Every finding on record at Otterbein Loveland

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure staff stored and prepared food in a sanitary manner, failed to ensure dishwasher temperatures reached safe levels, and failed to ensure hot food was held at safe and proper temperatures. This affected 21 (#22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #36, #37, #38, #39, #40, #41, #42, and #43) residents who received food prepared in the House Five kitchen of 56 residents residing in the facility. The facility census was 56 residents. Findings include: 1.Observation on 03/24/26 at 7:54 A.M. of the House Five kitchen refrigerator with Dietary Technician (DT) #506 revealed it contained an undated and uncovered pitcher of pink liquid and a piece of cardboard from a drink box was holding the water dispenser shut on the front of the refrigerator. Observation of the House Five kitchen freezer revealed it contained the following items: two undated medical ice packs, two undated gallon bags full of ice with ice crystals on them, an undated loaf of gluten free bread which was open to air. Further observation of the House Five kitchen pantry revealed there was a bucket full of dirty wash cloths next to a shelf where potatoes were being stored. The pantry freezer had a brown substance in it. The following cabinets in the pantry had a brown substance on them: the cabinet containing the crock pot and skillet, the cabinet containing the mixing bowl, the cabinet containing the cutting board, the cabinet drawer containing the measuring cups. Interview on 03/24/26 at 7:54 A.M with DT #506 confirmed the observations in the House Five kitchen. 2.Observation on 03/24/26 at 8:49 A.M. of the House Five kitchen dishwasher revealed the dishwasher wash temperature was 148 degrees Fahrenheit (F) and the dishwasher rinse temperature was 175 degrees F.Interview on 03/24/26 at 8:49 A.M. with DT #506 verified the dishwasher wash temperature was 148 degrees F and should have been above 160 degrees F, and the dishwasher rinse temperature was 175 degrees F and should have been 180 degrees F. 3.Observation of on 03/24/26 at 9:01 A.M. of food temperatures per Certified Nursing Assistant (CNA) #157 revealed the sausage was being held at 127.6 degrees F during meal service.Interview on 03/24/26 at 9:01 A.M with CNA #157 verified the sausage was being held at 127.6 degrees F during meal service. Review of the facility policy titled Food Temperatures dated May 2013 revealed hot foods must be kept at a temperature of 135 degrees F or higher. 4. Observation on 03/26/26 at 7:43 A.M. of meal preparation in the House Five kitchen revealed CNA #507 was cooking eggs and bacon on an electric skillet. CNA #507 had her hair in a ponytail but was not wearing a hair net.Interview on 03/26/26 at 7:43 A.M. with CNA #507 confirmed she was cooking eggs and bacon on an electric skillet and was not wearing a hair net. This deficiency represents noncompliance investigated under Complaint Number 2673774.

Based on medical record review, review of police report, staff interview, resident representative interview, and review of the facility policy manual, the facility failed to ensure the privacy of resident's health information. This affected one (Resident #71) of one resident reviewed for privacy of medical records. The facility census was 56 residents.Findings include:Review of the medical record for Resident #70 revealed an admission date of 09/10/25 with diagnoses including COVID-19, depression, and macular degeneration and a discharge date of 09/30/25. Review of the Minimum Data Set (MDS) assessment for Resident #70 dated 09/30/25 revealed the resident was cognitively intact and required supervision with activities of daily living (ADLs.) Review of nurse progress note for Resident #70 dated 10/01/25 revealed the resident left the facility against medical advice (AMA) on 09/30/25 per the request of the resident's representative. Upon discharge Licensed Practical Nurse (LPN) #142 accidentally provided Resident #70's representative with Resident #71's medications and discharge paperwork by mistake. LPN #142 did not identify the error until shift change when the night shift nurse was unable to find Resident #71's medications in the cart. Review of the medical record for Resident #71 revealed an admission date of 09/17/25 with diagnoses including cerebral infarction, seizures, and sepsis with a discharge date of 10/07/25. Review of the physician's orders for Resident #71 dated 09/30/25 revealed the resident had orders for the following medications: Norvasc, aspirin, Biotin, Cozaar, folic acid, Keppra, Lipitor, methotrexate, metoprolol polyethylene glycol, prednisolone eye drops, sennoside, Synthroid. Review of a police report dated 10/01/25 at 4:05 P.M. revealed on 10/01/25 Resident #70's representative made an in-person report at the police station regarding concerns with the resident's care at the facility. Review of the report revealed the resident's representative reported the resident discharged from the facility on 09/30/25 and discovered the facility had given her medications and written discharge instructions for a different resident. Resident #70's representative stated she had called the facility to notify them, and the staff acknowledged the error. The facility asked the representative to bring the medications and discharge instructions back so the facility could then provide the resident's representative with the correct information and medications. Resident #70's representative requested the police officer accompany her to the facility to make the exchange as she felt uneasy doing so. The officer followed Resident #70's representative to the facility where the medications and discharge instructions were exchanged without issue. Review of the report revealed Resident #70's representative confirmed the resident had not taken any of the medications the facility had provided in error. Interview on 03/24/26 at 3:03 P.M. with the Administrator and the Director of Nursing (DON) reported the nursing staff realized Resident #70 was given the wrong medications and wrong discharge instructions about two to three hours after the resident left the facility. The Administrator confirmed the facility staff called Resident #70's representative regarding the error and the representative said she would bring the medications and discharge instructions back the next day to exchange them for the correct ones. The Administrator confirmed the facility had inadvertently provided Resident #70 and her representative with private health information regarding Resident #71. Interview on 03/25/26 at 11:17 A.M. with Resident #70's representative confirmed upon discharge on [DATE] the facility sent another resident's discharge instructions and medications with the resident. Resident #70 confirmed the facility had given her and the resident private health information about another resident on 09/30/25. Review of the facility Health Insurance Portability and Accountability Act (HIPPA) Manual dated 03/15/22 revealed the facility would protect the privacy and confidentiality of resident's individually identifiable health information. This deficiency represents noncompliance investigated under Complaint Number 2671945.

