Every finding on record at Northfield Village Retirement Community

Based on observation and interview, the facility failed to maintain a safe and sanitary environment throughout the laundry room. This had the potential to affect all resident laundry processed within that department. The facility census was 62. Findings include: An observation was conducted on 07/20/26 at 3:42 P.M. of the facility laundry room with Laundry Aid (LA) #390 and revealed multiple concerns with the laundry room environment. There were two washers that were heavily covered with dry splatter marks of an unknown substance. The floors on the side of the laundry room where the washers and dryer were located were heavily covered with dirt and staining as if not routinely swept and mopped. Behind the washers there was a heavy build-up of dried white substance on the floor. A bucket that was turned upside down on the floor was covering a wet floor drain that had a loose drain cover exposing the open hole in the floor. In the clothes dryer there was a moderate accumulation of clumps of lint in the top, non-removable lint trap. A standard-sized (approximately 20 inches by 20 inch) box fan was sitting on top of a table at chest height and had a moderate build-up of dust on all the fan blades and the wire blade guard and was located in the clean side of the laundry room where all clean clothing and linens were stored. An interview on 07/20/26 at 3:50 P.M. with LA #390 verified the observation findings. LA #390 stated staff were told on 07/17/26 to clean the floors and washing machine. LA #390 verified there were clumps of lint accumulated on the non-removable lint trap. LA #390 stated Maintenance was responsible for vacuuming out that part of the lint trap. LA #390 confirmed the fan was used in the clean side of the laundry room and verified it was dusty and needed cleaned. LA #390 stated the bucket covering the floor drain was there so no one would slip on the loose drain cover. Follow up observation on 07/21/26 at 8:15 A.M. with Housekeeping Manager (HM) #308 revealed the washing machines were covered with dry splatter, and the fan blades, and the wire guard were covered with dust. An interview at this time with HM #308 verified the findings. HM #308 stated the laundry room was to be cleaned daily and verified the fan needed to be cleaned.An interview on 07/21/26 at 10:39 A.M. with Maintenance Director (MD) #316 revealed he vacuumed the dryers once a week to remove dust. MD #319 stated he last vacuumed the dryers on 07/17/26. MD #319 stated the dryers would be vacuumed twice weekly in the future. This deficiency represents noncompliance investigated under Complaint Number 2646123, 2970161 and 2965434.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure call lights were within reach and accessible for Resident #2. This affected one (Resident #2) of 18 sampled residents reviewed for call light accessibility. The facility census was 62.Findings include:Review of the medical record for Resident #2 revealed an admission date of 4/22/2026 and a readmission date of 5/12/2026 with diagnoses including Alzheimer's Disease with late onset, unspecified abnormalities of gait and mobility, osteoarthritis, generalized anxiety disorder, osteoporosis and unspecified dementia.Review of the quarterly Minimum Date Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had intact cognition with minimal or no memory or thinking difficulties. Resident #2 required supervision with eating and oral hygiene, dependence with toileting, substantial/maximum assistance with bathing, dressing, personal hygiene and dependence with bed mobility and transfers.An observation on 07/14/26 at 10:22 A.M. revealed Resident #2 was alert, oriented and able to answer questions while reclined in her bed. There was no call light within reach for Resident #2 to activate if she needed assistance by staff, as her call light was dangling from the bed rail by its cord with the activation button hovering one inch from the floor out of the resident's reach. An interview with Resident #2 at the time of the observation revealed Resident #2 stated she was unable to reach her call light so could not call for assistance.An interview on 07/14/26 at 10:25 A.M. with Licensed Practical Nurse (LPN) #330 confirmed Resident #2's call light was out of her reach.Review of the facility's undated policy titled Answering the Call Light revealed when the resident is in bed or confined to a chair, staff was to be sure the call light was within easy reach of the resident.This deficiency represents noncompliance investigated under Complaint Number 2646123.

Based on observation, interview, and record review, the facility failed to ensure meals were attractive and served at an appetizing temperature. This affected one (Resident #38) resident of four residents reviewed for food. The facility census was 62.Findings include:Review of the medical record for Resident #38 revealed an admission date of 8/26/2023 and a readmission date of 10/09/24 with diagnoses including end stage renal disease, depression, chronic respiratory failure, dependence on renal dialysis, anemia, type two diabetes mellitus with diabetic neuropathy, hypertension and Chronic Obstructive Pulmonary Disease (COPD). Resident #38's diet order was a regular texture, renal diet with thin liquids and a 1500 cubic centimeter (cc) daily fluid restriction.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 had intact cognition.An interview on 07/13/2026 at 2:38 P.M. with Resident #38 revealed hot foods were not hot when served to her. Resident #38 stated the food is terrible and it's always cold. Resident #38 also stated it was often impossible to tell what food was on her plate.An observation was conducted on 07/15/26 at 11:30 A.M. of the lunch tray line meal service and [NAME] #403 using the facility's calibrated thermometer to obtain tray line food temperatures of the lunch meal which were as followed: Sloppy Joes 175 degrees Fahrenheit (F), French fries 178 degrees F, mixed vegetables 192 degrees F. [NAME] #403 verified the food temperatures at the time of the observation which were all within acceptable range. Meal carts began leaving the kitchen at 11:55 A.M. and a test tray was the last tray placed on the last cart which left the kitchen at 12:20 P.M. At 12:30 P.M. the test tray was the last tray served during the tray pass and Dietary Manager (DM) #307 obtained temperatures using the facility calibrated thermometer. The French fries on the test tray were noted to be at 121 degrees F and were not crisp or hot. DM #307 verified the temperature of the French fries at 121 degrees F was not considered an appetizing food temperature. DM #307 stated it was very difficult for him to keep hot foods from losing temperature. DM #307 stated the kitchen used a pellet system to keep the meal plates warm, but after 15 to 20 minutes the pellets no longer kept the plates warm. This deficiency represents noncompliance investigated under Complaint Number 2625152.

Based on observation, interview, record review and review of facility policy, the facility failed to maintain proper infection prevention and control practices during urinary catheter care for Resident #45. This affected one (Resident #45) of five residents reviewed for infection prevention and control practices. The facility census was 62.Findings include: Review of the medical record for Resident #45 revealed an admission date of 05/21/26 with diagnoses including acute cystitis, acute kidney failure and benign prostatic hyperplasia (BPH). Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 05/28/26, revealed the resident had impaired cognition. Resident #45 required supervision with bed mobility and required substantial assistance for toileting hygiene. Resident #45 had an indwelling urinary catheter and was incontinent of bowel. Review of the Care Plan dated 06/01/26 revealed Resident #45 required enhanced barrier precautions (EBP) due to an indwelling catheter. Interventions included to don gloves and gown prior to high contact tasks and to remove gown and gloves prior to exiting the room. An observation on 07/13/2026 at 12:30 P.M. of Resident #45 revealed his indwelling urinary catheter bag was sitting directly on the floor by his bed and had no protective cover over the bag. Certified Nursing Assistant (CNA) #350 was present at the time of the observation and verified the finding. An observation on 07/15/26 at 10:28 A.M. of urinary catheter care for Resident #45 with CNA #373 revealed CNA #373 gathered incontinence supplies, washed her hands and donned gown, and gloves. CNA #373 removed the resident's brief and provided catheter care then emptied the urine bag of urine. CNA #373 then applied a clean brief with the same gloved hands to the resident and checked the catheter tubing for proper drainage. Without changing gloves or washing her hands, CNA #373 then adjusted Resident #45's blankets, grabbed the bed remote and lowered the bed with the soiled gloves. CNA #373 then removed her gown and gloves and placed them in the trash can and removed the trash from the room. CNA #373 did not sanitize or wash her hands prior to leaving the room. An interview on 07/15/26 at 10:55 A.M. with CNA #373 verified she did not remove or change her gloves or wash her hands between providing catheter care and adjusting Resident #45's bed and blankets and verified she did not sanitize or wash her hands prior to leaving the room. Review of the facility policy titled Catheter Care, Urinary revised August 2023, revealed after cleaning the catheter, check the drainage tube and discard any disposable items. Remove gloves and discard into designated containers and wash and dry hands. Reposition the bed covers and place call light within reach of the resident. This deficiency represents noncompliance investigated under Complaint Number 2625152.

