Every finding on record at O'Neill Healthcare Bay Village

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, review of incident reports, staff interview, and review of corrective action documents, the facility failed to ensure residents were transferred using mechanical lifts in a safe manner to prevent falls. This affected two (#10 and #15) of three residents reviewed for falls. The facility census was 100.Findings include:1. Record review for Resident #10 revealed the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia, osteomyelitis, hypertensive heart disease, and heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had intact cognition evidenced by Brief Interview for Mental Status (BIMS) score of 14. The resident was assessed to require staff assistance for mobility, bathing, and hygiene.Review of the incident report dated 06/06/26 revealed an accident occurring during the transfer of Resident #10 involving the use of a mechanical (Hoyer) lift and a bed-mounted trapeze. The resident was provided with a new air mattress, and staff were returning him to bed using the lift. During the transfer, the top portion of the Hoyer lift became entangled with the trapeze frame positioned above the resident's bed. To avoid causing the resident additional discomfort while untangling the equipment, staff activated the mechanical lift's emergency release mechanism. This caused the resident to be lowered more rapidly than intended; however, he was positioned directly over the bed and landed safely. The resident did not report any increase in pain beyond his baseline chronic discomfort related to a back incision. Staff assessments performed immediately after the transfer revealed no injuries.During an interview with the Director of Nursing (DON) and Regional DON #900 on 08/14/26 at 3:58 P.M., they confirmed the events of the incident on 06/06/26 involving Resident #10's transfer. They stated refresher training was provided to all nurses and certified nurse aides (CNAs) regarding safe use of mechanical lifts, with specific attention to the unique considerations required when a resident used a trapeze. 2. Record review for Resident #15 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, muscle weakness, major depressive disorder, muscle wasting, polyneuropathy, and hypertensive heart disease. Review of the quarterly MDS assessment dated [DATE] revealed Resident #15 had intact cognition and was assessed to require staff assistance for toileting and mobility. Review of the incident report dated 06/24/26 revealed Resident #15 was being transferred from her wheelchair to her bed using a mechanical lift with assistance from two staff members. During the transfer the mechanical lift began to tip, prompting the staff to immediately lower the resident toward the floor in a controlled manner. The resident was safely lowered without abrupt impact. Staff prevented the upper frame of the lift from pressing on the resident's chest. Resident #15 reported the lift made contact with her chest and immediately complained of new-onset chest pain in the mid sternal area accompanied by shortness of breath. She denied any other pain or injury and remained alert and oriented. Oxygen was reapplied at two liters via nasal cannula and vital signs were taken and found to be in the normal range. The resident did not sustain any injuries to the chest area. During an interview with Regional DON #900 on 08/14/26 at 5:47 P.M. she confirmed the events of Resident #15's fall investigation on 06/24/26 and determined was the mechanical lift tipped because the legs of the lift were narrowed by one of the staff members assisting with the transfer. Regional DON #900 stated mechanical lifts are designed to remain stable only when the legs are fully widened, especially during transfers when the resident's weight was elevated and centered above the frame. When the legs are kept in a narrowed position, the lift becomes top heavy and significantly more vulnerable to tipping. As the lift was maneuvered, the restricted leg width was unable to counterbalance the weight distribution, resulting in the lift becoming unstable and beginning to tip over. The deficient practice was corrected on 06/30/26 when the facility implemented the following corrective actions:- On 06/08/26, Maintenance Assistant #250 completed a check of all mechanical lifts to ensure proper functioning. There were no issues noted. - On 06/25/26, all direct care staff were provided education by the DON regarding proper use and operation of mechanical lifts during transfers.- On 06/25/26, the facility had a company perform lift preventative maintenance inspections on all 13 mechanical lifts used in the facility. The DON reviewed the results of the inspections on 06/25/26. - Beginning on 06/25/26, all direct care staff completed a mechanical lift competency check off evaluation to ensure proper techniques were utilized during resident transfers. All staff members completed the competency by 06/30/26.- Beginning on 06/29/26, the DON/designee began observations of residents that utilize Hoyer lifts for transfers to ensure the transfers were completed per the resident's plan of care. The observations were completed three times per week for two weeks, two times per week for two weeks, then randomly there after. The facility audits continued through 07/31/26 with no incidents or concerns identified. This deficiency represents non-compliance investigated under Complaint Number 3039185.

Based on observation, interview, and facility policy, the facility failed to ensure proper food storage and sanitation of the food preparation and storage area. This had the potential to affect all residents residing in the facility. The facility census was 117.Findings include: Observations during the initial kitchen tour on 01/13/26 at 8:30 A.M. with the Dietary Manager (DM) #586 revealed the following: Observation of the dry storage area, four containers of lemon-flavored thickened water were identified with an expiration date of 10/07/24. Thirteen packages of submarine rolls were observed in storage labeled with a best-by date of 01/10/26. Additionally, three yellow onions were observed with visible root growth, stored in a container in which multiple fruit flies were actively present. The floor of the dry storage area was observed to be visibly soiled, with scattered trash including clear plastic wrap, black dirt, a dark liquid-like substance, and areas of sticky residue. The main cooler revealed one opened to air and undated pack of hot dogs, one undated bowl of unidentified yellow solid substance, one undated pan of white unknown gravy, one open and undated bag of lettuce, and one undated and open plastic bag of purple grapes. Observation of Freezer #1 revealed one open and updated bag of corn, and one empty drinking tumbler wrapped in plastic wrap. Observation of Freezer #2 revealed one open and undated bag of chicken, and one open and undated bag of beef patty fritter. Observation of three garbage cans in the kitchen revealed trash and no lids. Dozens of fruit flies were observed in and around the trash can. Observation of the hood filters revealed visible dirt and residue. The hood was last cleaned in per the sticker on the hood suppression in January 2025. During observation, the microwave was noted to have visible food splatter present on the interior door and interior walls. A portable fan was observed on a shelf near the pureed food preparation area. The fan blades were visibly soiled, with a buildup of dust and a dark, black substance present on the surfaces. All of the above findings were verified with DM #586 at the time of observation. Review of the undated policy facility policy entitled Dietary Cleaning Schedule revealed floors were to be swept and mopped daily, including the storeroom and walk-in areas. Review of the undated facility policy entitled Food Storage revealed food should be dated as it is placed on the shelves, leftover food is stored in covered containers or wrapped carefully and securely, clearly labeled and dated before being refrigerated, and frozen food should be covered, labeled, and dated. Review of the policy dated 05/21/20 entitled Pest Control Policy revealed all garbage and other refuse shall be disposed of immediately after production or shall be stored in leak-proof containers with tight fitting covers until time of disposal.