Based on medical record review, review of police report, staff interview, resident representative interview, and review of the facility policy, the facility failed to provide a safe and orderly resident discharge from the facility. This affected one (Resident #70) of two residents reviewed for discharge. The facility census was 56 residents.Findings include:Review of the medical record for Resident #70 revealed andadmission date of 09/10/25 with diagnoses including COVID-19, depression, and macular degeneration and a discharge date of 09/30/2. Review of the Minimum Data Set (MDS) assessment for Resident #70 dated 09/30/25 revealed the resident was cognitively intact and required supervision with activities of daily living (ADLs.) Review of nurse progress note for Resident #70 dated 10/01/25 revealed the resident left the facility against medical advice (AMA) on 09/30/25 per the request of the resident's representative. Upon discharge Licensed Practical Nurse (LPN) #142 accidentally provided Resident #70's representative with Resident #71's medications and discharge paperwork by mistake. LPN #142 did not identify the error until shift change when the night shift nurse was unable to find Resident #71's medications in the cart. Review of the medical record for Resident #71 revealed an admission date of 09/17/25 with diagnoses including cerebral infarction, seizures, and sepsis with a discharge date of 10/07/25. Review of the physician's orders for Resident #71 dated 09/30/25 revealed the resident had orders for the following medications: Norvasc, aspirin, Biotin, Cozaar, folic acid, Keppra, Lipitor, methotrexate, metoprolol polyethylene glycol, prednisolone eye drops, sennoside, Synthroid. Review of a police report dated 10/01/25 at 4:05 P.M. revealed on 10/01/25 Resident #70's representative made an in-person report at the police station regarding concerns with the resident's care at the facility. Review of the report revealed the resident's representative reported the resident discharged from the facility on 09/30/25 and discovered the facility had given her medications and written discharge instructions for a different resident. Resident #70's representative stated she had called the facility to notify them, and the staff acknowledged the error. The facility asked the representative to bring the medications and discharge instructions back so the facility could then provide the resident's representative with the correct information and medications. Resident #70's representative requested the police officer accompany her to the facility to make the exchange as she felt uneasy doing so. The officer followed Resident #70's representative to the facility where the medications and discharge instructions were exchanged without issue. Review of the report revealed Resident #70's representative confirmed the resident had not taken any of the medications the facility had provided in error. Interview on 03/24/26 at 3:03 P.M. with the Administrator and the Director of Nursing (DON) reported the nursing staff realized Resident #70 was given the wrong medications and wrong discharge instructions about two to three hours after the resident left the facility. The Administrator confirmed the facility staff called Resident #70's representative regarding the error and the representative said she would bring the medications and discharge instructions back the next day to exchange them for the correct ones. Interview on 03/25/26 at 11:17 A.M. with Resident #70's representative confirmed upon discharge on [DATE] the facility sent another resident's discharge instructions and medications with the resident. Resident #70's representative reported the facility did call her about the error and she told the facility she would bring the medications and discharge instructions back the following day. Review of the facility policy titled Discharge/Transfer dated 03/07/25 revealed the facility would develop and implement a discharge planning process involving the resident and/or representative and the interdisciplinary care team to ensure the needs of the resident were identified and there would be a safe transition to a location that met the resident's needs. This deficiency represents noncompliance investigated under Complaint Number 2671945.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure resident pain medication was available for administration. This affected one (Resident #100) of six residents reviewed for medication availability. The facility census was 56 residents.Findings include: Review of the medical record for Resident #100 revealed an admission date of 09/19/25 diagnoses including osteoporosis and wedge compression fracture of first lumbar vertebra with a discharge date of 09/20/25.Review of the discharge Minimum Data Set (MDS) assessment for Resident #100 dated 9/20/25 revealed the resident's cognition and activities of daily living (ADL) needs were not assessed.Review of the baseline care plan for Resident #100 dated 09/19/25 at 8:15 P.M. revealed the resident was alert and oriented to person, place, and situation, but had a short term memory problem. Resident #100 required supervision with bed mobility, transfers, and toileting and was independent with eating. Resident #100 had lower back pain related to a fall with a fracture and rated her pain as a six on a scale of one to 10 with 10 being the worst pain on 09/19/25 at 8:30 P.M. Review of the physician's orders for Resident #100 revealed an order dated 09/19/25 for oxycodone one five milligram (mg) tablet by mouth every four hours as needed for moderate pain and one to two five mg tablets every four hours for moderate or severe pain for up to twenty doses in total. Review of the Medication Administration Record (MAR) for Resident #100 dated September 2025 revealed staff administered Tylenol 600 mg on 09/19/25 at 9:55 P.M. for a pain level of a six out of 10. Review of the MAR for Resident #100 revealed there were no other pain medications documented for the resident. Review of the pain level summary for Resident #100 dated 09/19/25 revealed the resident had a pain level of a six out of 10 on 09/19/25 at 8:30 P.M., a pain level of a six out of 10 on 09/19/25 at 9:55 P.M. and a pain level of a seven out of 10 on 09/19/25 at 11:24 P.M.Review of the nurse progress note for Resident #100 dated 09/19/25 at 8:30 P.M. revealed the resident was admitted from the hospital and reported last receiving pain medication at the hospital at 4:30 P.M. The nurse called the provider on call to verify Resident #100's admission medication orders and then faxed the medication list and prescriptions to the pharmacy.Review of the progress note for Resident #100 dated 09/19/25 at 9:20 P.M. revealed the nurse called the pharmacy to verify receipt of prescription for oxycodone. The pharmacy provided a code for the nurse to pull two five mg oxycodone tablets from the facility's emergency supply. The nurse attempted to pull the medication with a second nurse and the machine malfunctioned. The drawer did not open to remove the medication. The nurse attempted three more times without success. The nurse then called the pharmacy to alert them she was unable to remove the oxycodone. The pharmacy advised the nurse to contact the the Director of Nursing (DON) or the support number for the emergency supply machine. The nurse then called the Assistant Director of Nursing (ADON) and the DON to notify them of the situation. The nurse continued to attempt to retrieve the medication without success and then called the pharmacy to request immediate delivery of the oxycodone. The pharmacy verified Resident #100's oxycodone should arrive on 09/20/25 at approximately 2:00 A.M. to 3:00 A.M. The nurse then notified Resident #100 of the situation and offered Tylenol. Resident #100 rated her pain as a seven out of 10.Review of the nurse progress note for Resident #100 dated 09/20/25 at 12:45 A.M. revealed the aide notified the nurse the resident was requesting medication. Resident #100 told the nurse she was leaving because the facility did not have her oxycodone and the resident had called her family to come get her. During that time a second nurse arrived at the house and assisted in attempting to retrieve the medication from the machine for a seventh time and was successful. The nurse offered the medication to Resident #100, but the resident refused, because she questioned if the medication was actually oxycodone or a placebo of some kind. Resident #100's family arrived and took the resident away in a private vehicle. Resident #100 and her family member refused to sign discharge paperwork and/or the leaving against medical advice (AMA) form.Interview on 03/26/26 at 1:01 P.M with the Administrator and the DON confirmed Registered Nurse (RN) #15 had attempted to pull Resident #100's oxycodone on 09/19/25 at 9:20 P.M. without success, because the drawer to the emergency supply machine would not open. The Administrator and DON verified RN #15 called the pharmacy and arranged to have the oxycodone delivered between 2:00 A.M. and 3:00 A.M. on 09/20/25. The Administrator stated RN #15 and Licensed Practical Nurse (LPN) #502 tried to open the medication dispensing machine seven times without success. The Administrator stated the nurse administered Tylenol and provided non-pharmaceutical interventions while waiting for the oxycodone to arrive, and Resident #100's pain level was a seven out of ten on 09/19/25 at 11:24 P.M. The Administrator stated on 09/20/25 at 12:45 A.M. Resident #100 told staff she was leaving the facility, and her family was coming to pick her up. The Administrator confirmed the nurses had not notified Resident #100's physician that the facility did not have the resident's oxycodone available for administration.Review of the facility policy titled Controlled Substances Prescriptions dated May 2022 revealed the prescriber would be contacted for directions when the delivery of the medication will be delayed or the medication was not or would not be available. This deficiency represents noncompliance investigated under Complaint Number 2625197 and Complaint Number 2626925.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff donned proper personal protective equipment (PPE) for residents with physician's orders for enhanced barrier precautions (EBP). This affected one (Resident #31) of two residents with indwelling catheters. The facility census was 56 residents. Findings include: Review of the medical record for Resident #31 revealed an admission date of 01/29/24 with diagnoses including right hip fracture, dementia, insomnia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment for Resident #31 dated 01/15/26 revealed the resident had severe cognitive impairment and was dependent on staff assistance with activities of daily living (ADLs.) Review of the care plan for Resident #31 dated 01/13/26 revealed the resident had an indwelling catheter related to skin breakdown and urinary retention. Interventions included staff to maintain EBP for the resident due to the presence of the indwelling catheter. Review of the physician's orders for Resident #31 dated March 2026 revealed there was an order for the resident to be in EBP due to the indwelling catheter. Observation on 03/24/26 at 8:35 A.M. revealed there was an EBP cart stocked with personal protective equipment (PPE) outside Resident #31's room Observation of catheter care for Resident #31 on 03/24/26 at 8:45 A.M. per Certified Nursing Assistant (CNA) #75 revealed the aide did not don a gown prior to providing care. Interview on 03/24/26 at 8:56 A.M. with CNA #75 verified that Resident #31 was supposed to be on EBP and the aide had not donned a gown while providing care. Review of the facility policy titled Isolation Precautions Process dated 03/26/25 revealed EBP will be utilized for residents with urinary catheters during their entire stay at the facility.

Based on observation, staff interview, review of dishwasher, refrigerator, freezer, and food temperature logs, and policy review, the facility failed to ensure foods were stored in a manner to prevent spoilage and contamination and failed to ensure the kitchen and dishware were maintained in a sanitary manner. This had the potential to affect all 58 residents residing in the facility. The census was 58. Findings include: 1. During the initial kitchen tour on 08/18/25 from 8:48 A.M through 10:20 A.M. of each facility house with Dietary Technician (DT) #205 revealed, at 8:48 A.M., there was an open container of sour cream dated 08/04/25 with a used by date of 08/11/25 and an open unmarked package of food, identified by DT #205 to be fish aquarium food. Review of the food temperature log revealed no documentation of prepared food temperatures for all three meals for 15 days in July 2025. There were no refrigerator temperatures logged for August 2025 for refrigerator #2 and no temperatures logged for outside freezer #3 for July and August 2025.Interview with DT #205 verified the outdated sour cream and fish food in the resident food refrigerator, the absent food temperatures and refrigerator and freezer temperatures at the time of discovery.Observation of House #19 on 08/18/25 at 9:18 A.M. revealed the food preparation and work table had a large crack extending across the width of table and had a raised edge measuring approximately 1/8 of an inch with noted food debris. Review of the food temperature log had no temperature recorded for all meals of four days in August 2025. Refrigerator #1 and refrigerator #2 had no temperatures recorded for August 1 through August 17 and freezer #3 had no temperatures recorded for July or August 2025.Interview with DT #205 verified the above findings in House #19 at the time of discovery. Observation of House #9 on 08/18/25 at 9:43 A.M. revealed food temperature logs were not complete for all three meals for July 1 through July 28 and freezer #3 had no temperatures recorded for August 1 through August 4. Interview with DT #205 verified the above findings in House #9 at the time of discovery.Observation of House #5 on 08/18/25 at 10:00 A.M revealed no food temperatures for any of the three meals from August 13 to August 17 were recorded. There were no temperatures documented for refrigerator #1 for 12 days in August 2025 and freezer #3 had no recorded temperatures for all of August 2025.Interview with DT #205 verified the above findings in House #5 at the time of discovery.Observation of House #10 on 08/18/25 at 10:20 A.M. revealed there were no recorded temperatures for freezer #3 for all of August 2025.Interview with DT #205 verified the lack of recorded freezer temperatures in House #10 at the time of discovery.2. Review of the House #5 dishwasher log for August 2025 revealed the log listed the rinse cycle temperature of the dishwasher must reach 180 degrees Fahrenheit (F). Further review of the temperature log revealed on 08/02/25, 08/05/25, 08/07/25, 08/10/25, 08/12/25, 8/15/25, and 08/17/25 the dishwasher rinse cycle varied from 170 to 176 degrees F. There was no evidence the dishwasher was re-ran to attain a higher temperature. There was no documentation of any intervention in the comment section of the log regarding the deficient temperature correction. Review of the House #9 dishwasher log for August 2025 revealed the log listed the rinse cycle temperature of the dishwasher must reach 180 degrees F. Further review of the temperature log revealed on 08/03/25, 8/15/25, and 08/17/25 the dishwasher rinse cycle varied from 172 to 174 degrees F. There was no evidence the dishwasher was re-ran to attain a higher temperature. There was no documentation of any intervention in the comment section of the log regarding the deficient temperature correction. Review of the House #19 dishwasher log for August 2025 revealed the log listed the rinse cycle temperature of the dishwasher must reach 180 degrees F. Further review of the temperature log revealed on 08/04/25, 08/05/25, 08/06/25, 08/08/25, 08/09/25 and 08/10/25, the dishwasher rinse cycle varied from 140 to 146 degrees F. There was no evidence the dishwasher was re-ran to attain a higher temperature. There was no documentation of any intervention in the comment section of the log regarding the deficient temperature correction. Interview on 08/18/25 at 10:25 A.M with DT #205 verified dishwasher temperatures were below the required 180 degrees F during the rinse cycle for House #5, House #9, and House #19.Interview on 08/25/25 at 7:35 A.M. Maintenance Director (MD) #63 stated he had not been notified of the dishwasher rinse cycles not getting up to 180 degrees F in House #5, House #9, and House #19.3. Observation on 08/20/25 at 8:50 A.M. revealed Certified Nurse Aide (CNA) #32 prepared puree food in the same blender bowl for two different batches of food. Between the preparations of the foods CNA #32 handwashed the blender bowl with detergent and rinsed the bowl in water. There was no sanitizer system or chemical sanitizer used between the preparation of the foods. Interview on 08/20/25 at approximately 9:00 A.M., CNA #32 verified she did not use a sanitizer between the food preparation and did not know how to do so. She did not know how she would have sanitized the bowl as she had no chemicals and did not know the sanitizing process. Interview on 08/20/25 at 1:00 P.M. DT #205 verified CNA #32 should have sanitized the blender bowl between food preparations to prevent cross contamination.Review of facility policy titled, Refrigerators and Freezer Temperatures, dated May 2013, revealed temperatures are documented twice daily and recorded on the temperature logs.Review of facility policy titled, Food Storage, dated August 2022, revealed foods should be dated once opened and used within four to seven days. This deficiency represents non-compliance related to Complaint Number OH00167007 (1399080).