Based on closed record review, facility policy review, and interview, the facility failed to ensure accurate documentation of skin tear treatments were completed for Resident #51. This affected one (Resident #51) of three residents review for wound treatments. The facility census was 50. Finding include: Review of the closed medical record for Resident #51 revealed an admitted [DATE]. Diagnoses included end stage renal disease, anxiety, anemia, fracture of right femur, dependence on dialysis and depression. The resident was discharged from the facility on 12/04/24. Review of the care plan dated 11/13/24 revealed Resident #51 Resident had a skin tear to the left forearm due to limited mobility. Interventions included to monitor for signs of infection and provide wound treatments. Review of the admission assessment dated [DATE] revealed Resident #51 had intact cognition and had a skin tear to the left forearm. Record review Resident #51's physician's orders revealed an order dated 11/21/24 for a treatment to a left forearm skin tear. The order read to clean the area with normal saline, pat dry, apply oil emulsion, cover with an absorbent pad and wrap with gauze. The treatment was to be changed daily and as needed. Review of Resident #51's Treatment Administration Record (TAR) for December 2024 revealed treatments were not documented on 12/02/24, 12/03/24 and 12/04/24. There was no evidence in the medical record the treatment were documented as administered. Review of the skin assessment dated [DATE] revealed a left forearm skin tear measuring three centimeters (cm) by two (cm) signed by Licensed Practical Nurse (LPN) #200. Interview on 12/30/23 at 9:55 A.M. with LPN #200 stated he assessed Resident #51 left forearm skin tear on 12/03/24 and applied the dressing. LPN #200 stated he documents treatments after they completed however it was a busy and may have forgotten to document the treatment application. Interview on 12/30/24 at 10:05 A.M. with LPN #100 stated she changed Resident #51's left forearm dressing on 12/02/24 in the morning prior to her scheduled dialysis treatment. LPN #100 states she always documents treatments after they are administered, however she could have been distracted and forgotten to document the treatment application. Interview with the Director of Nursing (DON) on 12/30/34 at 12:22 P.M. verified treatment for the left forearm were not signed on 12/02/24, 12/03/24 and 12/04/24. The DON stated nurses are expected to document and sign off all treatments. Review of the facility's policy titled Wound Care revised October 2010, revealed documentation of wound care should include the name and title of person along with the date and time. This deficiency represents non-compliance investigated under Complaint Number OH00160401.

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect all residents receiving meals from the kitchen. The facility identified two Residents(#6 and #33) who do not receive food by mouth. The facility census was 56. Findings include: Observations on 03/10/24 at 8:15 A.M. of facility kitchen revealed in the walk-in cooler there was three plastic containers with lids containing Salisbury steaks, carrots, and hard-boiled eggs without a label or date, two metal pans covered with foil containing unidentified pureed substances without a label or date and a tray of uncovered fruit cups without a label or date. There was a splatter of food residue on the wall behind coffee machine and a dried coffee spill on floor in front of coffee machine. There was dark brown grease build up on the walls and floors behind and below dish machine area. There was dark brown grease build up and food debris observed below a rack containing plastic wares in dish machine area. There was dark brown grease build up and food debris on the floor and walls behind the steamer, oven, range top, and flat top grill. Interview on 03/10/24 at 8:25 A.M. with Dietary Cook #829 confirmed findings in walk-in cooler and cleanliness of walls and floors behind and below food prepartion equipement. Review of facility policy Date Marking undated revealed any ready-to-eat food prepared and held in refrigeration shall be date marked. Review of facility policy General Food Preparation and Handling dated 2010 revealed the kitchen and its equipment would be kept clean. The policy indicated food would be kept covered for storage.

Based on record review and staff interview the facility failed to complete a state specific Pre-Admission Screen and Resident Review (PASRR) form within thirty days of admission as required. This affected one (Resident #61) of two residents (Residents #41 and #61) reviewed for PASRR. The facility census was 56. Findings include: Review of the medical record for Resident #61 revealed an admitted [DATE]. Diagnoses included but were not limited to post traumatic stress disorder, tinea unguium, diabetes mellitus and vitreous degeneration. Review of the Medicare Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #61 was dependent on staff for most activities of daily living (ADLs). Further review of the medical record revealed no evidence a State of Ohio PASRR form was completed as required for Resident #61. A PASRR form was in the medical record from the state of Kentucky dated 01/22/24. Interview on 03/11/24 at 1:43 P.M. with Licensed Social Worker #873 verified an Ohio PASRR screen was not completed for Resident #61 as required.

Based on observation, interview, medical record and facility policy review, the facility failed to ensure preventative interventions were in place for treatment of pressure injury of left heel. This affected one Resident (#39) of three reviewed for pressure injuries. The facility census was 56. Findings include: Review of the medical record for Resident #39 revealed admitted [DATE] and diagnoses including polyneuropathy, diabetes mellitus, left ankle and foot osteomyelitis, moderate protein calorie malnutrition, peripheral vascular disease, and congestive heart failure. Review of the plan of care dated 12/23/23 revealed Resident #39 had impaired skin integrity related to pressure injury to left heel. Interventions included to elevate heels off surface of mattress. Review of Medicare Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #39 was dependent on staff for rolling left and right, sitting to lying, and lying to sitting. Resident #39 was at risk of developing pressure injuries and had one or more unhealed pressure injuries. Review of Braden Scale for Predicting Pressure Sore Risk Original assessment dated [DATE] revealed Resident #39 was at moderate risk for pressure injury. Review of the physician's order dated 02/16/24 revealed to float bilateral heels off surface of mattress when in bed and order dated 02/17/24 revealed to encourage resident to wear Prevalon heel boots (pressure off loading boots) at all times while in bed. Review of the Treatment Administration Records (TARs) from February 2024 and March 2024 revealed no documented refusals of floating bilateral heels off surface of mattress while in bed. Review of progress note dated 03/04/24 revealed Resident #39 had refused to wear Prevalon boots but was agreeable to having heels floated. Review of the Wound Evaluation and Management Summary dated 03/06/24 revealed Resident #39 had a stage two pressure injury to left medial heel measuring 1.5 centimeter (cm) length, 1.0 cm width, and 0.1 cm depth. Recommendations included off-load wound and pressure off-loading boot. Observation on 03/11/24 at 8:59 A.M. revealed Resident #39 was in bed with the head of bed raised for breakfast meal. Resident #39's bare feet were pressed against the foot board of bed frame. There was no evidence of offloading measures in place at time of observation. Interview on 03/11/24 at 9:06 A.M. with Licensed Practical Nurse (LPN) #826 revealed she was the assigned nurse for Resident #39. LPN #826 confirmed Resident #39 had left heel pressure injury. LPN #826 indicated Resident #39 was supposed to have pillow to float bilateral heels while in bed. Observation on 03/11/24 at 9:10 A.M. with LPN #826 verified Resident #39's bare feet were pressed against the foot board of bed frame. LPN #826 verified there were no pressure off-loading measures in place at time of observation. Review of the facility policy, Pressure Ulcer Risk and Skin Assessment revised 06/08/15 revealed resident specific interventions would be implemented for those residents deemed at risk for skin impairment.