Based on observation, staff interview, work orders, facility policy review and facility documents review, the facility failed to ensure an effective pest control program in the kitchen area and failed to ensure garbage receptacles had lids. This had the potential to affect all residents receiving food from the kitchen. The facility census was 117.Findings include:Observation of the main kitchen on 01/13/26 at 8:30 A.M. with the Dietary Manager (DM) #586 revealed several fruit flies were near the main freezer and juice dispenser. Three garbage receptacles in the kitchen had visible trash with no lids. Fruit flies were observed in the trash and in the yellow onion storage container. Interview on 01/13/26 with DM #586 at the time of the observation verified the findings.Review of work orders from the facilities contracted pest control company revealed the main kitchen was treated for fruit flies and general pests on 08/14/25, inspected for ants and fruit flies on 09/11/25, spot treated for fruit flies on 10/09/25, inspected for fruit flies on 11/13/25, spot treated for fruit flies on 12/09/25, and inspected and treated for fruit flies on 01/12/26.Review of the facility document titled, Pest Control Concern/Treatment Log revealed fruit flies in the kitchen on 01/12/26.Review of the facility policy titled, Pest Control Policy (5/21/20), revealed all garbage and other refuse shall be disposed of immediately after production or shall be stored in leak-proof containers with tight fitting covers until time of disposal. Staff were to report rodent or insect activity to the Maintenance Supervisor.

Based on observation, family interview, resident interview, and facility policy review, the facility failed to ensure foods were served at a palatable temperature and were visually pleasing. This affected sixteen (Residents #1, #4, #24, #25, #26, #28, #31, #48, #59, #65, #71, #72, #85, #98, #116, and #137) of 18 residents reviewed for dietary services. The facility census was 117. Findings include: 1. Interview with a family member of Resident #48 on 01/12/26 at 10:30 A.M. revealed multiple concerns related to food quality and temperature.2. Interview with Resident #137 on 01/12/26 at 10:55 A.M. revealed the food at the facility is always cold and Resident #137 has to ask the facility's Certified Nursing Assistants (CNAs) to warm up the food, which they do reluctantly.3. Interview with Resident #116 on 01/12/26 at 11:16 A.M. revealed the food had gone downhill.4. Interview with Resident #1 on 01/12/26 at 12:37 P.M. revealed the food at the facility is gross.5. Observation of the test tray for the breakfast meal on 01/13/26 at 8:00 A.M. with Dietary Manager (DM) #586 revealed the meal served was biscuits with sausage gravy, oatmeal, and orange juice. The biscuit was extremely hard and required significant force of a spoon to cut. The sausage gravy was bland with no seasoning and registered a luke warm temperature of 145 degrees. The oatmeal had a thick paste texture with no milk, brown sugar, or other seasonings/enhancers. DM #586 verified the findings of the test tray at the time of discovery.6. Completion of the resident council portion of the annual survey on 01/14/26 at 10:00 A.M. with Resident #4, #24, #25, #26, #28, #31, #59, #65, #71, #72, #85, #98 revealed the food at the facility is overcooked and hard and does not taste good. Review of the undated policy entitled meal service and distribution revealed Residents' meals are distributed promptly to maintain adequate temperature and appearance.This deficiency represents non-compliance investigated under Complaint Number 2703441.

Based on observation, resident interview, and staff interview, the facility failed to maintain a clean and sanitary environment. This affected 15 Residents (#4, #5, #10, #21, #26, #28, #32, #33, #40, #48, #50, #71, #78, #91, and #94) of 117 residents observed during the survey and had the potential to affect all residents residing in the facility. The facility census was 117.Findings include:Observation during environmental rounds on 01/15/2026 at 9:42 A.M. with the Director of Ancillary Services (DAS) #645 revealed the following that was verified at the time of discovery:- Resident #4's room had loose flooring under the bottom of the bed legs.- Resident #5's bottom bed sheet had a small hole and two small yellow stains at the end of the bed. There was a strong odor of urine in the room, but there was no visible urine.- Resident #10's room had an air conditioner filter that had visible dirt and debris. There was wall damage behind the bed.- Resident #26's room had loose flooring under three of four bed legs, and a dislodged floor baseboard cover and exposed heating element.- Resident #28's room had a broken windowsill ledge. Two triangular pieces of ledge were dislodged. There was a visible crack in the wall extending from the windowsill approximately 18 inches toward the floor. The inside surface of the bathroom door had an indented hole.- Resident #32's room had loose floorboards under the bed footers.- Resident #33's room had a hole in the wall behind the bed that was semi-plastered approximately seven inches long.- Resident #40's room had damage to the wall near the bed with visible paint and dry wall peeling.- Resident #48's room had a thin cover over the wall unit air conditioner vent. The cover was cold to touch. - Resident #71's room had a brown stain on the bed cover.- Residents #5, #21, #50, #78 and #91's room had a dislodged floor baseboard cover and an exposed heating element. - Resident #94's room had a damaged wall with plaster with dry wall exposed.- Dead bugs were observed in the hallway overhead lighting lids throughout the building.- An air filter unit in the hallway next to Resident #33's room had a dent in the unit with visible yellow/light brown discoloration to the outside of the unit and sticky to the touch.Interview on 01/15/26 at 9:50 A.M. with Resident #32 revealed the floor planking had been loose under her bed because of the way she is positioned in the bed.This deficiency represents non-compliance investigated under Complaint Numbers 2642470, 1266873 (OH00165876), and 1266871 (OH00165428).

Based on record review, resident and staff interviews, and facility policy review, the facility failed to ensure residents were involved in their ongoing plan of care. This affected one resident (#116) of 26 residents reviewed for care planning. The facility census was 117.Findings include: Resident #116 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis (paralysis and weakness), hypertension (high blood pressure), osteoarthritis, major depressive disorder, vertigo, and anxiety disorder. Review of the electronic medical record for Resident #116 revealed the last social service assessment progress note was recorded on 10/31/23, and social service progress note on 05/01/24. There was no documentation in the electronic medical record of a care conference from 10/31/23 to 01/13/26. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #116 was cognitively intact and required set up to partial/moderate assistance for completing his activities of daily living (ADLs). Interview on 01/12/26 at 11:22 A.M. with Resident #116 revealed he did not recall attending any care conferences or being updated on his plan of care. A second interview on 01/13/26 at 2:45 P.M. with Resident #116 revealed he had not seen a social worker, been invited to or attended a care conference since he has been at the facility. Interview on 01/13/26 at 2:15 P.M. with the Minimum Data Set Coordinator (MDSC) #605 revealed the social worker arranged the dates for care conference with the resident and scheduled the appointment. Further, there is a sign-in sheet for the care conference attendees, and the MDSC does not attend care conferences. The MDSC #605 verified there were no sign-in sheets for care conference or progress notes for care conference for Resident #116 in the electronic medical chart. Interview on 01/13/26 3:10 P.M. with Licensed Social Worker (LSW) #607 revealed the resident had not had a care conference since her employment beginning October 2025. LSW #607 verified in the resident's electronic medical record, the last social service progress note was written 05/01/24, the last social service assessment was on 10/31/23, and there were no care conference progress notes in the electronic medical record or physical chart. LSW #607 verified there were no care conference attendance sheets in the electronic medical record or the physical chart. Review of the facility policy titled Care Plan Meeting dated 02/01/12 revealed care plan meetings after admission and then at least quarterly and with any significant change in the resident's condition. The resident, responsible party, and outside consulting agencies when applicable, will be invited to attend the care conference.