Based on staff interview, review of Quality Assurance meeting sign-in sheets, and policy review, the facility failed to provide evidence the Medical Director attended and Quality Assurance committee meetings at least quarterly. This had the potential to affect all 58 residents. The census was 58.Findings Include:Review of the sign-in-sheets of the quarterly Quality Assurance (QA) committee meetings dated 09/30/24, 12/20/24, 03/28/25, and 06/19/25 revealed Medical Director #306 did not sign the sign-in attendance paperwork to show attendance.Interview on 08/25/25 at 1:58 P.M. the Administrator verified the MD must attend and participate at each quarterly QA committee meeting. The Administrator stated MD #306 did not sign the sign-in attendance sheet, and stated the MD #306 attended by telephone. The Administrator verified there was no other documentation to show MD #306 attended or participated in the most recent previous quarterly QA meetings. Review of facility policy titled, Quality Assurance and Performance Improvement Policy, dated 07/24/17, revealed the committee is made up of at least the Medical Director, the Administrator, Infection Preventionist, the Director of Nursing and at least two other care partners.

Based on observation, resident and staff interview, review of water temperature logs, review of a repair quote, and policy review, the facility failed to ensure the residents environment was safe, comfortable, and homelike. This affected nine (#14, #17, #19, #23, #34, #52, #54, #56, and #59) of nice residents reviewed for environment. The census was 58. Findings include: 1. Observation of Resident #19's room on 08/18/25 at 4:10 P.M. revealed the carpet in the resident's room was heavily stained. Observation of Resident #43's bathroom on 08/19/25 at 9:39 A.M. revealed there were three lights above the sink area that were dim to the point they were out. Interview with Maintenance Supervisor (MS) #63 on 08/21/25 at 7:12 A.M. confirmed the carpet in Resident #19's room was heavily stained and stated the lights in Resident #43's bathroom contained light bulbs that would go dim before they were ready to burn out. MS #63 confirmed the bathroom's lighting was very dim. 2. Medical record review for Resident #17 revealed he was admitted to the facility on [DATE]. His diagnoses included congestive heart failure (CHF), pressure ulcer of the right heel, depression, insomnia headache, and cluster headache syndrome. Review of the Minimum Data Set (MDS) assessment for Resident #17 dated 08/05/25 revealed he was cognitively impaired. Resident #17 was dependent on staff for medication administration. He required assistance from staff with eating. He required supervision from staff with oral hygiene, toilet use, bathing and moderate assistance from staff with dressing. Observation on 08/18/25 at 4:26 P.M. revealed Resident #17 had a brown substance that appeared to be dried bowel movement on his toilet seat and around the rim of the toilet and the bathroom floor was soiled with dirt and debris. Resident #17 had a dried substance on his pillow that appeared to be blood, crumbs and food debris throughout the carpet in his bedroom, and the window blinds were torn and had a black substance around the window frame. Interview with Resident #17 on 08/18/25 at 4:26 P.M. revealed he was not sure how often the facility staff clean his room. Interview with Certified Nurse Aide (CNA) #105 confirmed Resident #17’s window blinds were torn in his room, confirmed a black substance around his window frame, a dried brown substance on and around his toilet, the black substance throughout his bathroom floor, and the food debris and dirt all around the carpet throughout the bedroom. CNA #105 confirmed the soiled sheets that appeared to have dried blood on the pillow case, and the unknown splattered substance around the doorframe. CNA #105 stated the resident's sheets are usually changed on shower days and as needed. 3. Medical record review for Resident #14 revealed the resident was admitted to the facility on [DATE]. Her diagnoses included dorsalgia, essential primary hypertension, sciatica, dysphagia, atrial fibrillation, cerebral infarction, and depression. Review of the MDS assessment for Resident #14 dated 06/02/25 revealed she was cognitively intact. She was dependent on staff for medication administration and showers. She required set up assistance for oral hygiene and eating. She required maximum assistance from staff with toilet use and dressing. She required moderate assistance with personal hygiene. Interview on 08/19/25 at 9:17 A.M. with Resident #14 revealed the carpet was soiled with dirt and debris scattered throughout the bedroom area. The room had black marks along the wall and around the bathroom area. The toilet seat was soiled, and the bathroom floor appeared to be black and heavily soiled. Interview with Resident #14 on 08/19/25 at 9:17 A.M. revealed her family will clean her bathroom when they visit. Resident #14 stated her family will mop the bathroom floor and clean the toilet. Resident #14 stated she has ongoing issues with her toilet not flushing well. Observation on 08/19/25 at 9:18 A.M. of Resident #14’s bathroom revealed the floor was heavily soiled with black debris and the toilet was soiled. The room had black marks around the wall and debris scattered along the carpet. Interview on 08/21/2025 at 2:32 P.M. with CNA #40 confirmed Resident #14 had a soiled toilet. CNA #40 confirmed Resident #14’s bathroom toilet does not flush well and stated the issue was because Resident #14 had large bowel movements. CNA #40 confirmed the bathroom floor was soiled with black debris and stool was identified around the toilet seat. CNA #40 confirmed a black substance was along the wall when entering the room, around the wall, the bathroom, and under the window. CNA #40 confirmed the carpet had dirt and debris scattered throughout the room. CNA #40 confirmed the chunk of wood missing from the lower part of the bathroom door in Resident #14’s bathroom. 4. Record review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #23 include hemiplegia, cerebral infarction accident, history right hip fracture, seizure disorder, and hypertension. Review of the MDS assessment dated [DATE] revealed Resident #23 had intact cognition and required moderate staff assistance with bathing. Interview on 08/18/25 at 12:10 P.M., Resident #23 stated he received showers in which the water temperature was cold, even when the staff let the water run. Resident #23 stated he preferred warm showers. Review of water temperature logs revealed the hot water temperatures should be between 108 and 120 degree Fahrenheit (F). Further review of the logs revealed Resident #54's water temperatures were between 99 and 101 degrees F between February and July 2025. Resident #52's water temperatures were between 99 and 104 degrees F between February and July 2025. Resident #34's water temperatures were between 77 and 91 degrees F between March and June 2025. Resident #23's water temperatures were between 84 and 101 degrees F between February and July 2025. Resident #56's water temperatures were between 91 and 101 degrees F between February and July 2025. Resident #59's water temperatures were between 89 and 96 degrees F between February and July 2025. Review of a supply quote dated 05/07/25 revealed the facility obtained a quote for repair/replacement of water equipment. Interview on 08/25/25 at 7:25 A.M. with Maintenance Director (MD) #63 verified he obtained the residents' room water temperatures and documented them on the temperature log. MD #63 stated the minimum temperature should be 108 degrees F, per the facility requirements. MD #63 verified he did not get a quote for water repair supplies until May 2025 and stated he should have followed up and implemented an immediate intervention when the water temperature was below the threshold. Interview on 08/25/25 at 7:45 A.M with the Administrator verified MD #63 should have implemented an alternative plan to ensure the water temperatures were within correct range. Review of the facility policy titled, “Resident Rights, dated 01/22/20, revealed the Resident has the right to a clean, and safe environment. The deficiency represents non-compliance investigated under Complaint Number OH00167007 (1399080).