Based on record review and interview the facility failed to provide an appropriate diagnosis for the use of an antipsychotic. This affected one resident (Resident #45) out of five residents (#18, #39, #45, #50, and #271) reviewed for unnecessary medications. The facility census was 56. Findings include: Review of Resident #45's medical record revealed the resident was admitted on [DATE]. Diagnoses included but were not limited to restlessness and agitation, dysphagia, diabetes mellitus, and Alzheimer's disease. Review of Resident #45's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment, no behaviors were noted and required substantial assistance for activities of daily living (ADLs). Further review of the MDS revealed Resident #45 received an antipsychotic and there was no indication as to why in section N of the assessment. Review of Resident #45's physician orders for March 2024 revealed an order for divalproex sodium (anticonvulsant also used to treat mania) tablet delayed release 125 milligrams (mg) give two capsules by mouth two times a day related to unspecified signs and symptoms involving cognitive functions following cerebral infarction. Further review of the physician's orders revealed an order for mirtazapine (antidepressant) tablet 7.5 mg give one tablet by mouth one time a day related to Alzheimer's disease. Review of current resident diagnoses revealed Resident #45 did not have an active diagnosis seizures or depression in the medical chart. Interview on 03/11/24 at 3:40 P.M. with MDS Nurse #844 verified there was no evidence the use of mirtazapine and divalproex was being used to treat a specific condition as diagnosed and documented in the medical record.

Based on review of the medical record, interviews, and review of information from the Medscape website, the facility failed to ensure laboratory tests were completed as ordered for Resident #271 and Resident #64. This affected two residents (Resident #271 and Resident #64) of 21 residents whose medical records were reviewed for laboratory test results. Findings include: 1. Review of the medical record revealed Resident #271 was admitted to the facility on [DATE]. Diagnoses included left foot amputation, osteomyelitis, diabetes, right leg above the knee amputation, and peripheral vascular disease. Review of the physician's orders dated 02/28/24 revealed Resident #271 had an order for Vancomycin (antibiotic) 1000 milligrams every 12 hours until 03/22/24 dated 02/28/24. Review of the physician's orders dated 02/29/24 revealed Resident #271 had an order for a Vancomycin trough every Monday and fax the results to the physician (trough concentrations are recommended for therapeutic monitoring of Vancomycin. Trough levels are drawn prior to the administration of dose). Review of the laboratory report dated 03/04/24 revealed the collection time for the Vancomycin trough was at 11:10 A.M. It was reported within normal limits at 15.2. Review of the Admission Minimum Data Set assessment dated [DATE] revealed Resident #271 had intact cognition. Review of the physician's orders dated 03/11/24 revealed Resident #271 had orders to hold the morning dose of Vancomycin until the laboratory drew sample on laboratory days for Vancomycin level and a Vancomycin trough one time on 03/12/24. Review of the March Medication administration record revealed Resident #271 was administered Vancomycin at 6:02 A.M. on 03/11/24. Review of the laboratory report dated 03/11/24 revealed the collection time for the Vancomycin trough was at 7:52 A.M. (after the dose was administered) It was reported at high at 38.5 (normal 10-20). Review of the March Medication Administration Record (MAR) revealed Resident #271 was administered Vancomycin at 5:12 A.M. on 03/12/24; however, the administration time was lined out due to the resident later refused the dose because they had started the Vancomycin before the laboratory test (trough level) was obtained. Review of the Laboratory report dated 03/12/24 revealed the collection time for the Vancomycin trough was at 6:35 A.M. It was reported low at 9.9. On 03/13/24 at 9:4 5 A.M. an interview with Resident #271 (who was visibly upset) revealed she was upset that the facility gave her Vancomycin prior to her blood being drawn yesterday (03/12/24) in the morning. Resident #271 stated that on Monday (03/11/24), her Vancomycin laboratory results were high, so she had to get the test done again yesterday (03/12/24). She stated they told her it was elevated because they gave her the Vancomycin prior to her laboratory tests being drawn on 03/11/24, so going forward, they would draw the laboratory tests first then administer the Vancomycin. Resident #271 stated they did the same thing on Tuesday (03/12/24), they administered her Vancomycin prior to her laboratory tests being drawn so she was upset and refused the rest of the Vancomycin. On 03/13/24 at 9:57 A.M. an interview with Regional Nurse #893 with the Administrator present revealed Resident #271 came to them with a concern yesterday (03/12/24) about her antibiotic. She stated the nurse administered Resident #271's Vancomycin prior to the lab draw. The nurse started the Vancomycin, then went to sign it off on the MAR and noticed the order was put into the computer for the day before (03/11/24), she went into the room and stopped the Vancomycin infusion. Regional Nurse #893 stated it was only infusing for about a minute. Regional Nurse # 893 stated after the Vancomycin trough was drawn, the nurse went back into the room and Resident #271 refused the rest of the Vancomycin. On 03/13/24 at 2:50 P.M. an interview with Regional Nurse #893 confirmed the Vancomycin on 03/11/24 and 03/12/24 was given prior to the Vancomycin trough being drawn for Resident #271. However, she stated there was not an order prior to 03/11/24 to actually draw the Vancomycin trough before the Vancomycin was given. Review of the Medscape website revealed Vancomycin trough levels were to be drawn less than or equal to 30 minutes before the next dose. 2. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE]. Diagnoses included necrotizing fasciitis, right above the knee amputation, acute kidney disease, anemia, diabetes, hypotension, benign prostatic hyperplasia, retention of urine, bacteremia, cirrhosis of the liver, pulmonary hypertension, atrial fibrillation, liver disease, hypertension, aortic ectasia, and cardiomegaly. Review of the Admission Minimum Data Set assessment dated [DATE] revealed Resident #64 had moderately impaired cognition. Review of the physician's orders from 02/13/24 through 03/13/24 revealed Resident #64 did not have an order for a prealbumin level. Review of the laboratory results from 02/13/24 through 03/13/24 revealed Resident #64 did not have a prealbumin level done. Review of the Wound Physician's notes from 02/28/24 revealed an initial wound evaluation for Resident #64. Physician #894 had orders a prealbumin level for Resident #64. On 03/13/24 at 11:43 A.M. an interview with Regional Nurse #892 confirmed the prealbumin level had not been done on 02/28/24; however, she stated the physician had canceled the order when he visited on 03/06/24. Regional Nurse #892 verified the prealbumin level should have been done prior to 03/06/24. On 03/13/24 at 3:40 P.M. an interview with Physician #894 revealed he wrote the order on 02/28/24 for a prealbumin level. He stated he came back in on 03/06/24 and saw it had not been done. He stated he then found out the facility had a dietitian following Resident #64 so he canceled the order on 03/06/24. He stated he expected the prealbumin level to be done when he ordered it, he would have already had the results and would not have had to cancel the order.