Based on record review, interview, and facility policy review, the facility failed to ensure Resident #31 had an activities care plan including the resident's choices and preferences for activities. This finding affected one (Resident #31) of one resident reviewed for activities. The facility census was 117. Findings include:Review of Resident #31's medical record revealed the resident was admitted on [DATE] with diagnoses including Parkinson's Disease without dyskinesia, diabetes and muscle weakness.Review of Resident #31's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #31's care plans did not reveal evidence of a care plan that was implemented to reflect the resident's choices or preferences for activities.Interview on 01/12/26 at 10:10 A.M. with Resident #31 revealed some activities were cancelled due to lack of resident participation.Interview on 01/20/26 at 10:04 A.M. with Activity Director (AD) #542 confirmed Resident #31's medical record did not have evidence a Activity Care Plan was implemented to indicate the resident's choices and preferences for activities.Review of the Advanced Care Planning Policy dated 11/2024 revealed it was the policy of the facility to ensure that all residents admitted to a facility were assessed upon admission and periodically thereafter.

Based on record review and staff interview, the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) accurately captured all of the resident's current mental health and intellectual disability conditions. This affected one resident (#98) of one resident reviewed for PASARR. The facility census was 117.Findings include: Resident #98 was admitted to the facility on [DATE] with diagnoses that included unspecified intellectual disabilities, schizoaffective disorder, major depressive disorder, and Alzheimer's disease.Review of Resident #98's most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #98 was moderately cognitively impaired and required hands-on assistance from one staff person to complete activities of daily living.Review of the Preadmission Screening and Resident Review (PASARR) assessment dated [DATE] revealed the facility failed to accurately identify Resident #98's mental health and intellectual disability diagnoses. Specifically, review of Question #1 in Section D of the PASARR revealed the facility did not indicate diagnoses of schizoaffective disorder or major depressive disorder. Further review of Question #1 in Section E revealed the facility answered No to the question, Does the individual have a diagnosis of mental retardation (mild, moderate, severe, or profound) as described in the AAMR manual Mental Retardation: Definition, Classification, and Systems of Support (2002 or more recent version)? despite documented diagnoses of unspecified intellectual disabilities. No additional PASARR assessments were identified in the resident's medical record.In an interview conducted on 01/13/26 at 4:30 P.M., Licensed Social Worker (LSW) #607 confirmed that Resident #98's PASARR did not accurately reflect the resident's diagnoses of schizoaffective disorder, major depressive disorder, or unspecified intellectual disabilities.During a follow-up interview on 01/14/26 at 4:00 P.M., LSW #607 reported that a new PASARR had been completed, and Resident #98 was subsequently identified as having a possible Level II intellectual disability.

Based on observation and interview, the facility failed to ensure a safe and homelike environment. This affected two residents (#26 and #81) of 26 sampled residents. The facility census was 117. Findings include: Observation on 01/15/26 at 9:42 A.M. of Resident #26's room revealed a rolled towel which was placed at the base of the room window next to the bed. Cold air was felt from the base of the closed window. Interview on 01/15/26 at 10:05 A.M. with Resident #26 revealed that cold air comes through the window and is uncomfortable, and that is why the rolled towel is placed.Observation on 01/15/26 at 9:45 A.M. of Resident #81's room revealed a gap above the air conditioner unit below the window. Cold air was felt through the gap.Interview on 01/15/26 at 9:42 A.M. with Resident #81 revealed the resident stated he was cold in his room and was uncomfortable.Interview and environmental rounds on 01/15/26 at 2:25 P.M. with the Director of Ancillary Services (DAS) #645 confirmed the above findings.This deficiency represents non-compliance investigated under Complaint Numbers 2642470, 1266873 (OH00165876), and 1266871 (OH00165428).

Based on record review, observation and staff interview, the facility failed to ensure a functional call light system was in place for Residents #4 and #16. This affected two (Residents #4 and #16) of 26 sampled residents. The facility census was 117.Findings include:1. Resident #16 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, osteoarthritis and major depressive disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #16 was cognitively intact and was dependent on staff for completing his activities of daily living. Interview with Resident #16 on 01/12/26 at 4:45 P.M. revealed concerns related to the functionality of Resident #16's call light. Observation of Resident #16's call light on 01/12/26 at 4:50 P.M. revealed a red cord was looped through a hole in a switch affixed to the wall with a note above the switch plate which read, Pull For Nurse. The red cord lead from the switch down through an eyelet at the bottom of the switch plate and the length of the call light cord extended out from the eyelet which a resident could use to pull and activate the call light. When tested, the eyelet prevented the call light cord from being fully pulled and would not activate the call light from within the room. Certified Nursing Assistant (CNA) #614 verified that Resident #16's call cord was not engaging or activating Resident #16's call light in an interview on 01/12/26 at 4:55 P.M. 2. Record review of Resident #4 revealed she was admitted [DATE] and had diagnoses including schizoaffective disorder, unspecified dementia, and type II diabetes. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #4 had severe cognitive impairment and was dependent on staff for assistance transferring from the bed. Observation of Resident #4 on 01/13/26 at 2:29 P.M. revealed she was lying in bed, and the call light cord was hanging behind her dresser out of reach. Interview with her at this time revealed she denied knowledge of having a call button or cord she could use to contact staff for assistance. Interview with CNA #519 on 01/13/26 at 2:35 P.M. confirmed the above findings. Following surveyor intervention, she placed the call light string within reach of Resident #4.