Based on observation, medical record review, resident, resident representative, and staff interviews, review of activity calendars, and policy review, the facility failed to ensure activity programs were provided for residents to support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This affected five (#16, #20, #36, #43, and #48) of five residents reviewed for activities. The census was 58.Findings include: 1. Medical record review for Resident #16 revealed an admission date of 01/26/22. Medical diagnoses included non-traumatic brain dysfunction, dementia, and diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was severely cognitively impaired. Review of the activity care plan dated 05/26/25 for Resident #16 revealed she enjoyed activity programs but needed encouragement, reminders, and motivation. Interventions included to invite her even if she may not attend or participate in them. Her preferences were to watch television, look at picture books, play BINGO if someone would sit with her, and coloring and painting. Review of the activity calendar dated 08/20/25 revealed at 9:00 A.M. the activity was morning reminiscing and at 11:00 A.M. the activity was pottery. The activity was labeled to be in all houses. Observation on 08/20/25 at 8:44 A.M. to 9:15 A.M. in House #19 revealed there was not morning reminiscing with the residents. Observation on 08/20/25 from 10:42 A.M. to 10:55 A.M. revealed there was not any pottery done with the residents in House #19. Interview with Certified Nurse Aide (CNA) #72 and CNA #125 on 08/20/25 at 10:55 A.M. confirmed they were not able to conduct activities in House #19 because they were busy in the kitchen and the residents liked to stay in their rooms. 2. Medical record review for Resident #43 revealed an admission date of 02/28/23. Medical diagnoses included non-traumatic brain dysfunction, dementia, cancer, and coronary artery disease. Review of a quarterly MDS assessment dated [DATE] revealed Resident #43 was severely cognitively impaired. Review of the activity care plan dated 05/29/25 revealed Resident #43 enjoyed activities and programs; however, he needed encouragement, reminders and motivation. He liked to watch television, walk, make crafts, visit with family, playing BINGO, putting together wooden planes, and to sit at the table and listen to the resident's talk. Review of the activity calendar dated 08/20/25 revealed at 9:00 A.M. the activity was morning reminiscing and at 11:00 A.M. the activity was pottery. The activity was labeled to be in all houses. Observations were made on 08/20/25 from 8:57 A.M. to 9:12 A.M. in House #5 of Resident #43 and revealed he was sitting at the dining room table eating breakfast. There were no observed activities taking place and no staff were observed asking the residents to attend activities. Observation on 08/20/25 at 11:00 A.M. revealed CNAs #51 and CNA #302 were sitting at the table outside of the kitchen area. There were no activities taking place. Interviews with CNA #51 and CNA #302 on 08/20/25 at 11:22 A.M. confirmed there was not any activities taking place in the house because everyone wanted to be in their rooms and residents were not invited to do an activity. 3. Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #20 include Parkinson's disease, Alzheimer's disease, heart failure, anxiety, hypertension, and history of trans ischemic attacks. Review of the MDS assessment dated [DATE] revealed Resident #20 had severely impaired cognition and required moderate assistance with activity of daily living (ADLs). Review of the activity care plan dated 07/17/25 revealed Resident #20 enjoyed activity programs but needed encouragement, reminders, and motivation. Her preferences were to watch television, watching crafts, being around other elders, and worship services. Review of the activity calendar dated 08/19/25 revealed at 9:00 A.M. the activity was morning stretches and at 10:30 A.M. the activity was one-on-one visits. The activity was labeled to be in all houses. Review of the activity calendar dated 08/20/25 revealed at 9:00 A.M. the activity was morning reminiscing and at 11:00 A.M. the activity was pottery. The activity was labeled to be in all houses. Observation on 08/19/25 at 9:00 A.M. to 9:15 A.M. in House #5 revealed there were no morning stretches with the residents. Observation on 08/19/25 from 10:30 A.M. to 10:55 A.M. revealed there was no one-on-one provided for Resident #20. Observation on 08/20/25 at 8:44 A.M. to 9:15 A.M. in House #5 revealed there was no morning reminiscing with the residents. Observation on 08/20/25 from 11:12 A.M. to 11:55 A.M. revealed there was no pottery done with the residents in House #5. Interviews with CNA #90 on 08/19/25 at 11:30 A.M. and CNA #51 on 08/20/25 at 11:55 A.M. confirmed they were not able to conduct activities in House #5. They stated they were busy in the kitchen. The CNAs verified they did not encourage or gather the residents for activities in the mornings. 4. Review of Resident #36's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included atrial fibrillation, hypertension, dementia, and depression. Review of the MDS assessment dated [DATE] revealed the resident had severely impaired cognition and required partial to moderate assistance with ADLs. Review of the activity care plan dated 07/17/25 revealed Resident #36 enjoyed activity programs but needed encouragement, reminders, and motivation. Her preferences were to watch television, reading, and visits. Review of the activity calendar dated 08/19/25 revealed at 9:00 A.M. the activity was morning stretches and at 10:30 A.M. the activity was one-on-one visits. The activity was labeled to be in all houses. Review of the activity calendar dated 08/20/25 revealed at 9:00 A.M. the activity was morning reminiscing and at 11:00 A.M. the activity was pottery. The activity was labeled to be in all houses. Observation on 08/19/25 at 9:00 A.M. to 9:15 A.M. in House #5 revealed there were no morning stretches with the residents. Observation on 08/19/25 from 10:30 A.M. to 10:55 A.M. revealed there was no one-on-one visit for Resident #36. Observation on 08/20/25 at 8:44 A.M. to 9:15 A.M. in House #5 revealed there was no morning reminiscing with the residents. Observation on 08/20/25 from 11:12 A.M. to 11:55 A.M. there was no pottery done with the residents in House #5. Interview on 08/18/25 at 12:18 P.M. with Resident #36's family representative stated the resident needed at lot of encouragement to attend activities and preferred one-on-one visits. Interviews with CNA #90 on 08/19/25 at 11:30 A.M. and CNA #51 on 08/20/25 at 11:55 A.M. confirmed they were not able to conduct activities in House #5. They stated they were busy in the kitchen and verified they did not encourage or gather the residents for activities in the mornings. 5. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus without complications, mild intellectual disabilities, interstitial pulmonary disease and depression. Review of the most recent MDS assessment for Resident #48 dated 07/24/25 revealed the resident had moderately impaired cognition. Review of the care plan for Resident #48 dated 07/29/25 revealed the resident enjoyed many activities and programs, however, needed continuous encouragement, reminders, and motivation. Observation of Resident #48 on 08/19/25 at 8:23 A.M. revealed the resident was in bed after eating breakfast. Resident #48 refused to complete an interview. Observation on 08/20/25 from 8:55 A.M. to 9:30 A.M. and 11:00 A.M. to 11:30 A.M. revealed no activities in House #10. Interview on 08/20/25 at 9:24 A.M. with CNA #32 confirmed activities are not done every day and in only certain different houses because of the residents receiving skilled therapy services. Review of the policy titled, Engagement and Activities, dated 04/01/13, revealed the goal of the neighborhoods is to create a home where persons living in the home have choice and excellent quality of life and care coupled with providing an environment rich in meaningful engagement experiences. Staff are held accountable to proper documentation of the engagement experience by following the Documentation of Engagement and Activity process. Furthermore, it is everyone's responsibility to engage the resident/elders in all facets of life.

Based on medical record review and staff interview, the facility failed to ensure the Medical Director visited residents once every 60 days. This affected four (#4, #16, #43, and #61) of four reviewed for physician visits. The census was 58. Findings include: 1. Medical record review for Resident #4 revealed an admission date of 05/16/23. Medical diagnoses included pneumonia meningitis, ulcerative colitis, and viral hepatitis.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact.2. Medical record review for Resident #16 revealed an admission date of 01/26/22. Medical diagnoses included non-traumatic brain dysfunction, dementia and diabetes. Review of the quarterly MDS assessment dated [DATE] revealed Resident #6 was severely cognitively impaired. 3. Medical record review for Resident #43 revealed an admission date of 02/28/23. Medical diagnoses included non-traumatic brain dysfunction, dementia, cancer, and coronary artery disease.Review of quarterly MDS assessment dated [DATE] revealed Resident #43 was severely cognitively impaired.4. Review of the medical record for Resident #61 revealed an admission date of 01/14/25. Medical diagnoses included Alzheimer's disease, renal insufficiency, diabetes, and psychotic disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #61 was severely cognitively impaired.Review of the Medical Director visits revealed the last visit for Resident #4, Resident #16, Resident #43, and Resident #61 was on 05/21/25. Interview with the Administrator on 08/21/25 at 10:30 A.M. confirmed the Medical Director had not seen Resident #4, Resident #16, Resident #43, or Resident #61 within 60 days of the last visit. The Administrator stated the Medical Director was not aware she had to see residents every 60 days.

Based on observation, medical record review, staff interview, and policy review. the facility failed to ensure soiled linens were properly handled and failed to ensure proper hand sanitation during wound treatments. This affected two (#2 and #62) of four residents reviewed for infection control measures during care and services. The census was 58. Findings include: 1. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident # 2 include hypertension, cerebral vascular accident affected right side, heart disease, diabetes, and anxiety disorder. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #2 had intact cognition and was dependent for toileting and hygiene assistance. Observation on 08/19/25 at 10:27 A.M. of Certified Nurse Aide (CNA) #90 revealed the CNA exiting Resident #2's room with both arms and hands ungloved carrying uncovered linens, which were touching CNA #90's body. She carried the linens through the hallway to the laundry room which was approximately 40 yards from Resident #2's room. Interview on 08/19/25 at 10:28 A.M. CNA #90 verified she changed Resident #2's linens and carried them with ungloved hands through the hallway to the laundry room. CNA #90 verified the linens were touching her body. She stated she should have bagged the linens but had no bags. Review of facility policy titled, Used Linen Handling, dated May 2013, revealed staff should always wear gloves when handling used linen, and handle linen as little as possible held away from the body and covered when taken to the dirty utility room. 2. Review of Resident #62's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #62 include hypertension, osteoporosis, anxiety disorder, and dementia. Review of the MDS comprehensive assessment dated [DATE] revealed Resident #62 had impaired cognition and required maximum assistance for transfers and set up assistance for eating. Review of physician orders revealed Resident #62 had orders to cleanse bilateral legs with calcium alginate and medihoney, and wrap in kerlix and ACE wrap once each shift. Observation on 08/21/25 at 12:33 P.M. revealed Licensed Practical Nurse (LPN) #88 was observed to apply the treatment to Resident #62's lower extremity skin tears on bilateral legs at three different areas on the legs. LPN #88 did not change gloves or sanitize her hands between treatments of the three different areas on Resident #62's legs. Interview on 08/21/25 at 12:33 P.M. LPN #88 verified she did not change gloves or sanitize her hands between treatments of the three different wound sites on Resident #62's legs. LPN #88 stated she should have changed gloves and sanitized her hands between administration of the treatments between each of the three wound sites. Interview on 08/25/25 at 3:17 P.M. the Director on Nursing (DON) verified changing gloves and sanitizing hands should occur between application of wound treatments for different wound sites. Review of policy titled, Hand Hygiene Procedure, dated November 2017, revealed hand hygiene occurs after contact with wound dressings. This deficiency represents non-compliance related to Complaint Number OH00167007 (1399080) and Complaint Number OH00165718 (1399078).

Based on medical record review, staff interview, and policy review, the facility failed to obtain written documentation in the medical record of the code status of one (#41) resident of three residents reviewed for advance directives. The facility census was 58.Findings include:Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus without complications, severe sepsis without septic shock, cellulitis, rheumatoid arthritis, and atrial fibrillation. Review of Resident #41's admission summary dated [DATE] revealed the resident was alert and a full code (initiate cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest). Review of a physician order dated [DATE] revealed Resident #41 had an advance directive for Do Not Resuscitate Comfort Care (DNRCC; meaning no CPR will be performed for cardiac or respiratory arrest and only comfort care measures will be initiated).Review of a physician progress note dated [DATE] revealed Resident #41's code status was listed as a full code.Review of Resident #41's electronic health record (EHR) revealed no copy of an advanced directive in the record and documentation in the banner of DNRCC.Review of Resident #41's hard medical record revealed no copy of an advanced directive in the record, but was labeled with DNRCC on the outside of the hard chart.Interview on [DATE] at 3:11 P.M. with Quality of Life Coordinator #206 stated the team discussed the code status of residents during care conferences. She confirmed there was no signed advance directive in Resident #41's paper chart or EHR for a DNRCC code status. Interview on [DATE] at 12:15 P.M. with the Administrator confirmed Resident #41 admitted with a DNRCC code status according to the records they received but when they spoke with the family and Resident #41 at a later date (not specified) they discovered the family and Resident #41 wanted to be a full code status. The Administrator also added it was changed yesterday ([DATE]) in the Resident #41 EHR, the physician order for the DNRCC was removed, and the DNRCC was removed from the banner. Review of the policy for Advance Directives, dated [DATE], revealed on admission, the facility will determine whether the resident has executed an advance directive, and if not, whether the resident's physician issued a DNR order in another setting and whether the resident would like a DNR order issued while in the facility. Copies of all Advance Directives will be obtained from the resident and/ or family and placed in the medical record. If applicable, a DNR order will be obtained from the resident's physician and placed in the medical record.