Based on observation, record review and interview, the facility failed to ensure the accuracy of Resident #18's wound type in the medical record. This finding affected one (Resident #18) of four residents reviewed for pressure ulcers. Findings include: Review of Resident #18's medical record revealed the resident was admitted on [DATE] with diagnoses including altered mental status, other chronic pain and emphysema. Review of Resident #18's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #18's Wound Assessment form dated 01/15/24 revealed the resident had an in-house acquired suspected deep tissue injury (SDTI) pressure wound to the left heel (unable to determine a pressure ulcer stage at this point) acquired 01/12/24 which measured 4.0 centimeters (cm) length by 2.0 cm width by 0 cm depth. Review of Resident #18's Wound Assessment form dated 01/18/24 revealed the resident had a venous stasis ulcer non-pressure wound to the left heel acquired 01/12/24 which measured 2 cm length by 4 cm width by undetermined (UTD) depth. Review of Resident #18's Wound Assessment form dated 01/22/24 revealed the resident had a venous stasis ulcer non-pressure wound to the left heel acquired 01/12/24 which measured 3.2 cm length by 4.0 cm width by no depth. Review of a text message from the Director of Nursing (DON) sent to Podiatrist #866 dated 01/25/24 at 9:27 A.M. revealed a text message which stated good morning, just for your information (fyi), Physician #865 was the community physician for Resident #18 and had been his patient for years. He gave a diagnosis of venous stasis ulcer to the left heel, but she was going home tomorrow. Review of Resident #18's progress note dated 01/26/24 at 1:36 P.M. authored by the DON indicated per the physician, the resident had an ongoing history of edema to the bilateral lower extremity, had venous stasis ongoing and had been in the community for years. The left heel ulcer was a venous stasis ulcer and elevated heels on pillows while in bed. Review of Resident #18's Wound Assessment form dated 01/29/24 revealed the resident had a left heel in-house acquired deep tissue injury (DTI) pressure wound and the site was documented as the left heel with the type indicating it was a vascular non-pressure wound acquired 01/12/24 which measured 2.5 cm length by 4.3 cm width by no depth. Review of Resident #18's Podiatrist Wound Evaluation form dated 01/29/24 revealed the resident had a left heel venous non-pressure wound with 100% epithelial tissue which measured 2.5 cm wound length, 4.3 cm wound width with no depth. The wound was purple and non-blanchable. The venous duplex was reviewed which demonstrated compressibility of the deep veins with no evidence of thrombosis. Per the primary physician, the resident's left heel sore was related to her venous stasis. Review of Resident #18's Wound Assessment form dated 02/05/24 revealed the resident had a left heel in-house acquired DTI pressure wound and the site was documented as the left heel with the type indicating it was a vascular non-pressure wound acquired 01/12/24 which measured 2.5 cm length by 3.5 cm width by no depth. Review of Resident #18's Wound Assessment form dated 02/13/24 revealed the resident had a left heel in-house acquired DTI pressure wound and the site was documented as the left heel with the type indicating it was a vascular non-pressure wound acquired 01/12/24 which measured 2.5 cm length by 3.5 cm width by no depth. Review of the Podiatrist Wound Evaluation form dated 02/13/24 revealed the resident had a left heel venous ulcer non-pressure wound with 100% epithelial tissue bed with no drainage which measured 2.5 cm length by 3.5 cm width with no depth. The wound was purple and non-blanchable. Review of Resident #18's physician progress note authored by Physician #865 dated 02/19/24 indicated the resident had an area of eschar on her left heel with a heel wound. The resident had venous stasis with a history of severe leg edema where she required diuresis. The discoloration of her lower extremity was consistent with venous stasis and venous dermatitis. Observation on 02/20/24 at 6:20 A.M. of Resident #18's left heel wound care with Licensed Practical Nurse (LPN) #826 revealed the resident's left leg and heel were extremely dry with skin observed flaking onto the bed. The left heel did not have an open area and no drainage was noted. A darker area was observed on the left heel. The top aspect of Resident #18's foot appeared edematous with no drainage noted. Interview with LPN Wound Nurse #812 revealed Resident #18 had a left heel wound which Wound Nurse Practitioner (NP) #868 had assessed as a SDTI. LPN Wound Nurse #812 indicated Podiatrist #866 also assessed the wound on Resident #18's left heel and determined the wound was SDTI. Interview on 02/20/24 at 7:53 A.M. with Wound NP #868 stated she had assessed Resident #18's left heel one time and determined it was a SDTI. She stated Podiatrist #866 took over after that assessment. Observation on 02/20/24 at 8:58 A.M. with Podiatrist #866 and LPN Wound Nurse #812 of Resident #18's left heel wound revealed the wound measured 2.0 cm length by 3.3 cm width with no drainage. Interview on 02/20/24 at 10:07 A.M. with Podiatrist #866 indicated she had assessed Resident #18 on 01/22/24 for a left heel discoloration and determined the resident had a SDTI to the left heel which was purple and non-blanchable. She stated she ordered a noninvasive vascular study in relation to the left heel wound and did not determine the wound was vascular in nature. She indicated that she received a text message from the DON on 01/25/24 which stated Resident #18's primary care physician (Physician #865) had reclassified the left heel wound as a vascular ulcer instead of a pressure. She stated at that point (01/29/24, 02/05/24, 02/13/24 and 02/20/24), she changed her documentation to vascular instead of pressure as she was a consulting physician and not the primary physician. Interview on 02/20/24 at 10:37 A.M. with the DON and Registered Nurse (RN) Regional #867 indicated the DON did not recall talking to or sending Podiatrist #866 a text. She stated she called Physician #865 and asked him if the resident had any vascular issues. She confirmed Physician #865 indicated Resident #18 had venous stasis and the area to the resident's left heel was vascular. Telephone interview on 02/20/24 at 11:59 A.M. with Physician #865 with the DON present indicated he had known Resident #18 for [AGE] years and the resident had venous stasis. He stated he told the DON that she had venous stasis with kidney problems and had a mixed etiology which could compromise wounds. He indicated he was aware of Resident #18's vascular and arterial studies and thought the left heel wound could be vascular or it could be pressure and he was not sure. Interview on 02/20/24 at 12:09 P.M. with the DON indicated she texted LPN Wound Nurse #812 that Physician #865 thought Resident #18's left heel wound could be vascular, but she did not talk or text Podiatrist #866. Telephone interview on 02/21/24 at 9:54 A.M. with RN Regional #867 confirmed Physician #865 had assessed Resident #18 on 02/18/24 and determined the resident had a left heel vascular wound. She was unsure why Resident #18's wound documenting inaccurately reflected both pressure and non-pressure on the wound skin grids. Review of the Pressure Ulcer Prevention and Assessment policy dated 12/17/13 revealed it was the facility policy to prevent the development of pressure ulcers to the greatest extent possible and as allowed by the resident's compliance, cognition and/or physical function. This deficiency represents non-compliance investigated under Complaint Number OH00150445.