Based on observation, interview, record review, and facility policy review, the facility failed to implement appropriate infection control measures during wound care. This affected one resident (#10) of three residents reviewed for wound management. The facility census was 117. Findings include: Review of the medical record revealed Resident #10 was admitted on [DATE] with diagnosis of hemiplegia, hemiparesis, type II diabetes, dysphagia, cerebral infarction a stoke, depression, anxiety, contracture right knee, hypertension heart, and heart failure.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was cognitively impaired and dependent on staff for hygiene and transfers. The resident had a stge II pressure ulcer and moisture associated skin damage (MASD).Review of the Care Plan dated 11/13/25 stated Resident #10 required Enhanced Barrier Precautions (EBP) related to multidrug resistant organism (MDRO) infection in the right foot wound. Review of the physician orders for January 2026 revealed an order to cleanse the right fifth toe with normal saline, pat dry, apply calcium alginate (an absorbent dressing), and cover with a foam dressing.Observation on 01/14/26 at 1:16 P.M. revealed Licensed Practical Nurse (LPN) #649 providing wound care to Resident #10's right fifth toe wound. LPN #649 gathered supplies and walked into the room. The outside door to Resident #10's room revealed signage indicating the resident required EBP. The signage stated that providers and staff must wear gloves and a gown when providing wound care to any skin opening requiring a dressing. LPN #649 did not put on a gown. LPN #649 washed her hands, put on gloves, and removed the old dressing to Resident #10's right fifth toe. With the same gloves used to remove the soiled dressing, she cleansed the wound and applied calcium alginate. LPN #649 then changed her gloves and applied a foam dressing. Interview on 01/14/26 at 1:56 P.M. with LPN #649 verified she did not change her gloves after removing the dressing and prior to cleansing the wound. Further interview on 01/14/26 at 5:00 P.M. revealed LPN #649 verified Resident #10 required EBP and stated she was required to wear gloves and gown while proving wound care.Review of the facility policy titled Wound Care dated 2002 stated procedures for wound care include was and dry hands, position the resident, put on gloves and remove the dressing, wash and dry hand, put on gloves and complete the dressing and wash and dry hands,This deficiency represents non-compliance investigated under Complaint Numbers 2703441 and 2642470.

Based on observation, record review, interview, and facility policy review, the facility failed to comprehensively assess a newly identified skin alteration to Resident #8's sacral/buttock area and ensure the resident's care plan for pressure ulcer prevention and treatment was timely revised. This affected one resident (#8) of two residents reviewed for pressure ulcers. The facility census was 117.Findings include:Resident #8 was admitted on [DATE] which included diagnoses of senile degeneration of brain, emphysema, heart block, emphysema, obstructive and reflux uropathy, hyperlipidemia, heart failure, and atrial fibrillation.Review of the admission Nursing Data Collection Tool dated 11/11/25 at 6:30 P.M. revealed Resident #8 had no pressure areas upon admission. The skin condition on admission revealed scattered bruising to the bilateral upper extremities, a right chest abrasion, a left groin abrasion, bruising and scabs to the right trochanter (hip), scabs to the right forearm, and a surgical incision to the front left shoulder. The resident had a pain score of zero (no pain) upon admission to the facility. Review of the Braden Scale for Predicting Pressure Sore Risk dated 11/11/25 at 7:19 P.M. revealed a total score of 12 (high risk for skin breakdown). The resident was assessed as very limited in sensory perception, very moist (skin if often but not always moist), chairfast (ability to walk severely limited or non-existent), mobility very limited (makes occasional slight changes in body or extremity position to unable to make frequent or significant changes independently), probably inadequate nutrition, and potential problem for friction and shear. Review of the nutrition assessment in the progress notes dated 11/13/25 at 1:01 P.M. in the electronic medical record revealed Resident #8 was on a regular diet, mechanical soft texture, and required feeding by the staff. Recent labs reviewed and were noted to be unremarkable. The diet was adequate to meet the resident's needs. The resident was at risk for skin breakdown but had no pressure ulcers were identified. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had no pressure ulcers and was dependent on staff for all activities of daily living (ADL) care. Resident #8 had an indwelling urinary catheter (a device to collect urine) and was incontinent of bowel. The social services assessment on 11/18/25 at 5:41 P.M. revealed a Brief Interview for Mental Status (BIMS) score of 9 (moderate impairment).Review of the electronic medical record progress note by Licensed Practical Nurse (LPN) #575 revealed Resident #8 sustained an unwitnessed fall on 11/19/25 at 1:45 P.M. The progress note revealed LPN #575 found Resident #8 on the floor sitting on his bottom. Resident #8 stated that he did have pain on his bottom and upon assessment, and an injury on his coccyx (buttocks) was noted (a skin tear and redness on coccyx). Resident #8 was then assisted back into his wheelchair. Further review of the medical record revealed no evidence that the skin tear suffered by Resident #8 as a result of the fall on 11/19/25 was measured, assessed, or a treatment was implemented. Review of the facility Fall Report dated 11/19/25 at 1:45 P.M. by LPN #575 revealed the resident had an injury on his coccyx, and a skin tear and redness was noted to the coccyx Injury locations at the time of the fall were a bruise to coccyx, a bruise to right cheek, and a skin tear to the coccyx.Review of the facility weekly wound documentation for the right buttock and coccyx dated 11/19/25 revealed there was bruising measuring 4.5 centimeters (cm) x 2.6 cm. The wound bed was described as 100% purple. A skin tear to coccyx with no measurements or additional description was documented to describe the periwound area. Review of the care plan initiated on 11/19/25 revealed the resident had potential for alteration in skin integrity. Interventions included encourage the resident to turn and reposition every two hours and prn (when needed); offload and elevate the heels in bed, a pressure reducing cushion to the chair, a pressure reducing mattress to the bed, remove wet or soiled clothing or briefs, provide incontinent care and apply protective barrier after each incontinent episode. There was no care plan for the right buttock bruise and skin tear to coccyx that was sustained on 11/19/25. A progress note written on 11/20/25 at 1:48 P.M. by the Unit Manager (UM) #628 revealed the son of Resident #8 gave consent for the house wound team for the right buttock and coccyx. A treatment order was in place for the right buttock and coccyx. Review of the Treatment Administration Record (TAR) for November 2025 revealed a treatment to the right buttocks/coccyx was ordered on 11/20/25 at 2:01 P.M. to cleanse with normal saline, pat dry, apply Triad cream (a paste to maintain a moist wound healing environment and facilitate autolytic [breaking down of cellular components] debridement) every shift and when necessary for a skin tear related to a fall.Review of the wound team Certified Nurse Practitioner (CNP) #644 wound care notes dated 11/25/25 at 11:00 A.M. revealed the purpose of the visit was to evaluate the right buttock wound. The wound was classified as a pressure ulcer, with 100% slough (moist, stringy dead tissue and indicates the presence of a full-thickness pressure wound; slough covering the entire wound bed prohibits the wound's true depth from being accurately measured) described as yellow and soft, with a moderate amount of serous (thin and watery) drainage. The wound measured 4.5 cm by 2.5 cm by depth unable to be determined (UTD). Review of the facility weekly wound documentation for the right buttock dated 11/25/25 (no time) revealed an unstageable pressure ulcer measuring 4.5 cm x 2.5 cm x UTD, 100% slough, moderate serous drainage, with the periwound intact. The treatment was changed to apply Medihoney (ointment which supports the removal of dead tissue to aid in wound healing), calcium alginate (to absorb drainage), and cover with a dressing every day and as needed every day shift. Review of Resident #8's physician orders revealed an air mattress to the bed was ordered on 11/25/25 when the skin tear/bruise was classified as a pressure ulcer.Continued review of Resident #8's care plan dated 11/19/25 revealed there was no care plan initiated or revised to include the unstageable pressure ulcer identified on 11/25/25 or a revised intervention of an air mattress which was ordered on 11/25/25.Interview on 01/14/26 7:19 A.M. with the Director of Nursing (DON) verified the treatment to the coccyx/right buttocks bruise and skin tear was ordered on 11/20/25, and the new treatment to the same area now classified as a pressure area was ordered on 11/25/25. Interview on 01/14/26 at 9:10 A.M. with Regional Director Clinical Services (RDCS) #631 revealed he personally saw the bruise on Resident #8's right buttocks the day of the fall on 11/19/25. He described the area as a skin tear to the coccyx with bruising that extended to the right buttocks. Triad cream was ordered as a treatment every shift and as needed (PRN). RDCS #631 did not have knowledge of why a skin tear and initial bruise on 11/19/25 was classified as an unstageable pressure ulcer on 11/25/25.Interview on 01/14/26 at 12:55 P.M. with LPN #575 revealed he was at the nurse's station when he heard a crash. The Certified Nursing Assistant (CNA) notified him that Resident #8 was on the floor. Upon entering the resident room, the resident was noted in a sitting position next to his bed. LPN #575 noted a skin tear (approximately 4.0 cm by 3.0 cm, using his hands to make a shape of the approximate size) with bruising around it. Interview on 01/14/26 at 2:55 P.M. with the Minimum Data Set Coordinator (MDSC) #605 verified that the care plan was not updated to include the identification and treatment of the skin tear and bruising treatment to the right buttock and coccyx that was ordered on 11/20/25. Further, the care plan was not updated to identify or include the pressure ulcer, the new treatment to the coccyx/right buttocks ordered on 11/25/25, and additional pressure reducing interventions such as the air mattress ordered on the same date.Interview on 1/14/26 at 3:31 P.M. with the CNP #644 revealed the coccyx/right buttock was staged as a pressure ulcer on 11/25/25 because bruises don't have slough in them. CNP #644 reported she did not remember exactly what the wound looked like the first time she saw it, but if the note referenced the wound contained 100% slough, then it was for sure a pressure ulcer as bruises do not have slough. CNP #644 reported she did not recall a nurse manager informing her the resident had a recent fall, but when she saw the wound for the first time, the wound did not present as a bruise, it was a pressure ulcer. Review of the facility policy Pressure Ulcer Prevention and Treatment Protocol dated 01/2014 revealed residents with a Braden score of 12 or less will be considered high risk for pressure ulcer development. Residents who are admitted with or who develop a pressure ulcer, the following interventions occur: The resident will be evaluated by the dietitian/diet tech to ensure appropriate nutritional support and interventions are in place. The dietician/diet tech will continuing monitoring for effectiveness of interventions on a regular basis and make adjustments in interventions as needed. Interventions for wound care will be implemented per the Wound Care Protocol and/or per the MD orders. Referrals may be made, as needed, to wound care specialist or therapy to aid in treatment and healing of the wound. The care plan will be modified to reflect changes in the resident's condition. The resident or responsible party will be notified of any change in condition and orders as needed. Periwound skin will be monitored daily and the wound will be evaluated with each dressing change; the wound will be measured weekly and the status of the wound will be discussed weekly by the IDT. Adjustments to treatment measures will be made as needed. Resident's will be evaluated for pain and medicated as appropriate prior to dressing change. MD/NP will be consulted as needed for pain management. If pain is noted during the dressing change, the nurse will stop the treatment, cover the wound with a temporary dressing, provide medication and then resume the dressing change as ordered once the medication has had time to take effect. A monthly review of facility statistics of pressure ulcers admitted and developed will be completed and reviewed with the facility Medical Director; if issues are identified, an action plan will be implemented and reviewed through the facilities QAPI process. This deficiency represents non-compliance investigated under Complaint Numbers 2681855 and 2642470.