Based on medical record review, review of self-reported incidents, staff interview, and review of a policy, the facility failed to timely report an allegation of abuse. This affected one (#23) of one residents reviewed for abuse. The facility census was 58. Finding include: Review of Resident #23's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included hemiplegia, cerebral infarction accident, history right hip fracture, seizure disorder, and hypertension. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #23 had intact cognition and required moderate staff assistance with bathing. Review of a self-reported incident (SRI) dated 08/18/25 revealed, during the annual survey, Resident #23 alleged abuse during personal care of a previous incident in March 2025. During the investigation, Certified Nurse Aide, (CNA)# 133 stated earlier in the month of August 2025 , Resident #23 reported to her an unnamed CNA said, You understand this, and turned cold water onto him during his shower. CNA #133 sent a text message to Coach Manger (CM) #129 and asked CM #129 to come and talk to her. CM #129 did not talk to CNA # 133 until 08/18/25 during the SRI investigation, when CNA #133 revealed the allegation.Interview on 08/21/25 at 3:07 P.M. CNA #133 stated, on 07/31/25, Resident #23 reported an allegation to her and CNA #107 that a few months ago an unknown CNA intentionally turned cold water onto him in the shower saying, You understand this, and turned the cold shower water onto him. CNA #133 stated on 07/31/25 she asked CM #129 to come talk to her, but CM #129 did not. On 08/14/25, CNA #133 went to CM #129 and in-person told CM #129 Resident #23's allegation of abuse. CNA #133 stated she reminded CM #129 on 08/18/25 for the reported allegation on 08/14/25. CNA #133 stated she had not reported to anyone else in management from 07/31/25 through 08/14/25 about Resident #23's allegation of abuse. Interview on 08/22/25 at 11:36 A.M. with CNA #107 stated she was very close to Resident #23 and he reported to her a staff member sprayed him with cold water because he told her he could not understand her. CNA #107 denied any knowledge of physical or verbal abuse, however, stated Resident #23 was very clear when he said the CNA turned the cold water on and sprayed him with the cold water. CNA #107 stated she reported it to CM #129 on 07/31/25. CNA #107 verified on her telephone the date of the reported abuse allegation to CM #107 was 07/31/25. CNA #107 stated she had not reported the allegation to any other manager or the Administrator. Interview on 08/25/25 at 10:3 A.M. with CM #129 verified she was contacted by CNA #133 on 07/31/25 to follow-up on a request for communication, and stated she did not follow up on the request. CM #129 verified on 08/14/25, CNA #133 reported in-person of an allegation of abuse reported by Resident #23. CM #129 verified she did not report the allegations to the Administrator on or after 08/14/25. CM #129 stated CNA #133 reported the allegation late in the day on 08/14/25 when CNA #133 left work at the end of the day shift between 7:00 A.M. to 3:00 P.M. Interview on 08/25/25 at 11:35 A.M. the Administrator verified she was not contacted by CM #129, CNA #133, or CNA #107 of an allegation of abuse by Resident #23 from 07/31/25 through 08/17/25. The Administrator stated she first heard of an allegation of abuse regarding Resident #23 when it was reported on 08/18/25 by the surveyor. The Administrator stated the staff should contact her directly if an allegation of abuse was made and if she was not available, report it to their supervisor. The direct supervisor of the CNAs was CM #129 or the Director of Nursing (DON). The Administrator stated the reporting of an allegation of abuse was immediate and stated CM #129, CNA #133, and CNA #107 should have reported the allegation immediately to her. Review of a facility policy titled, Abuse , Mistreatment, Neglect and Exploitation, dated 10/25/22, revealed the residents have the right to be free from abuse. The employees are to immediately report all allegations to the Administrator.

Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure fall incidents were reviewed and interventions put in place in a timely manner and failed to ensure established fall interventions were in place as care planned. This affected two (#25 and #64) of six residents reviewed for falls. The census was 58. Findings include:1. Medical record review for Resident #25 revealed she was admitted to the facility on [DATE]. Her diagnoses included, major depressive disorder, essential primary hypertension, generalized anxiety, hallucinations, bipolar disorder, insomnia, anemia, anorexia nervosa, and candidal esophagitis. Review of the Minimum Data Set (MDS) assessment, dated 07/02/25, revealed Resident #25 was cognitively intact. Resident #25 was dependent on staff for medication administration, lower body dressing, and putting on/taking off shoes. Resident #25 required supervision with meals and oral hygiene. Resident #25 required maximum assistance from staff with toilet use, bathing, upper body dressing, personal hygiene, and sit to stand positions. Review of the progress notes for Resident #25, late entry dated on 12/27/25 for 12/23/24 at 9:29 P.M., revealed Resident #25 was found on the floor in Resident #25's room. No immediate intervention was listed. On 12/24/24, Resident #25 was assessed by the nurse practitioner and a stat x-ray was ordered related to Resident #25's complaints of pain. The x-ray results confirmed a probable fracture of the distal clavicle without dislocation and an age indeterminate T12 compression fracture. Review of the interdisciplinary team (IDT) note on 12/26/24 at 1:24 P.M. revealed the IDT met to review the fall from 12/23/24 when Resident #25 was found on the floor by a certified nurse aide (CNA) in front of Resident #25's bed. Resident #25 was assessed by the nurse and denied pain. Resident #25 had complaints of pain with the nurse practitioner visit on 12/24/24 and an order for an x-ray of the left shoulder and lumbar spine was ordered with resulted findings of probable fracture of the distal clavicle and findings of an age indeterminate T12 compression fracture. The IDT intervention was a scoop mattress in place to prevent sliding out of bed. Interview with the Administrator and the Director of Nursing (DON) on 08/21/25 at 9:25 A.M. confirmed no immediate intervention was listed. The Administrator and the DON confirmed the IDT team did not meet until 12/26/25 to review the fall that occurred on 12/23/25 and the intervention put in place at that time was for Resident #25 to utilize a scoop mattress. Review of the progress notes for Resident #25 revealed a late entry dated 04/25/25 at 8:03 A.M. for 04/23/25 at 8:30 A.M. that a CNA attempted to transfer Resident #25 from wheelchair to the shower chair and lowered Resident #25 to the floor. Resident #25 stated she was lowered to the floor. No immediate intervention as listed in the progress notes. Review of the IDT team note dated 05/01/25 at 7:10 P.M. for the fall on 04/23/25 revealed a CNA attempted to transfer Resident # 25 from the wheelchair to the shower chair and lowered Resident #25 to the floor. The intervention was to have Resident #25 utilize two staff members to transfer to the shower chair verses one person for transfer to the shower chair.Interview with the DON on 08/21/25 at 9:30 A.M. confirmed the facility failed to place an immediate intervention in place. The IDT did not meet until 05/01/25 and the intervention for two caregivers to transfer Resident #25 to her shower chair was implemented. Review of the progress notes dated 06/28/25 at 12:30 P.M. for Resident #25 revealed she was sent to the emergency room post fall with head trauma and pain was rated a six out of 10. Resident #25 fell when she attempted to transfer herself. No immediate intervention was listed. Review of the IDT note dated 06/30/25 at 1:31 P.M. for 06/28/25 revealed Resident #25 was discharged to the emergency room for evaluation related to the resident falling, hitting her head, and had complaints of pain. Resident #25 fell when she attempted to transfer herself. The intervention was to encourage Resident #25 to utilize a recliner chair when out of the bed.Interview on 08/21/25 at 9:35 A.M. with the Administrator and the DON confirmed Resident #25 tried to transfer herself and it resulted in a fall. The Administrator and the DON confirmed the facility failed to implement an immediate intervention. Resident #25 was discharged to the emergency room for evaluation on 06/28/25 at 12:30 P.M. per the progress notes and returned to the facility on [DATE] at 4:46 P.M. The IDT met on 06/30/25 and Resident #25's new intervention was placed on 06/30/25. Interview with the Administrator on 08/20/25 at 3:54 P.M. confirmed the facility will meet as an IDT and review falls that have occurred the previous business day. The Administrator confirmed the facility identified concerns related to a delay in the time the IDT members have met in relation to a fall. The Administrator confirmed the facility identified a concern with immediate interventions being identified, documented, and put in place immediately after a fall has occurred. The Administrator and the DON confirmed the facility expectation and the facility fall policy require the supervising nurse at the time of the fall should identify an immediate intervention document the intervention in the resident's medical chart and ensure the intervention is in place. The IDT will meet the next business day and review the resident's fall and ensure the intervention was appropriate.2. Medical record review for Resident #64 revealed an admission date of 06/08/23. His medical diagnoses included Parkinson's disease, renal insufficiency, non-Alzheimer's dementia, and dysphagia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #64 was moderately cognitively impaired. His functional status was setup or clean-up assistance for eating, supervision or touching assistance for toileting, independent for bed mobility, and partial/moderate assistance for transfers. Review of the care plan revised on 05/03/25 revealed Resident #64 was at risk for falls related to Parkinson's disease, repeated falls, unsteadiness on his feet, and weakness. Interventions for his falls were to ensure Dycem (non-skid pad) to his wheelchair seat was in place, lanyard attachment to his wheelchair to ensure his grabber was within reach at all times, and Dycem to his bedside tabletop to keep needed items in place Observation of Resident #64 on 08/21/25 at 1:17 P.M. revealed he did not have his lanyard on his wheelchair to keep his grabber in place and had no Dycem to his wheelchair seat or to the top of his bedside table. Interview with Therapy Supervisor (TS) #304 on 08/21/25 at 1:25 P.M. confirmed the interventions were not in place for Resident #64. Review of the facility policy titled, Falls Management, dated 12/03/19, revealed in the event a fall should occur the nurse should complete a physical assessment, provide immediate care, notify the family and physician of the fall, complete the accident and injury report, determine immediately if any interventions are needed, institute the interventions to prevent a further fall, update the care plan and Kardex with new interventions, and the documentation in the notes should include a complete account of the fall. This deficiency represents non-compliance investigated under Complaint Number OH00167007 (1399080) and Complaint Number OH00164135 (1399075).