Based on closed record review, review of court records, review of facility policy and interviews, the facility failed to timely release requested resident records for Resident #49. This affected one resident (#49) of three reviewed for timely release of medical records. The facility census was 50. Findings include: Review of the closed medical record for Resident # 49 revealed an admitted [DATE] with diagnoses including congestive heart failure, chronic kidney disease, primary hypertension, and malignant neoplasm of the bladder. The resident was discharged on [DATE] to his home with his wife. Review of a document from the Summit County Probate Court titled Order Authorizing Release of Descendant's Medical Records, dated 02/10/23, revealed the court had authorized the release of Resident #49's medical records to Resident #49's wife. Review of the facility documentation of a fax dated 03/02/23 revealed a medical records request was signed by Resident #49's wife and faxed to the facility medical records director which included a letter requesting the records, a copy of Resident#49 death certificate, a Court Order from The Probate Court of Summit County Authorizing Release of Decedent's Medical Records and a HIPAA Privacy Authorization Form. The form also indicated that pursuant to the (HITECH) Health Information Technology for Economic and Clinical Health Act the facility had 30 days from the date of request, March 2, 2023, to provide the records in the format requested. Further review of the closed medical record for Resident #49 revealed the facility did not mail Resident #49's requested medical records to the resident's wife/her legal council until 05/01/2023. Interview with the Director of Medical Records #102 on 11/16/23 at 1:11 P.M. confirmed she received the request for the release of Resident #49's medical records on 03/02/23 but did not mail them until 05/01/23. An interview with the Administrator on 11/16/23 at 2:05 P.M. revealed Residents #49's records were not released within 30 days because they had to go through a process of being reviewed by the corporate personnel and lawyers before releasing the records to Resident #49's wife. Review of the facility policy titled Release of Information, dated 10/21/16, revealed the following: The Resident may initiate a request to release information contained within his/her records to anyone he/she wishes. Such requests will be honored only upon the receipt of a written, signed and dated request from the Resident or Legal Guardian. A Resident may have access to his/her records within twenty-four (24) hours (excluding weekends and holidays) of the written or oral request. A Resident may obtain photocopies (or electronic form) of his/her records by providing the facility with two (2) working days' notice (excluding weekends and holidays). A reasonable fee will be charged that includes the cost of labor and supplies. A Request/or Release of Medical Records form will be completed and signed by the Resident/Legal Guardian when requesting copies of the record. With respect to discharged Residents, the facility has no later than 30 calendar days from receiving the individual's request. This deficiency represents non-compliance investigated under Complaint Number OH00147961.

Based on observation and interview, the facility failed to ensure a well-maintained and homelike environment. This affected four residents (Resident's #8, #9, #33 and #37) of 42 residents observed during the annual survey. The facility census was 42 residents. Findings include: Observation on 02/14/22 at 9:45 A.M. with Resident #8 revealed large gouges in the wall behind her bed exposing the wall material beneath the paint. An area of water damage was noted above the heater in Resident #8's room. Interview with Resident #8 at the time of observation revealed she did not know how long these areas had been present. Observation on 02/14/22 at 10:07 A.M. with Resident #9 revealed large gouges in the wall behind her bed. Interview with Resident #9 at the time of observation revealed she had asked staff to do something about it and someone would come in the room to spray for ants, but no one would repair her wall. Observation on 02/14/22 at 11:10 A.M. with Resident #33 revealed a large area behind the bed had been spackled but not repainted and an area above the heater was chipped away and had the inner wall material exposed. Interview with Resident #33 at the time of observation revealed the wall had looked like that since his admission in August 2021. Observation of the facility on 02/14/22 from 4:49 P.M. to 5:26 P.M. with Regional Registered Nurse (RRN) #361 revealed the following concerns: · Resident #8's room had a large gouge to the wall over approximately one foot by one foot behind the bed exposing the inner wall material. Also, above the heater there were areas of wall chipped away exposing the inner wall material. · Resident #9's room had a large gouge approximately one foot by two inches behind the bed. · Resident #33's room had a large area behind the bed approximately two feet by two feet spackled and not painted and an area above the heater was chipped away exposing the inner wall and measured approximately six inches long. · Resident #37's room had an area by her bathroom where the drywall was exposed down to the base of the wall and the floor trim was coming away from the wall. Interview with RRN #361 on 02/14/22 at 4:57 P.M. verified the above areas of concern and revealed maintenance issues went into an electronic system where Maintenance Staff (MS) #342 would receive an email of the reported concern. There were no other maintenance support staff at the facility. RRN #361 was requested to bring the surveyor three months of maintenance request documentation. Interview with MS #342 on 02/16/22 at 1:55 P.M. revealed he got hundreds of emails regarding maintenance requests each day. MS #342 confirmed he was the only maintenance staff at the facility and would have to prioritize what tasks would get done each day. MS #342 stated since November 2020 there had been conversations about obtaining plastic sheeting to go behind residents' beds to prevent wall damage from occurring, but he kept getting pulled to other maintenance tasks and it had never come to fruition. MS #342 was requested to bring the surveyor three months of maintenance request documentation. No maintenance request documentation was provided by the end of the annual survey.

Based on observation, interview, taste test, and Diet and Nutrition Manual review the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This affected five residents (Resident's #5, #10, #23, #24 and #40) who were prescribed a pureed diet of 42 residents who consumed meals from the facility's kitchen. The facility census was 42. Findings include: 1. Observation on 02/15/22 at 12:15 P.M. of the lunch meal revealed that the pureed stuffed peppers and pureed peas and carrots had lumps, skins, and did not appear smooth. The pureed stuffed peppers and peas and carrots were tasted. The mixture was not smooth and not of proper consistency. Interview with Dietary Manager (DM) #363 verified the consistency of the pureed stuffed peppers and pureed peas and carrots. 2. Observation on 02/15/22 at 3:00 P.M. of the puree preparation revealed Cook #338 was preparing pureed chicken tenders for dinner meal. Taste test of puree chicken tenders revealed chunks of breading. The mixture was not smooth and not of proper consistency. Interview with DM #363 verified the consistency of the pureed chicken tenders. Interview with DM #363 on 02/15/22 at 3:10 P.M. indicated upon taste test regarding the food processor I think we need a new blade. Review of the resident diet list revealed Resident's #5, #10, #23, #24 and #40 were prescribed a pureed diet. Review of the Diet and Nutrition Care Manual, dated 2019, revealed pureed foods are generally cohesive, moist mashed potato or pudding-like consistency for people who cannot tolerate regular or mechanical soft foods. Food is pureed in a food processor to achieve a consistent smooth and easy-to-swallow product.