Based on interview, record review, and facility policy review, the facility failed to ensure dietary preferences were honored for one resident (#137) of one resident reviewed for preferences. The facility census was 117.Findings include:Review of the medical record for Resident #137 revealed an admission date of 01/07/26. Diagnoses included but were not limited to nondisplaced transverse fracture of right patella, type II diabetes mellitus with neuropathy, obesity, and hypertensive heart disease.Review of the physician orders for Resident #137 revealed a diet order dated 01/07/26 for a low concentrated sweets diet with thin liquids.Review of Resident #137's lunch meal ticket dated 01/14/26 revealed the ticket referenced the resident was on a regular diet with no specified likes or dislikes.Review of the five-day admission Minimum Data Set (MDS) 3.0 revealed Resident #137 had intact cognition and was independent for eating.Review of the diet history and food preferences assessment dated [DATE] for Resident #137 revealed a regular diet with preference for cranberry juice for breakfast, lunch, dinner and coffee for breakfast.Interview on 01/14/26 at 1:03 P.M. with Resident #137 revealed she had spoken with Dietary Manager (DM) #586 earlier that morning and requested to have a grilled cheese sandwich and cottage cheese added to her lunch and dinner meals daily due to not liking the facility's food. Resident #137 stated she had not received the items on her lunch tray.Interview on 01/14/26 at 2:25 P.M. with DM #586 confirmed he had spoken with Resident #137 about food concerns and the resident wanted the dietary staff to add a grilled cheese sandwich and cottage cheese to the lunch and dinner meals daily per her preference. DM #586 confirmed he had forgotten to add the preference for cottage cheese and grilled cheese to her meal ticket and the resident had not received it for her lunch meal as requested.Interview on 01/14/26 at 2:36 P.M. with Resident #137 revealed the Certified Nursing Assistant (CNA) had brought the lunch tray which did not have any beverages. Resident #137 stated she requested beverages, but the CNA never returned with them. The Occupational Therapist came for therapy later after lunch and went to get Resident #137 a carton of milk.Interview on 01/20/26 at 8:49 A.M. with Resident #137 confirmed over the previous weekend there were multiple meals where cottage cheese and/or grilled cheese did not come with her lunch and dinner meals.Review of the undated facility policy called; Dietary History revealed information will be gathered upon admission to inform the dietary department of the resident's food preference and diet history.