Based on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure incontinence care was provided timely and adequately. This affected two (#4 and #41) of two residents reviewed for bowel and bladder. The census was 58.Findings include:1. Medical record review for Resident #4 revealed an admission date of 05/16/23. Medical diagnoses included pneumonia meningitis, ulcerative colitis, and viral hepatitis.Review of the care plan dated 01/20/25 revealed Resident #4 was at risk for bladder incontinence related to impaired mobility. Interventions included to clean the peri-area after each incontinence episode, and wash, rinse, and dry after each incontinence episode. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact. His functional status was supervision or touching assistance for eating, and was dependent for toileting, bed mobility, and transfers. He was frequently incontinent for bladder and bowel.Observation of incontinence care for Resident #4 on 08/18/25 at 2:00 P.M. revealed Certified Nurse Aide (CNA) #83 provided the care for the resident who was saturated with urine and had feces on his bottom. CNA #83 was observed to wipe the front of Resident #4 in a quick motion over the penis and did not pull back the foreskin and did not adequately clean the resident's scrotum. CNA #83 then turned the resident over and wiped his buttocks and finished the care.Interview with CNA #83 on 08/18/25 at 2:09 P.M. confirmed she did not pull back Resident #4's foreskin of the penis when providing incontinence care and confirmed she did not wipe the scrotum adequately or dry the resident during the care provided. CNA #83 stated she came in late that morning and was in a hurry.Review of the policy titled, [NAME] Solutions, dated 05/19/25, revealed staff are to wet the washcloth with warm water from a running spigot and apply mild soap. Hold the shaft of the penis with one hand. Wash the penis with the washcloth, beginning at the tip and working in a circular motion from the center to the periphery to avoid introducing microorganisms into the urethra. Use a clean section of washcloth for each stroke to prevent the spread of contaminated secretions or discharge. Wet a clean washcloth and rinse the area thoroughly using the same circular motion. Wash the rest of the penis using downward strokes toward the scrotum. If appropriate, rinse well and pat dry with a towel. Clean the top and sides of the scrotum; if appropriate, rinse thoroughly and pat dry. Handle the scrotum gently to avoid causing discomfort. Turn the patient onto the side (if possible) to expose the anal area. Clean the bottom of the scrotum and the anal area. If appropriate, rinse well and pat dry. 2. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus without complications, severe sepsis without septic shock, cellulitis, rheumatoid arthritis and atrial fibrillation. Review of the most recent MDS assessment dated [DATE] revealed Resident #41 had no behaviors, did not reject care, and did not wander. The resident was dependent for toileting, required substantial assistance with bathing, and was dependent for transfers. Review of the care plan for Resident #41 dated 08/16/25 revealed the resident was frequently incontinent of bladder and bowel. Interview and observation with Resident #41 on 08/20/25 at 8:52 A.M. stated she rang the call light over an hour ago and no one came; however, stated a nurse and a nurse aide came in 30 minutes ago and asked if she needed anything and she let them know she had gone to the bathroom in her pants in the bed. The resident appeared frustrated that she had the accident. Interview with Registered Nurse (RN) #300 on 08/20/25 at 8:55 A.M. confirmed she and the nurse aide went in and asked if Resident #41 needed anything 30 minutes ago and the resident indicated she needed help with toileting and RN #300 was not sure if anyone went in to help her. Interview on 08/20/25 at 8:58 A.M. with RN #300 stated she was going to finish giving medications to another resident and then she would assist Resident #41. Interview on 08/20/25 at 9:00 A.M. with Resident #41 confirmed she was not happy and embarrassed about sitting in soiled pants. She stated it did not happen all of the time, and she was worried because her skin was sensitive. Observation on 08/20/25 at 9:04 A.M. revealed RN #300 walked into Resident #41 ' s room. Interview on 08/20/25 at 9:08 A.M. with CNA #32 verified she was in Resident #41 ' s room about 30 minutes ago and aware at that time the resident had an incontinence accident in her bed, and she added she let the resident know she had to come out and make breakfast for the other residents first.

Based on observation, resident and staff interview, and medical record review, the facility failed to ensure the facility was adequately staffed to provide timely care and services for residents. This affected one (#41) of two residents reviewed for bowel and bladder. The census was 58. Findings include:Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus without complications, severe sepsis without septic shock, cellulitis, rheumatoid arthritis and atrial fibrillation. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had no behaviors, did not reject care, and did not wander. The resident was dependent for toileting, required substantial assistance with bathing, and was dependent for transfers. Review of the care plan for Resident #41 dated 08/16/25 revealed the resident was frequently incontinent of bladder and bowel. Interview and observation with Resident #41 on 08/20/25 at 8:52 A.M. stated she rang the call light over an hour ago and no one came; however, stated a nurse and a nurse aide came in 30 minutes ago and asked if she needed anything and she let them know she had gone to the bathroom in her pants in the bed. The resident appeared frustrated that she had the accident. Interview with Registered Nurse (RN) #300 on 08/20/25 at 8:55 A.M. confirmed she and the nurse aide went in and asked if Resident #41 needed anything 30 minutes ago and the resident indicated she needed help with toileting and RN #300 was not sure if anyone went in to help her. Interview on 08/20/25 at 8:58 A.M. with RN #300 stated she was going to finish giving medications to another resident and then she would assist Resident #41. Interview on 08/20/25 at 9:00 A.M. with Resident #41 confirmed she was not happy and embarrassed about sitting in soiled pants. She stated it did not happen all of the time, and she was worried because her skin was sensitive. Observation on 08/20/25 at 9:04 A.M. revealed RN #300 walked into Resident #41 ' s room. Interview on 08/20/25 at 9:08 A.M. with CNA #32 verified she was in Resident #41 ' s room about 30 minutes ago and aware at that time the resident had an incontinence accident in her bed, and she added she let the resident know she had to come out and make breakfast for the other residents first.Interview on 08/20/25 at 9:52 A.M. with RN #300 stated it was only her and the nurse aide working at the time they went into Resident #41's room. She stated they were short staffed.Interview on 08/20/25 at 9:55 A.M. with CNA #83 confirmed the facility was short staffed and she just got called in to work at 9:15 A.M. This deficiency represents non-compliance investigated under Complaint Number OH00167007 (1399080), Complaint Number OH00165643 (1399077), and Complaint Number OH00164139 (1399076).

Based on record review, observations, staff interviews, and policy review, the facility failed to perform appropriate hand hygiene while preparing food for residents. This affected four (#13, #20, #21, and #22) of six residents sampled for food preparation. The facility census was 58. Findings include: 1. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] and had diagnoses including unspecified epilepsy and stage III chronic kidney disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] and had diagnoses including type II diabetes and vascular dementia. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #20 was cognitively intact, had no behaviors, did not wander, and did not reject care. 3. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, and coronary artery disease. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #21 was cognitively intact, had no behaviors, did not wander, and did not reject care. 4. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia and alcoholic polyneuropathy. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #22 had severely impaired cognition, had no behaviors, did not wander, and did not reject care. Observations made on 03/28/2024 from 12:24 P.M. to 12:34 P.M. revealed Stated tested Nurse Aide (STNA) #119 prepared lunch for Residents #21 and #22. STNA #119 used gloved hands to place slices of pizza onto serving platter after using salad tongs to transfer salad from carryout carton to a porcelain serving dish. STNA #119 handed serving tray and porcelain bowl to STNA #115. STNA #119 did not change gloves or sanitized hands before preparing lunch plate for Resident #13. STNA #119 sliced pizza in the box with a wheeled pizza slicer then used her gloved hands to transfer pizza from the pizza box to plate. STNA #119 scooped a serving of green beans on the plate and covered the plate with foil. STNA #119 went to the pantry and came back with a serving tray. STNA #119 placed the plate and Styrofoam cup on the tray and handed the tray to STNA #115 to deliver to Resident #13. STNA #119 did not change gloves or perform hand hygiene before she began to prepare food for Resident #20. STNA #119 used tongs to transfer salad from the large foil carry-out container to a porcelain serving bowl and covered the bowl with foil. STNA #119 sliced pizza then transferred pizza with her gloved hands from the pizza box to the dinner plate and covered the plate with aluminum foil. During an interview on 03/28/2024 at 12:34 P.M. 12:34 P.M. STNA #119 verified she had not changed her gloves or performed hand hygiene between preparing food plates or touching food items for Resident #13, #20, #21 and #22. STNA #119 stated she was supposed to change her gloves every time. Review of policy titled Hand Hygiene Procedure dated 11/05/2021 revealed hand hygiene occurred before cooking and assisting with meals and after removing personal protective equipment. This deficiency represents non-compliance investigated under Complaint Number OH00151947.