Based on record review and staff interview, the facility failed to ensure the resident record contained current and accurate information. This affected three (Resident's #13, #37 and #348) of three residents reviewed for accurate medical records. The facility census was 42. Findings include: 1. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 was alert with cognitive impairment and required assistance of one staff for activities of daily living (ADL). Review of the physician orders dated 12/27/21 revealed an order stating if bleeding occurs from the [CONDITION(S)] site, apply pressure, call 911, and document. Review of the physician orders dated 12/29/21 revealed an order to assess the [CONDITION(S)] site before and after [CONDITION(S)] for unusual findings, document unusual findings, and report to physician. Review of the physician orders dated 01/06/22 revealed an order to give one [MEDICATION(S)] 0.8 packet three times a day related to [CONDITION(S)] mixed with four ounces of water with meals three times a day. Review of the physician orders dated 01/10/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of all other documented physician orders located in the electronic and manual medical record revealed no other orders related to [CONDITION(S)]. Review of the care plan dated 12/27/21 revealed Resident #13 required [CONDITION(S)] with interventions that included [CONDITION(S)] as ordered and monitor daily for signs and symptoms of infection. Interview on 02/16/22 at 12:01 P.M. with Licensed Practical Nurse (LPN) #313 confirmed Resident #13 did not have a [CONDITION(S)] order in place. 2. Review of Resident #37's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #37 had moderately cognitive impairment, had no behaviors, required supervision for eating and required extensive assistance of one staff for dressing. The assessment indicated Resident #37 received [CONDITION(S)]. Review of Resident #37's current physician orders included an order dated 10/08/21 stating assess the [CONDITION(S)] site before and after [CONDITION(S)] for unusual findings, document yes or no for presence/absence of unusual findings. No physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 02/16/22 at 11:18 A.M. with LPN #313 revealed Resident #37 was currently out of the facility at [CONDITION(S)]. LPN #313 reviewed Resident #37's electronic medical record and paper chart and verified no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #313 explained the nurse who was on the hall receiving a new resident was responsible for their admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #313 denied any concerns regarding Resident #37 and [CONDITION(S)]. The Administrator was made aware of the above findings during an interview on 02/16/22 at 4:18 P.M. 3. Review of the medical record revealed Resident #348 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS 3.0 assessment revealed an admission assessment was in progress. Review of the baseline care plan dated 02/10/22 revealed Resident #348 required [CONDITION(S)]. Interventions included to provide [CONDITION(S)] as ordered, monitor daily for signs and symptoms of infection, and no blood pressure or blood draws in [CONDITION(S)] access arm. Review of the current physician's orders for 02/16/22 for Resident #348 revealed no order to specify details of [CONDITION(S)] treatments. There was no order to indicate treatment days, time, or location of [CONDITION(S)]. Interview on 02/16/22 at 2:32 P.M. with Registered Nurse (RN) #339 verified the lack of [CONDITION(S)] order.

Based on observation, record review, staff interview, and policy review the facility failed to ensure functioning call lights were placed within reach of residents. This affected three (Resident's #10, #31 and #38) of three residents reviewed for call light function. The facility census was 42. Findings include: 1. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 was alert and oriented to person, place, time, and was a one-staff physical extensive assist for activities of daily living (ADL). Observation on 02/14/22 at 10:19 A.M. revealed Resident #38's call light was not within reach and was located hanging near the floor on the ride side of the bed. Interview on 02/14/22 at 10:19 A.M. with Resident #38 revealed his right side was paralyzed, and he could not reach his call light. Resident #38 revealed his call light did not work. Demonstration on 02/14/22 at 10:20 A.M. of call light function revealed Resident #38's call light was not in working order. Interview on 02/14/22 at 10:21 A.M. with Licensed Practical Nurse (LPN) #313 confirmed Resident #38's call light was not within reach and was not in working order. Interview and demonstration on 02/14/22 at 10:25 A.M. with Maintenance Director (MD) #342 confirmed Resident #38's call light was not in working order. 2. Review of the medical record revealed Resident #31 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS 3.0 assessment dated [DATE] revealed Resident #31 had intact cognition. Resident #31 required extensive assistance of one staff for toileting, bed mobility, dressing, and personal hygiene. Review of the care plan initiated 12/25/21 revealed Resident #31 was at risk for falls. Interventions included to use call light and wait for assistance, request assistance for all transfers, always keep call light in easy reach and answer promptly. Observation on 02/14/22 at 11:00 A.M. revealed Resident #31 sitting in reclining chair angled to watch television with the call light tied to the grab bar on the bed out of reach. Interview on 02/14/22 at 11:00 A.M. with Resident #31 reported she was unable to reach the call light and would have to yell if she needed assistance. Interview on 02/14/22 at 11:15 A.M. with Medical Records (MR)/State tested Nursing Assistant (STNA) #306 confirmed the call light was out of reach of Resident #31. MR/STNA #306 had to untangle the call light from the bed's grab bar to hand to Resident #31. 3. Record review for Resident #10 revealed an admitted [DATE] and a readmitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly MDS 3.0 dated 02/01/22 revealed Resident #10 had severely impaired cognition. Resident #10 required extensive assistance of one staff for transfers and limited assistance of one staff for locomotion on the unit. Review of the care plan for dated 08/27/21 revealed Resident #10 was at risk for falls. Interventions included to always keep call light in easy reach and answer promptly and keep the bed in the lowest position while occupied. Observation and interview on 02/14/22 at 10:25 A.M. revealed Resident #10 lying in bed. Resident #10's bed was not at lowest position, and the call light was not within reach. The bed was located against wall with a fall mat on the side of the bed. Resident #10 stated she utilized the call light at times. Observation and interview on 02/14/22 at 10:26 with Administrator #316 verified the observations and stated the call light was wrapped around the grab bar located against the wall. Administrator #316 could not get to the call light to put it within reach of Resident #10. Review of the facility policy titled Answering the Call Light, revised September 2003, revealed the facility had a policy in place to respond to the resident's requests and needs. Review of the policy revealed when a resident was confined to a chair or in bed, the call light was to be within easy reach of the resident. Review of the policy also revealed all defective call lights should be reported to the Nurse Supervisor promptly. Review of the facility document revealed the facility did not implement the policy. This deficiency substantiates Master Complaint Number OH 368.

Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) 3.0 assessments for two (Resident's #30 and #31) of twenty-one residents reviewed for assessments. The facility census was 42. Findings include: 1. Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of MDS 3.0 assessment dated [DATE] revealed Resident #31 required extensive one staff assistance for toileting. The assessment indicated Resident #31 was always continent of bowel and bladder. Review of bladder and bowel continence documentation for last 30 days revealed Resident #31 was incontinent of bowel and bladder. Review of the care plan initiated 12/25/21 revealed Resident #31 had bowel incontinence. Interventions included to give peritoneal care after each episode of incontinence, apply barrier cream as needed, toilet resident promptly, and toilet resident in advance of need. Interview on 02/16/22 at 10:34 A.M. with State Testing Nursing Assistant (STNA) #352 confirmed incontinence of bowel and bladder for Resident #31. STNA #352 reported Resident #31 needed assistance during toileting. Interview on 02/16/22 at 12:03 P.M. with Registered Nurse (RN) #339 revealed RN #339 was also the MDS coordinator. RN #339 reported they had not completed the assessment for Resident #31. RN #339 reported they had corporate assistance for completing assessments. Interview on 02/16/22 at 12:20 P.M. with Regional Assessment Coordinator (RAC) #362 revealed they had assisted RN #339 with the MDS assessment for Resident #31. RAC #362 indicated review of the look back period for bowel and bladder indicated Resident #31 was incontinent. RAC #362 reported being confused as Resident #31 was continent at the last assessment. RAC #362 reported the STNAs were documenting incorrectly. Interview on 02/16/22 at 2:14 P.M. with Restorative RN #315 revealed Resident #31 had more frequent episodes of incontinence of bowel and bladder since return from hospital on 01/03/22. Restorative RN #315 indicated Resident #31 was being reviewed in facility risk meeting for a bowel and bladder restorative program. 2. Record review for Resident #30 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #30 had mild cognitive impairment. Review of the bladder and bowel revealed Resident #30 had no indwelling catheter. Review of the care plan dated 10/07/21 revealed Resident #30 required an alternate means of urinary elimination, and a Foley catheter in place. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .M. revealed 16 French five milliliter foley catheter to continuous drainage. Resident #30 was to have catheter care every shift. Review of the Treatment Administration Record (TAR) for January 2022 and February 2022 revealed the catheter care was completed as ordered. Observation on 02/16/22 at 7:52 A.M. revealed Resident #30 was lying in bed. Resident #30's Foley catheter was draining clear yellow urine. Interview on 02/16/22 at 3:50 P.M. with MDS RN #339 confirmed Resident #30 had an indwelling Foley catheter since admission on 10/06/21. MDS RN #339 confirmed an inaccurate code on the MDS submission dated 01/10/22 regarding indwelling Foley catheter.