Based on interview, record review, and facility policy review, the facility failed to ensure transportation was adequately setup for Resident #31's outside appointments. This finding affected one (Resident #31) of three residents reviewed for outside appointments. The facility census was 117. Findings include:Review of Resident #31's medical record revealed the resident was admitted on [DATE] with diagnoses including Parkinson's Disease, muscle weakness, and cognitive communication deficit.Review of Resident #31's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #31's physician orders revealed an order dated 12/02/25 for an appointment to podiatry on 12/04/25 at 11:15 A.M. and an order dated 01/05/26 for an appointment on 01/08/26 at 2:15 P.M. to the foot doctor. Review of Resident #31's medical record revealed the resident was currently insured by an Ohio managed Medicaid.Interview on 01/12/26 at 10:10 A.M. with Resident #31 revealed he had missed two appointments because the facility did not setup transportation to outside appointments timely.Interview on 01/13/26 at 2:36 P.M. with Outside Office Staff #646 revealed Resident #31 was a no show to quite a few appointments due to transportation issues and the facility staff did not call to cancel or reschedule Resident #31's appointments. Interview on 01/15/26 at 3:01 P.M. with Nurse Practitioner (NP) #647 revealed she was not notified of any missed appointments for Resident #31. NP #647 confirmed transportation was a problem.Telephone interview on 01/20/26 at 8:57 A.M. with Insurance Transportation Representative #648 revealed no transportation had been setup for Resident #31, for any past or future/upcoming appointments. Interview on 01/20/26 at 9:19 A.M. with Registered Nurse (RN) Unit Manager (UM) #626 revealed confirmation for the transport was sent to Resident #31's phone, but the phone was broken.Interview on 01/20/26 at 10:03 A.M. with Resident #31 revealed he could not receive texts due to a broken phone for the last two years. Interview 01/20/26 at 1:00 P.M. with RN UM #626 confirmed Resident #31 was not transported to the physician appointment on 01/08/26 due to transportation issues.Review of the undated Transportation Guidelines revealed for skilled residents, transportation would not be scheduled if it was not in direct relation to the resident's stay in the facility. All routine or unrelated appointments should be cancelled and/or rescheduled during a skilled stay. All Medicare transport for residents without a secondary insurance needs to be billed to the resident at the time of the booking. The form noted transports with Resident #31's specific Ohio managed Medicaid coverage should have transportation scheduled at least two days in advance and the coverage allows up to 30 round trip visits (60 one way trips) in a 12 month period.This deficiency represents non-compliance investigated under Complaint Numbers 2575250 and 2714442.

Based on observation, record review, interview, facility policy review, and review of manufacturer's guidelines, the facility failed to ensure medication error rates did not exceed 5%. This affected two residents (#40 and #97) of five residents observed for medication administration. A total of 29 opportunities with two errors were identified which resulted in a medication error rate of 6.9%. The facility census was 117.Findings include:1. Review of Resident #40's medical record revealed the resident was admitted on [DATE] with diagnoses including schizophrenia, type two diabetes mellitus with diabetic neuropathy and generalized anxiety disorder. Review of Resident #40's physician orders revealed an order dated 03/16/25 for Humalog KwikPen (short acting insulin) per sliding scale with meals for diabetes to inject 1 unit for a blood sugar of 151 to 200; 2 units for a blood sugar 201 to 250; 3 units for a blood sugar of 251 to 300; 4 units for 301 to 350; 5 units for 351 to 400; and greater than 400 give six units and call the physician; and an order dated 03/27/25 for Humalog KwikPen inject 14 units subcutaneously one time a day for diabetes with breakfast and inject 16 units subcutaneously one time a day for diabetes with lunch and inject 10 units subcutaneously one time a day for diabetes with dinner. Review of Resident #40's Diabetes Care Plan revealed an intervention dated 04/04/24 to administer diabetes medication as ordered by the doctor. Review of Resident #40's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Observation on 01/12/26 at 8:34 A.M. with Registered Nurse (RN) Unit Manager (UM) #626 of Resident #40's medication administration revealed six medications were administered with one error. Registered Nurse (RN) Unit Manager (UM) #626 administered 15 units of Humalog (scheduled 14 units plus one additional unit per sliding scale orders for a blood glucose result of 157) via a Kwikpen and did not prime the insulin pen per the manufacturer's directions. Interview on 01/12/26 at 8:51 A.M. with RN UM #626 verified the above findings. Review of the Humalog KwikPen manufacturer directions revised 07/2023 to wash the hands with soap and water; check the pen to make sure it was the correct insulin; pull the pen cap straight off; wipe the rubber seal with an alcohol swab; check the liquid in the pen for color as it should be colorless and clear; select a new needle; push the capped needle straight onto the pen and twist the needle on until it was tight; pull of the outer needle shield; pull off the inner needle shield and throw away; prime your pen means removing the air from the needle and cartridge that may collect during normal use and ensure that the pen was working correctly; to prime the pen, turn the dose knob to select two units, hold the pen with the needle point up and tap the cartridge holder gently to collect air bubbles, continue holding your pen with the needle point up and push the dose knob in until it stops at 0; select dose and inject insulin. 2. Review of Resident #97's medical record revealed the resident admitted on [DATE] with diagnoses including malignant neoplasm of prostate, obstructive and reflex uropathy and cognitive communication deficit. Review of Resident #97's Care Plan revealed an intervention dated 12/09/25 to administer medications per physician order. Review of Resident #97's admission MDS 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of Resident #97's physician orders revealed an order dated 12/04/25 for Abiraterone Acetate (also known as Zytiga, an oral antineoplastic medication) 250 mg give four tablets by mouth in the morning for prostate health to be given every morning before breakfast. Observation on 01/12/26 at 8:54 A.M. with Licensed Practical Nurse (LPN) #558 of Resident #97's medication administration revealed eleven medications were administered with one error. LPN #558 administered Zytiga 250 mg four tablets after breakfast. Interview on 01/12/26 at 1:50 P.M. with LPN #558 confirmed the above findings. A total of 29 medications were administered with two identified errors which resulted in a medication error rate of 6.9%. Review of Medication Administration Policy revised 02/2024 revealed it is the policy of the facility to make sure that medications were administered in a safe manner.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, witness statements, policy review, and interview, the facility failed to ensure Resident #121 was transferred appropriately using a Hoyer mechanical lift. This finding affected one (Resident #121) of two residents reviewed for transfers. The facility census was 117. Findings include:Review of Resident #121's medical record revealed the resident was admitted on [DATE], readmitted on [DATE] and discharged on 09/05/25 with diagnoses including chronic obstructive pulmonary disease, lumbago with sciatica right and left side and chronic atrial fibrillation. Review of Resident #121's Mobility Care Plan revealed an intervention dated 11/30/23 to transfer the resident with the assistance of two staff members using a Hoyer mechanical lift and the medium purple sling. Review of Resident #121's physician orders revealed an order dated 03/01/24 for a Hoyer lift for all transfers every day and night shift. Review of Resident #121's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of the Self-Reported Incident Form Tracking Number #259111 dated 04/07/25 revealed on 04/07/25 at 8:11 A.M., the Administrator received a message from the resident's daughter with concerns because the resident complained of back pain after getting out of bed the previous evening. The resident's daughter was concerned that the back pain was related to a staff transfer. The daughter called the local police department to report the alleged incident and did not notify facility staff that she had called the police department. The patrol officer came to the facility and interviewed the resident, with no concerns or negative findings. An investigation was initiated and the staff was suspended. Review of the Police Department Investigative Report Supplement dated 04/07/25 revealed on 04/07/25 at 10:00 A.M., Resident #121's daughter spoke with an officer over an incident that occurred at the facility. The daughter stated Resident #121 called on 04/06/25 around 8:30 P.M. to report pain. The police officer spoke with the resident who was able to communicate well. The resident stated her sister and nephew were coming to visit, so she gets in her chair to be able to leave the room for a visit. Resident #121 did not know who the aide was but described her as a black female in her late 20's. Resident #121 stated she picked her up under both armpits and placed her in a wheelchair. The resident reported pain during the move from her bed to her chair. Review of Resident #121's witness statement dated 04/07/25, revealed the Administrator and Prior Director of Nursing (DON) #635 spoke with Certified Nursing Assistant (CNA) #634 by phone. The CNA confirmed that she worked dayshift on 04/06/25 on Unit 2 and cared for Resident #121. She stated she transferred the resident with another aide (CNA #633) twice on the shift from the bed to the chair then later from the chair back to the bed. CNA #634 stated that she had the gait belt but did not use it and never knew Resident #121 was a Hoyer mechanical lift and refused to get out of bed. CNA #634 also stated that the resident appeared comfortable and there was no fall or incident. Resident #121 voiced no concerns with the transfer and was excited to visit with family in the lobby. CNA #634 stated that the family was present when the resident was transferred back to bed. On 01/31/26 at 9:30 A.M., a telephone interview was attempted with CNA #634 and no answer was obtained. The staff member no longer worked in the facility. On 01/13/26 at 8:13 A.M., a telephone interview was conducted with CNA #633. When questioned about the transfer, CNA #633 stated he assisted CNA #634 with the transfer of Resident #121, and they had used a Hoyer mechanical lift and the family lied and said they did not use a Hoyer mechanical lift. The staff member no longer worked in the facility. Interview on 01/13/26 at 9:11 A.M. with the Administrator revealed Resident #121's daughter had called her office and left a voicemail. When the daughter was called, she had voiced that the resident was transferred inappropriately and the facility did not use a Hoyer mechanical lift as required and no injuries were noted. The Administrator confirmed both CNA #633 and CNA #634 were suspended pending the investigation, and the facility determined CNA #633 and CNA #634 had not used a Hoyer mechanical lift and instead body lifted the resident from the bed to a chair and from the chair back to the bed. The Administrator confirmed staff education was completed for all nursing staff including nurses and aides, and ongoing audits were conducted to ensure compliance and provided the corrective action plan and indicated the deficient practice was corrected as of 04/10/25. Review of the Fall policy revised 01/2024 revealed it was the policy of the facility to identify residents at risk for falls and plan appropriate care and interventions to maintain resident safety to the extent possible. The deficiency was correct on 04/10/25 when the facility implemented the following corrective actions: On 04/07/25, Resident #121 was assessed and no injuries were noted. On 04/07/25, both Certified Nursing Assistants (CNAs) #633 and #634 were suspended pending an investigation. On 04/07/25, the Administrator initiated a Self-Reported Incident (SRI) for neglect related to Resident #121. The SRI was unsubstantiated for neglect. During the investigation, like residents were identified with no concerns related to transfers. All residents were assessed with no negative findings or injuries identified. From 04/08/25 to 04/10/25, all nursing staff were educated by Prior DON #635 regarding transfers and where to find the information of how to transfer specific residents in the wall charting kiosks which included a hands-on demonstration with return demonstration related to the location of the Kardex's. Nurses were included in the demonstration. An educational review of the Activities of Daily Living policy including transfers were provided to all nurses and CNAs. On 04/15/25, CNAs #633 and #634 received a Written Warning form dated 04/15/25 on inappropriate transfers. Registered Nurse (RN) #626 conducted audits of three resident transfers three times a week for four weeks, then randomly thereafter. Any non-compliance would be addressed individually with the staff by the DON/designee. This deficiency represents non-compliance investigated under Complaint Number 2575250.

