07/23/13 to remove the resident from the dining room after meal, the resident was left unsupervised in the dining room on 10/11/13 and fell . She confirmed that Resident #13 fell in the hallway on 10/01/13 hitting her head and fell again on 10/16/13 outside of room in hallway resulting in a head laceration that required staples despite an intervention in the care plan to place the resident in a common area where she could be closely monitored by staff.