Based on observation, interview, and record review the facility failed implement interventions to prevent falls for one resident (Resident #10) of one resident reviewed for falls. The facility census was 42. Findings include: Record review for Resident #10 revealed an admitted [DATE] and a readmitted [DATE] with diagnoses including fracture of other parts of pelvis, anxiety disorder, history of falls, and dementia without behavioral disturbance. Record review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 had severely impaired cognition. Resident #10 required extensive assistance of one staff for transfer and limited assistance of one staff for locomotion on the unit. Record review of the care plan dated 08/27/21 revealed Resident #10 was at risk for falls. Interventions included always keep the call light within easy reach and answer promptly and keep the bed in the lowest position while occupied. Observation and interview on 02/14/22 at 10:25 A.M. revealed Resident #10 lying in bed. Resident #10's bed was not in the lowest position, and the call light was not within reach. The bed was located against the wall, and a fall mat was on the side of the bed. Resident #10 stated she utilized the call light at times. Observation and Interview on 02/14/22 at 10:26 A.M. with Administrator #316 verified the observations and stated the call light was wrapped around the grab bar located against the wall, and the bed was not in the lowest position. Administrator #316 could not get to the call light to put it within reach of Resident #10. This deficiency substantiates Master Compliant Number OH 368 and Complaint Number OH 616.

Based on observation, record review, staff interview, and policy review the facility failed to ensure it had functional call lights in place. This affected one (Resident #38) of one resident reviewed for call light functioning. The facility census was 42. Findings include: Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting the right dominant side, repeated falls, muscle weakness, [CONDITION(S)], and essential hypertension. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 was alert and oriented to person, place, time, and required one-staff physical extensive assist for activities of daily living (ADL). Observation on 02/14/22 at 10:19 A.M. revealed Resident #38's call light was not within reach and was located hanging near the floor on the ride side of the bed. Interview on 02/14/22 at 10:19 A.M. with Resident #38 revealed his right side was paralyzed and he could not reach his call light. Resident #38 revealed his call light did not work. Demonstration on 02/14/22 at 10:20 A.M. of call light function revealed Resident #38's call light was not in working order. Interview on 02/14/22 at 10:21 A.M. with Licensed Practical Nurse (LPN) #313 confirmed Resident #38's call light was not within reach and was not in working order. Interview and demonstration on 02/14/22 at 10:25 A.M. with Maintenance Director (MD) #342 confirmed Resident #38's call light was not in working order. Review of the facility document titled Answering the Call Light, revised September 2003, revealed the facility had a policy in place to respond to the resident's requests and needs. Review of the policy revealed when a resident was confined to a chair or in bed, the call light was to be within easy reach of the resident. Review of the policy also revealed all defective call lights should be reported to the Nurse Supervisor promptly. Review of the facility document revealed the facility did not implement the policy. This deficiency substantiates Master Complaint Number OH 368.

Based on observation, interview and record review, the facility failed to ensure interventions had been put into place to assist in the prevention of falls and potential injuries for two residents (Residents #146 and #124). Actual Harm occurred to Resident #146 when the facility failed to ensure the resident's bed was placed in the low position resulting in a fall on 12/04/20 requiring an emergent transfer to the hospital. Resident #146 sustained a new neck fracture, two arm fractures, a broken hip and a broken clavicle as a result of the fall This affected two residents (Resident #146 and #124) of three residents reviewed for falls. The facility census was 43. Findings include: Record review for Resident #146 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Minimum Data Set 3.0 ((MDS) dated [DATE] completed revealed Resident #146 had a Brief Interview of Mental Status (BIMS) of 12, indicating the resident was moderately cognitively impaired. Resident #146 required extensive assistance for bed mobility and transfers. Record review revealed a fall assessment was completed on 11/13/20 with a score of 11 (if the total score is 10 or greater, the resident should be considered high risk for potential falls). An additional fall assessment was completed on 11/18/20 with a score of 13. Two additional fall risk assessments were completed on 12/01/20 scoring 11 and 12/04/20 with a score of 15. Record review of the care plan dated 11/13/20 for Resident #146 revealed he was at risk for falls. Interventions included bed in low position when occupied, floor mat to the right side of the bed when occupied and proper footwear. Record review of the progress note dated 11/18/20 at 6:20 P.M. completed by RN #318 revealed Resident #146 was found on the floor laying on his back next to the wall. Resident #146 was sitting in his [MEDICAL TREATMENT] chair and was trying to get to his wheelchair. Resident #146 had a new skin tear on his right arm. The intervention had been put into place to lay Resident #146 down after [MEDICAL TREATMENT]. Record review of the progress note dated 12/01/20 at 4:53 A.M. completed by LPN #317 revealed LPN #317 found Resident #146 on the floor with his back against the bed. The [MEDICAL TREATMENT] chair was tipped over on him and he had been leaning on the footboard of the bed. Resident #146 had an abrasion to the right elbow from the fall. The intervention put into place was to keep Resident #146's bed in the lowest position while in bed. Record review of the progress note dated 12/04/20 at 7:10 P.M. completed by LPN #315 revealed Resident #146 was found laying on his back by the side of his bed. Resident #146 had fallen out of his bed. Resident #146 had a laceration to the left side of his head and a skin tear to his right wrist. Resident #146 was sent to the hospital. Record review and interview on 12/09/20 at 10:40 A.M. with Restorative Nurse #303 revealed her responsibilities also included investigating falls and assuring interventions were put into place. Record review of her investigation regarding the fall for Resident #146 on 12/04/20 revealed his bed had been in the high position when he had fallen out of bed. Interview with Restorative Nurse #303 revealed she had completed the investigation by interviewing LPN #315. Interview on 12/09/20 at 3:50 P.M. with LPN #315 revealed on 12/04/20 prior to the fall, Resident #146 was in his room in his bed. LPN #315 stated, he has had a few falls before, he takes his bed remote at times and puts his bed in high position, he has done that before, on that day a resident next to him heard a noise and put the call light on, I found him on the floor and his bed was in the high position. LPN #315 revealed Resident #146 was found on the left side of the bed on the floor with a large amount of blood on the floor. Interview on 12/09/20 at 4:30 P.M. with Restorative Nurse #303 revealed she was not made aware Resident #146 had been raising his bed up to a high position. Restorative Nurse #303 confirmed if she had been aware, she would had ordered him a different bed that could not go into a high position. Interview on 12/09/20 at 4:53 P.M. with State tested Nurse Aide (STNA) #319 revealed Resident #146 frequently tried to get out of his bed unassisted. STNA #319 stated, (Resident #146) has been raising his bed up high since he came. STNA #319 went on to reveal she had reported this to the nurse on several occasions. STNA #319 stated, we put it down and he raises it right back up. Record review of documentation from the hospital completed by RN #322 revealed Resident #146 was diagnosed on [DATE] with a broken neck (2 neck fractures), broken arm (2 arm fractures), broken hip and broken clavicle. 2. Record review for Resident #124 revealed an admission date of [DATE]. Resident #124 had [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] completed by RN #304 revealed a BIMS score of six (severe cognitive impairment). Resident #124 used a wheelchair for mobility and required extensive assist with locomotion. Record review of the physician order [REDACTED].M. by LPN #314 revealed a physician order [REDACTED]. Record review of the care plan dated 09/25/20 revealed Resident #124 had been at risk for falls. Interventions included Dycem to the wheelchair to decrease the risk of sliding. Record review for the previous 12 months for Resident #124 revealed Resident #124 had a fall on 01/12/20, 03/16/20, 03/22/20, 06/17/20, 07/28/20, 08/19/20, 09/20/20, and 10/25/20. Fall risk assessment completed on 10/25/20 by LPN #320 revealed a fall assessment score of 12. Observation on 12/09/20 at 11:30 A.M. revealed Resident #124 had been sitting up in her wheelchair. Observation revealed Resident #124 did not have dycem in her wheelchair. Restorative Nurse #303 assisted Resident #124 to a standing position and verified Resident #124 did not have dycem above or below her wheelchair cushion. This deficiency substantiates Complaint Number OH 935