Based on observation and staff interview, the facility failed to maintain its garbage disposal area in a clean and sanitary condition. This had the potential to affect all residents in the facility. The facility census was 117. Findings include: Observation and interview of the facility's garbage disposal area with Dietary Manager (DM) #586 on 01/20/26 at 8:30 A.M. revealed significant food refuse and other trash all (used gloves, plastic utensils, dirt, leaves, and boxes of food) around the dumpster area. DM #586 verified the above findings at the time of discovery.

Based on record review, observation, and interview, the facility failed to ensure posted staffing information included an accurate count of certified nurse aides (CNAs) working within the facility. This had the potential to affect all residents residing within the facility. The facility census was 117. Findings include: Record review of the daily staffing posting for 01/13/26 revealed the posted staffing indicated there were 12 CNAs working from 7:00 A.M. to 7:00 P.M. Observation of the staffing levels on 01/13/26 at 9:34 A.M. revealed only 10 CNAs were working within the facility at that time. Record review of the facility staffing schedule for 01/13/26 revealed the facility scheduled eight CNAs to work from 7:00 A.M. to 7:00 P.M., one aide to work 7:00 A.M. to 3:00 P.M., one aide to work 3:00 P.M. to 7:00 P.M., and one aide to work 9:30 A.M. to 5:00 P.M. Six further CNAs were scheduled to work starting at 7:00 P.M. and two were scheduled to work starting at 11:00 P.M. Interview with Human Resources Director #597 on 01/13/26 at 9:51 A.M. confirmed the above findings. She said she was covering for the usual scheduler and could not account for why the daily posting differed from the scheduled staffing and actual staff present in the facility.