Based on record reviews, staff interviews, and review of facility incident log, the facility failed to ensure residents received adequate supervision to prevent a fall with injury. Actual harm occurred when Resident #24 who was assessed and care planned for two staff assistance for toileting fell and sustained a fracture which required hospitalization and surgical intervention after being left unattended while toileting. This affected one resident (#24) out of the three residents reviewed for falls during the annual survey. The facility census was 57. Findings include: 1. Record review for Resident #24 revealed this resident was admitted to the facility on [DATE] and had diagnoses including difficulty walking, muscle weakness, shortness of breath, and restlessness and agitation. Review of the annual Minimum Data Set (MDS) assessment, dated 01/25/23, revealed this resident was assessed to have moderately impaired cognition. This resident was assessed to require extensive assistance from two staff members for bed mobility, transfers, and toileting. Review of the care plan, initiated 02/01/22, revealed this resident had an Activities of Daily Living (ADL) self-care and/or physical mobility deficit related to weakness. Interventions included extensive assistance from two staff members for toileting and moving between surfaces. Review of the care plan, revised 02/12/23, revealed this resident was at risk for falls. Interventions included Dycem to wheelchair to prevent sliding, anticipate and meet needs, and keep needed items in reach. Review of the facility incident log, dated 04/01/22 through 04/25/23, revealed Resident #24 was documented to have fallen in the facility on 05/19/22, 06/11/22, and 03/24/23. Review of the nurse progress note, dated 03/24/23, revealed Resident #24 had an unwitnessed fall in the bathroom around 10:40 A.M. and was found lying on his right side with his head towards the shower. The resident stated he was trying to ambulate to the shower and lost his balance. The resident was complaining of pain to the right hip. The Nurse Practitioner was notified and provided new orders for an X-ray of the right hip to be performed. Review of the nurse's progress note, dated 03/25/23, revealed X-ray results for Resident #24 came back positive for a closed fracture of the femoral neck of the right hip. The Nurse Practitioner was notified and provided orders for the resident to be sent out to the hospital. Review of the nurse's progress note, dated 03/29/23, revealed Resident #24 returned to the facility after being hospitalized with an admitting diagnosis of closed displaced fracture of right femoral neck. There were orders to leave the Mepilex silver dressing in place to the right hip unless it became saturated. Interview with State tested Nursing Assistant (STNA) #800 on 04/26/23 at 1:40 P.M. revealed she was working on 03/24/23 and had assisted Resident #24 to the restroom prior to giving the resident a shower. STNA #800 stated she realized she had forgotten to get towels and had asked Resident #24 if he could stay put while she went to get towels and Resident #24 stated he would. STNA #800 stated when she returned to the room, Resident #24 was lying on the floor. Interview with STNA #540 and STNA #840 on 04/26/23 at 3:30 P.M. revealed both STNA's worked evening shift at the facility and frequently provided care to Resident #24. They stated prior to Resident #24's fall on 03/24/23, the resident required assistance from two staff members for transfers and toileting due to being weak and unsteady and was not to be left on the toilet unsupervised due to the risk of falling.

Based on record reviews, staff interviews, and review of on line medication guidance, the facility failed to ensure as needed (prn) psychotropic medications were not prescribed for longer than 14 days and failed to ensure psychotropic medications were only used for appropriate indications. This affected five residents (#5, #11, #21, #34, and #39) out of the six residents reviewed for unnecessary medications and hospice services. The facility census was 57. Findings include: 1. Record review for Resident #5 revealed this resident was admitted to the facility on [DATE] and had diagnoses including depression and anxiety. Review of the significant change Minimum Data Set (MDS) assessment, dated 04/01/23, revealed this resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11 out of 15. This resident was assessed to require extensive assistance from two staff members for transfers, bed mobility, and toileting. This resident was assessed to receive hospice services. Review of the active physicians order, dated 03/22/22, revealed this resident had an order for Lorazepam (an anti-anxiety medication) to be administered every four hours prn for anxiety. This order did not contain a stop date. Interview with Registered Nurse (RN) #901 on 04/27/23 at 9:00 A.M. verified Resident #5 had an active order for the prn administration of Lorazepam which did not contain a stop date. 2. Record review for Resident #21 revealed this resident was admitted to the facility on [DATE] and had diagnoses including anxiety disorder and adjustment disorder. Review of the quarterly MDS assessment, dated 03/23/23, revealed this resident had intact cognition evidenced by a BIMS assessment score of 15 out of 15. This resident was assessed to require supervision for bed mobility and transfers and limited assistance from one staff member for toileting. Review of the active physicians order, dated 04/15/23, revealed this resident had an order for Vistaril (an anti-anxiety medication) to be administered every six hours prn for itching. This order did not contain a stop date. Interview with RN #901 on 04/27/23 at 9:00 A.M. verified Resident #21 had an active order for the prn administration of Vistaril which did not contain a stop date. 3. Record review for Resident #34 revealed this resident was admitted to the facility on [DATE] and had diagnoses including dementia, down syndrome, and anxiety. Review of the quarterly MDS assessment, dated 04/14/23, revealed this resident had moderately impaired cognition evidenced by a BIMS assessment score of 02. This resident was assessed to require limited assistance from one staff member for bed mobility, transfers, and toileting. Review of the active physicians order, dated 11/10/22, revealed this resident had an order for Risperidone (an anti-psychotic medication) to be administered every afternoon for agitation related to anxiety. Interview with RN #901 on 04/27/23 at 9:00 A.M. verified Resident #34 had an active order for the administration of Risperidone to treat agitation related to anxiety. Review of the online medication guidance from Drugs.Com titled Risperidone (https://www.drugs.com/risperidone.html), last updated on 02/20/23, revealed the medication Risperidone was used to treat Schizophrenia and symptoms of Bipolar Disorder (manic depression). The guidance contained a warning that Risperidone was not approved for use in older adults with dementia-related psychosis. 33023 4. Record Review of Resident #11 on 04/26/23 at 08:27 A.M. revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: unspecified dementia, osteoarthritis, stress incontinence, Vitamin D deficiency, tremors, anxiety, depression, difficult ambulation, akathisia, and muscle weakness. Review of the MDS assessment completed on 02/28/23 revealed this resident is rarely/never understood. Review of Physician Orders revealed this resident is receiving the following medications: Depakote 250 milligrams (mg) 1 tablet by mouth twice daily for agitation and Risperidone oral solution 1mg/ml give 0.5 ml by mouth three times a day for agitation. Review of current resident diagnoses revealed this resident does not have an active diagnosis of psychosis in the medical chart. Interview with Registered Nurse #901 on 04/26/23 at 11:37 A.M. verified Risperidone and Depakote are to have an actual diagnosis and not just treating a symptom such as agitation. 5. Record Review of Resident #39 on 04/25/23 at 03:24 P.M. revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: chronic kidney disease, atherosclerosis, vascular dementia, congestive heart failure, atrial fibrillation, hypercholesterolemia, hypertension, orthopnea, anxiety, depression, and edema. Review of the MDS assessment completed on 02/21/23 revealed this resident had severe cognitive impairments. Review of Physician Orders revealed this resident is receiving the following medications: Lexapro 10 mg 2 tablet by mouth daily for vascular dementia without behavioral disturbance, mood disorder, anxiety, and psychotic disturbance. Interview with the Registered Nurse #901 on 04/26/23 at 11:41 A.M. verified this resident is receiving an antidepressant for a diagnosis of vascular dementia without behavioral disturbance, mood disorder, anxiety, and psychotic disturbance as written on Physician Orders. She stated this is not an acceptable diagnosis for the use of Lexapro.