Based on observation, interview and record review the facility failed to ensure Resident #7 and Resident #5 were transferred properly when being transferred with a mechanical lift. Harm occurred when Resident #5 fell from a mechanical lift sustaining multiple rib fractures, subarachnoid hemorrhage, subdural hematoma to the head and multiple contusions. This affected two of three residents reviewed for mechanical lift transfers. Findings include: 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED].#5 was to be transferred using a mechanical lift. Review of a care conference summary dated 01/05/16 revealed Resident #5 required a mechanical lift for all transfers. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #5 had moderate cognitive impairment and the resident required total assistance of two or more staff for transfers. Review of a nursing note dated 02/20/16 revealed at 3:00 P.M., Licensed Practical Nurse (LPN) #12 observed Resident #5 on the floor lying on her right side next to the bed. The resident was sent to the hospital for evaluation. Review of the facility's investigation regarding the fall, signed by the director of nursing (DON) and administrator on 02/22/16, revealed the fall occurred on 02/20/16 when Resident #5 was being transferred from the bed into a wheelchair with the use of a mechanical lift. As the resident was being moved from the bed toward the wheelchair the straps on the lift sling, both upper and lower broke. The resident fell to the floor hitting her head. She was alert and responding appropriately to questions. Resident #5 stated her pain was a six out of 10. The transfer from the bed to wheelchair was being completed with one STNA. Review of STNA #13's statement revealed the resident did not have a sling in her room so she had to find one. STNA #13 indicated she strapped the sling to the hooks with the green on top and black on the bottom. STNA #13 indicated she requested assistance but no one ever came to help her. It was the end of her shift, about 2:40 P.M., so she transferred the resident herself. STNA #13 indicated as the resident was being lowered in the wheelchair she heard the resident falling out of the sling. After the resident was on the floor she stated she hit her head on the lift legs. The straps were still hooked to the lift with one side detached. Review of the emergency department transfer note dated 02/20/16 revealed the obese female fell two to three feet from a lift. Hitting the front and back of her head and right knee on the ground. The resident complained of chest pain, abdominal pain, right shoulder pain and right knee pain. Review of a CT of the head without contrast dated 02/20/16 at 6:04 P.M., revealed small focus of subarachnoid hemorrhage in the right sylvian fissure and small right tentorial subdural hematoma measuring four millimeters in maximal thickness. Review of a CT of the chest, abdomen and pelvis dated 02/20/16 revealed non-displaced fractures of the right anterior third through seventh ribs, a minimally displaced fracture of the right posterior lateral fifth rib, right upper back and periscapular contusion and small subcutaneous hematoma, suspected small subcutaneous hematomas in the upper medial right chest wall, and small subcutaneous contusion in the right lateral pelvis. Review of a nursing note dated 02/23/16 revealed Resident #5 was readmitted to the facility from the hospital with multiple rib fractures and traumatic subarachnoid hemorrhage. Review of the facility's undated mechanical lift procedure revealed mechanical lifts were to be completed by two staff members. Staff were to select the correct size sling, center the sling under the resident and place the chair parallel to the bed facing the foot of the bed. Review of the manufacturer's instructions for operating the bariatric mechanical lift, dated 2005, revealed staff were to use the sling that was recommended by the physician, keep the resident centered between the base legs and have the resident face the attendant. On 02/26/16 at 12:20 P.M., interview with the DON revealed STNA #13 was suspended pending investigation and never returned to work. The DON confirmed the investigation did not determine if the correct sling was used, if the sling was properly secured to the hooks, if the wheelchair was positioned appropriately, if there were any mechanical problems with the lift, or if the sling was worn or damaged prior to use. On 02/26/16 at 1:10 P.M., interview with the administrator and DON revealed and confirmed when observing a similar sling, because the facility threw away the defective sling, the sling had four main hooks (with multiple color loops) each with two sets of black nylon straps (over an inch in width each) sewn into the sling pad. Four of the black nylon straps were separated horizontally (all on the right side top and bottom) in the middle but there was no damage where the straps were sewn into the sling pad. On 02/26/16 at 1:36 P.M., interview with Resident #5 revealed she remembered falling out of the lift onto the floor and hitting her head on the lift legs. Resident #5 said only one staff was in the room but could not identify the staff. Resident #5 said she had to be admitted to the hospital and it was scary and hurt but she could not remember any other details related to the incident. 2. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition and was totally dependent on two or more staff for transfers. On 02/26/16 at 8:45 A.M., the resident was observed in the dining room in a wheelchair with a mechanical lift sling behind her back and under her buttocks. On 02/26/16 at 2:20 P.M., STNA #16 and #17 were observed transferring Resident #7 from a wheelchair into a bed utilizing the 600 mechanical lift. STNA #16 said she always used the green colored loop of the sling on all four hooks and said she was using the sling that was in the room. The resident was seated in the wheelchair which was positioned with the back of the wheelchair against the bed. The wheelchair was not parallel with the bed per the facility's policy and procedure. Resident #7 was seated in the wheelchair and STNA #16 faced the resident with the lift. After the resident was lifted from the chair the resident was turned 180 degrees to the right, facing away from the lift but parallel with the bed. The lift was then repositioned and pushed towards the bed and the resident was lowered to the bed. On 02/26/16 at 2:28 P.M., interview with STNA #16 and #17 verified the above and they confirmed they did not transfer the resident according to the manufacturer's guidelines and facility policy. On 02/26/16 at 5:40 P.M., interview with DON confirmed Resident #7 was not transferred according to the manufacturer's instructions or the facility's policy and procedure. This deficiency substantiates Complaint Number OH 761.