Based on observations, record reviews, staff interviews, and review of facility policies the facility failed to provide nutritional and hydration care and services to meet the needs of one resident (Resident #108) out of three residents reviewed for nutrition and hydration and of eight facility identified eight residents requiring feeding assistance. The facility census was 107. Findings include: Review of the medical record for Resident #108 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included encephalopathy (brain function impairment), dysphagia (difficulty swallowing), failure to thrive, chronic respiratory disease, hypertension, muscle weakness, atrophy (muscle wasting), anxiety, Alzheimer's disease, depression, and bipolar disorder. Review of the admission minimum data set (MDS) assessment completed 02/03/25 revealed Resident #108 had severely impaired cognition. The Resident #108 was dependent on staff for all self-care and required assistance for eating. The assessment indicated the resident had a weight of 131 pounds, had no or unknown weight loss, and required a mechanically altered diet. The Resident #108 was edentulous (lacking teeth). Review of the admission nursing assessment dated [DATE] identified the Resident #108 was admitted with a weight of 130.6 pounds. Review of the dietary orders dated 01/24/25 for Resident #108 revealed a no added salt diet, pureed texture with honey thickened liquids. Review of the nutritional assessment dated [DATE] stated the Resident #108 had advanced Alzheimer's disease and is alert only to self. admitted with no added salt diet order with pureed food texture and honey thick liquids. The assessment recommend providing fortified pudding with each afternoon meal and a frozen desert cup (Magic Cup) with each evening meal. Additionally, the assessment indicated Resident #108 had high sodium levels, was confined to bed and required total assistance with feeding with the nutritional analysis revealing the resident needed a total of 1800 calories a day with total protein needs of 78 grams; and total fluid needs of 1800 milliliters. Review of the speech therapy evaluation dated 01/28/25 revealed the Resident #108 was at risk for aspiration, further decline in function, dehydration, and pneumonia. Evaluation of pharyngeal swallow function revealed incomplete bolus formation, delayed oral transit, oral residue, delayed swallow onset, no cough or throat clear was elicited. Recommendations were close supervision for oral intake. Review of the background assessment revealed Resident #108's dentition was edentulous, the resident was non-verbal, had limited eye opening despite cues, did not follow one step commands, and had poor position when in bed due to neck position flexed to the left. Review of the plan of care dated 01/29/25 revealed the Resident #108 was at risk for altered nutrition and dehydration related to Alzheimer's disease, hypertension, weight loss, dysphagia, and poor oral intake. Resident #108 had goals that included for the resident to be free from signs and symptoms of dehydration, and to consume equal to or greater than 75 percent (%) of each meal. Interventions included a magic cup per order, no added salt, pureed texture, and honey thick liquid diet, monitoring of weight, and the monitoring oral intake. Review of meal intakes for Resident #108 dated 01/23/25 to 02/05/25 revealed no documentation of Resident #108's intake recorded on 01/23/25, 01/24/25, 01/28/25, 01/30/25, 02/01/25, 02/02/25, and 02/04/25. Review of the meal intake for 01/25/25 revealed the Resident #108 refused all meals. Review of the meal intake for 01/29/25 revealed 25% to 50% of meal was consumed for breakfast and dinner, and 51% to 75% for lunch. Review of the meal intake for 01/31/25 revealed 51% to 75% was consumed for breakfast and lunch, no entry for dinner. Review of the meal intake for 02/03/25 revealed 25% to 50% of meal was consumed for breakfast and lunch, dinner was refused. Review of the meal intake for 02/05/25 revealed the Resident #108 was out of the facility. Review of the emergency department medical record dated 02/03/25 and timed 10:10 P.M., revealed Resident #108 was seen for chief complaint of dehydration and high blood sodium. Review of the history and physical revealed Resident #108 has had multiple workups and hospitalization s for the same complaint and the cause is likely multifactorial. Review of the record revealed prior discussions regarding enteral feeding tube placement with family, which had been declined. Upon assessment, Resident #108 appeared to be clinically dehydrated, was minimally responsive (at baseline), and was nonverbal. Per emergency transport services, Resident #108 had a reported sodium obtained earlier in the day with a result of 165 milliequivalent's per liter (mEq/L), normal sodium range is 136 to 145 mEq/L. A repeat blood sodium level was completed in the emergency department at 11:25 P.M. with a result of 160 mEq/L. Resident #108 was admitted to the intensive care unit with a diagnosis of hypernatremia (high sodium). Review of the inpatient hospital medical record revealed Resident #108 was provided with gentle fluids with a plan to monitor laboratory tests results, consult palliative care and discuss feeding tube placement with family. A recorded weight on 02/04/25 revealed Resident #108 weighted 117.6 pounds. Resident #108 was returned to the facility on [DATE]. Interview on 02/26/25 at 10:38 A.M., Registered Dietician (RD) #400 stated the specific guidelines for feeding assistance should be listed in the care plan. RD #400 confirmed Resident #108 was dependent on staff to assist with feeding to ensure the resident's nutrition and hydration. Interview on 02/26/25 at 11:48 A.M., the Administrator confirmed the facility orders and care plan did not address the extent of feeding assistance required for Resident #108. The Administrator confirmed the weights documented in the Resident #108's medical record and verified Resident #108 was dependent on staff for feeding for both hydration and nutrition. The Administrator further confirmed Resident #108 did not have the percentage of meal intake recorded on 01/23/25, 01/24/25, 01/28/25, 01/30/25, 02/01/25, 02/02/25, and 02/04/25. Review of facility policy titled Preservation of (Activities of Daily Living) ADLs Policy, dated 12/2023 revealed if a resident is unable to carry out ADLs, he/she will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. For these residents, care plan goals may not be stated in terms of what the resident is able to achieve, but in terms of the outcome of care and/or services provided. Review of facility policy titled Weights Protocol- Obtaining and Recording, dated 01/2024, revealed the purpose is to ensure accurate weights are obtained for residents in order to enable the appropriate evaluation of nutritional/clinical status. This deficiency represents non-compliance investigated under Complaint Number OH00162313 and Complaint Number OH00161145.

Based on observation, record review, and interview, the facility failed to ensure care and treatment to a skin tear was completed per physician order. This affected one resident (Resident #109) of two residents reviewed for wound care. The facility census was 107. Findings include: Review of the medical record for Resident #109 revealed an admitted [DATE] with diagnoses including stroke, diabetes mellitus, kidney disease, anxiety, post-traumatic stress disease, and cognitive impairment. Review of the progress note dated 02/25/25 at 8:26 A.M. revealed Resident #109's wife was notified of Resident #109 being transferred for evaluation after experiencing a fall on 02/24/25 at 7:00 A.M. Review of an active physician order dated 02/25/25 revealed Resident #109 was to have a left-hand skin tear cleansed with normal saline, patted dry, triple antibiotic ointment applied, covered with non-adherent dressing and wrapped with gauze once daily until healed. Observation of the Resident #109 on 02/26/25 at 11:32 A.M. revealed a left-hand laceration with four steri-strips covering the laceration, two steri-strips edges were peeling away from the skin. The laceration was open to air with a moderate amount of dried blood noted the lateral aspect of the left hand. Observation on 02/27/25 at 8:48 A.M. of Resident #109 revealed the resident was up to chair in the common area eating breakfast and watching television. The Resident #109 was observed with clean, dry bandage to left hand dated 02/26/25. Interview on 02/26/25 at 11:32 A.M., Resident #109's wife revealed the Resident #109 had no dressing on his left hand yesterday, 02/25/25 after emergency department visit or this morning. Interview on 02/26/25 at 11:33 A.M. with Resident #109's son also confirmed no dressing was on the Resident #109's left hand on 02/25/25 after returning from the emergency department and there was not a dressing in place upon his arrival to the facility the morning of 02/26/25. Interview on 02/26/25 at 3:48 P.M. with Licensed Practical Nurse (LPN) #200 verified she was the Resident #109's nurse yesterday, 02/25/25 and confirmed she did not perform the wound care on 02/25/25 stating revealed she was unaware of the wound orders for the Resident #109's left hand. This deficiency represents non-compliance investigated under Complaint Number OH00161145.