Based on record review, observation, resident and staff interviews, and review of the menu, the facility failed to provide food portions as approved by a Registered Dietitian and offer food choices. This affected thirteen residents, (#11,#10,#09,#16,#19,#02,#36,#15,#48,#33,#40,#47, and #216) of 55 residents who received food from the kitchen. The total facility census was 57. Findings Include: 1. Review of the Resident #33 chart revealed Resident #33 admitted to the facility on [DATE] with diagnoses including hemiplegia, anorexia nervosa, gastro- esophageal reflux disease, vitamin D deficiency and iron deficiency anemia. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition and the physician ordered a regular pureed texture with nectar thick liquid diet. Review of the breakfast meal menu on 04/26/23 for House #9 revealed the 04/26/23 breakfast menu posted on the kitchen refrigerator consisting of one doughnut, two eggs, one cup of cereal, four ounces of fruit and six ounces of yogurt. Observation on 04/26/23 at 8:26 A.M. State tested Nurse Aide (STNA) #120 in House #9 kitchen prepared one doughnut and one package of oatmeal for Resident #33. STNA # 120 measured the prepared one package of oatmeal at four ounces. No other items were prepared until the surveyor brought the posted menu to STNA #120's attention. Interview on 04/26/23 at 8:37 A.M. with Diet Technician, (DTR) # 720 verified STNA #120 only prepared the doughnut and cereal until the surveyor brought it to STNA #120 attention. DTR #720 verified the prepared cereal portion measured four ounces instead of the posted menu amount of eight ounces, DTR #720 verified the STNA #120 should have prepared the posted menu for food items and portions , unless the resident preferred an alternate food. Interview on 04/026/23 at 8:48 A.M. STNA #120 verified she did know the menu and food portions was posted on the refrigerator, and did not know eggs, fruit and yogurt were listed in addition to the doughnut and cereal. STNA #120 stated she should have prepared two packages of cereal to reach measurement of eight ounces as listed on the menu. Interview on 04/26/23 at 9:14 A.M. Resident #33 stated she does not like yogurt but likes eggs and fruit in additional to cereal and doughnuts. She denied she had been asked her food preferences for the breakfast meal on 04/026/23. 2. Record review for Residents #10, #16, #36,#15,#48, and #47 revealed physician orders for regular diet. Residents #11 and #02 had physician orders for regular with soft bite sized foods diet. Residents #09 and #19 had physician orders for no added salt diets. Review of lunch menu of House #9, dated 04/26/23, revealed diets of regular, regular with bite sized foods and no added salt diets were to receive six ounces of bean and [NAME] casserole, four ounces of tater tots, four ounces of corn, four ounces of fruit and four ounces of ice cream. Observation on 04/26/23 at 11:57 A.M. revealed STNA #780 served Residents #10, #16, #36, #15, #48, #47, #11, #02, #09 and #19 four ounces of beans and [NAME] casserole, four ounces of tater tots and four ounces of corn. Four ounces of fruit and four ounces of ice cream were not served or offered to the residents. Observation on 04/26/23 at 12:48 P.M. DM #720 measured the beans and [NAME] serving spoon portion and the portion was four ounces. Interview on 04/26/23 at 12:35 P.M. STNA #780 verified she had not followed the portions of beans and [NAME] and food items posted on the menu for resident served regular, soft and bite sized and no added salt diets. She stated she did not see the fruit and ice cream on the menu and had not asked the residents their preferences for fruit and ice cream. No resident had denied fruit or ice cream. Interview on 04/26/23 at 12:48 P.M. DTR #720 verified the bean and [NAME] portion was posted on the refrigerator with portion size of six ounces and fruit and ice cream were listed on the menu. DTR #720 verified STNA #780 served the residents in House #9 a four-ounce portion of beans and [NAME] instead of six ounces. The fruit and ice cream were not served as posted on the menu. 3. Record review of Resident #216 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #216 included dysphagia, malignant carcinoid tumor of rectum, atherosclerotic heart disease, hypertension, and chronic obstructive pulmonary disease. Review of the initial admission assessment dated [DATE] revealed the resident had intact cognition. Physician orders, dated on admission of 04/19/23, revealed orders for Regular soft and bite sized nectar thick liquid texture diet, ice chips, and fluid restriction 1000 milliliters a day. Review of diet listing provided on 04/24/24 at 8:30 A.M., Resident #216 was listed on diet of regular soft and bite sized nectar thick liquid texture diet. There was no listing of 1000 milliliters fluid restriction. Observation on 04/24/23 at 9:15 A.M., the kitchen diet posting dated 04/24/23 revealed Resident #216 had regular soft and bite sized nectar thick liquid texture diet. There was no listing of 1000 milliliters fluid restriction. Interview on 04/26/23 at 9:42 A.M. State tested Nurse Aide (STNA) # 940 revealed she relied on the kitchen diet postings for resident therapeutic diets. She verified on 04/26/23 Resident #216 diet had been changed and posted to include fluid restriction of 1000 milliliter and the amount to be provided by meal service on 04/26/23. Prior to 04/26/23, the therapeutic diet posting did not include a fluid restriction. Interview on 04/26/23 at 2:57 P.M. Registered Dietitian, (RD) # 950 verified Resident #216 was not listed on the kitchen diet therapeutic diet list for 1000 milliliters fluid restriction dated 04/24/23 , but had been updated on 04/26/23 and now included fluid amount divided by meal service and nursing. 33023 4. Record Review of Resident #40 on 04/25/23 at 01:36 P.M. revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: cerebral infarction, hypertension, asthma, hypothyroidism, hyperlipidemia, depression, morbid obesity, anxiety, arthropathy, osteoarthritis, cataracts, and hypertensive heart disease. Review of the MDS assessment completed on 02/07/23 revealed this resident had minimal cognitive impairments. Interview with Resident #40 on 04/24/23 at 12:10 P.M. revealed she is unaware of any meal substitutes being provided with the exception of a peanut butter and jelly sandwich or a grilled cheese sandwich. She stated she has never been provided with a substitution menu if she does not like what is being served. This resident stated this bothers her that those are the only items that she knows of that are available. Interview with Dietary Technician #720 on 04/26/23 at 08:37 A.M. stated that always available foods are not displayed due to the owner not wanting it posted to maintain a homelike environment. She verified there is no posting for residents or staff to know of alternate foods or what else is available. This deficiency represents non compliance investigated under Complaint Number OH00136551.

Based on record review, observation, interview, policy review and review of the National Pressure Injury Advisory Panel (NPIAP) recommendations, the facility failed to ensure one (Resident #31) of three residents reviewed for pressure injuries received adequate care, monitoring, and treatment to prevent the development of a pressure ulcers. This resulted in actual harm when Resident #31 was discovered with an avoidable Stage III wound to the right heel caused by a walking boot. The facility identified three residents with pressure injuries. The census was 48. Findings included: Record review revealed Resident #31 was admitted on [DATE] and a readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of the care plan, dated 04/05/18, revealed the resident had an activities of daily living self-care and /or physical mobility performance deficit. An intervention dated 06/05/20 revealed weight bearing with black boot to right lower extremity only, with boot and assistance of walker with therapy only. Review of the Braden scale for skin risk, dated 09/18/20, revealed Resident #31 was at moderate risk for pressure ulcer development. Review of nutritional assessment dated [DATE] revealed the resident's body mass index (BMI) was 25.2. which indicated he was over weight. He had no significant weight loss in the past 180 days. He ate 75 to 100 percent of his meals. He was receiving oral supplements of Glucerna 237 milliliter's (ml) twice a day and Prostat 30 ml every day. Resident #31 accepted the supplements well. Review of therapy notes dated 11/03/20, 11/05/20, 11/09/20, 11/12/20, 11/13/20 and 11/16/20 revealed Resident #31 participated in therapy with the boot to the right foot and ambulated at least 20 feet. Review of weekly skin sweeps dated 11/05/20, 11/12/20, and 11/19/20 revealed no skin concerns. Review of wound center notes dated 11/11/20 revealed Resident #31 had no wounds and prior wounds were healed. Orders were for skin barrier protectant to heels, reddened areas over bony prominence and areas of foot and apply a [MEDICATION NAME] as prevention over heels if red. Review of physician orders, Treatment Administration Record (TAR) and Medication Administration Record [REDACTED]. Review of physician notes dated 11/15/16 and 11/16/20 revealed Resident #31 had no open wounds. Review of wound center notes dated 11/18/20 for Resident #31 revealed there was a new wound, identified as Wound #13, which was a pressure injury to the calcaneus at a Stage III. The wound measured one centimeter (cm) by two cm x 0.1 cm. There was no tunneling or undermining. There was a medium amount of serosanguinous drainage. There was a medium red granulation within the wound bed. There was a small (1-33 percent) amount of necrotic tissue within the wound bed including adherent slough. The wound was debrided on this visit. Orders were to continue skin barrier protectant to heels and [MEDICATION NAME] and [MEDICATION NAME] as prevention over heels if red daily. The orders further revealed to offload footwear, no physical therapy with the black boot as the heel had a sore due to friction. Review of physician orders, TAR and MAR indicated [REDACTED]. Review of wound notes dated 11/25/20 for Resident #31 revealed the Stage III ulcer on the calcaneus measured 3 cm by 2.5 cm by 0.1 cm. There was no tunneling or undermining. There was a medium amount of serosanguinous drainage. There was small amount (1-33 percent) red, friable granulation within the wound bed. There was a large (67-100 percent) amount of necrotic tissue within the wound bed including adherent slough. The orders were for a total contact cast with a donut around the heel for extra off loading of the right leg. Provide skin protectant to heels and reddened area over bony prominences of the foot. Review of physician notes dated 11/30/21 revealed Resident #31 had developed a wound on the right heel about three weeks ago according to Wound Physician (WP) #200 due to an ill-fitting right lower extremity immobilizer boot. Review of wound documentation dated 12/30/20 for SR revealed his wound to the right calcaneus had declined, and was now a Stage IV pressure injury. The wound measured 4 cm by 3.2 cm by 0.4 cm. There was tendon and fat exposed. There was a medium amount of serosanguinous drainage. There was medium amount (34-66 percent) red, friable granulation within the wound bed. There was a medium (34-66 percent) amount of necrotic tissue within the wound bed including adherent slough and eschar. Review of wound notes dated 03/17/21 revealed his wound on the resident's calcaneus was measured at 3.5 cm by 2.2 cm by 0.5 cm. There was tendon and fat exposed as well as the Achilles tendon. There was a medium amount of serosanguinous drainage. There was medium amount (34-66 percent) red granulation within the wound bed. There was a medium (34-66 percent) amount of necrotic tissue within the wound bed including adherent slough. Interview with the Wound Physician (WP) #131 on 03/18/21 at 3:20 P.M. revealed he has been seeing Resident #31 weekly since 2019. On 11/11/20 all wounds were healed. The resident wanted to be able to ambulate, so there were orders made for physical therapy to work on the ambulation with a black boot. The orders were for not too much for therapy because of muscle tone elasticity. The black boot caused shearing on the right calcaneus and caused a stage III pressure injury. During interview on 03/22/21 at 2:50 P.M., the Administrator revealed she didn't know when the wound was found and didn't know why the wound wouldn't be found with dressing changes being done to other parts of the foot on 11/14/20, 11/15/20, or 11/16/20. She said she had seen pictures of the wound that were provided by the family and didn't know how it could be missed. She verified the treatments weren't completed for the skin prep. Review of the facility policy entitled Skin Management Program dated 11/02/18 revealed it was the policy of the facility to follow all applicable state and federal regulations regarding skin care management. (Reference F686, Guidance to Surveyors for Long Term Care Facilities). 1) Identify individual at risk for development of pressure ulcers and initiate management programs which stabilize or minimize underlying risk factors or changes in conditions. 2) Implement, monitor, and modify if needed appropriate strategies to attain or maintain intact skin; prevent complications; promptly identify and manage complications and involve resident and caregiver in skin care management. 3) Promote the healing of pressure ulcers that are present. 4) Evaluate and manage potential risks for development of additional pressure ulcers including changes in condition. 5) Identify and manage potential for infection. 6) Promote comfort by managing pain associated with pressure ulcers Review of NPIAP website (https://npiap.com/) a Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epiboly (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epiboly (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. This deficiency substantiated Complaint Number OH 228.

Based on record review, staff interview, and policy review, the facility failed to ensure a resident was free from significant medication errors. This resulted in actual harm when Resident #22 was being administered [MEDICATION(S)], a diuretic, at the incorrect dosage. The resident required emergency treatment at a hospital for a low potassium level. This affected one (Resident #22) of the three residents reviewed for diuretics. The facility census was 46. Findings include: Review of the medical record for Resident #22 revealed an original admitted [DATE]. The resident was discharged with return anticipated on 03/20/21 and readmitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of plan of care for Resident #22 revealed resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included administer medications as ordered and monitor for adverse reactions and side effects. Review of the active physician orders dated 03/25/21 revealed the resident was ordered to receive [MEDICATION(S)] 50 milligrams (mg) twice daily, for a total of 100 mg daily, for localized [CONDITION(S)]. Review of the nursing progress notes for Resident #22 dated 04/13/21 revealed the resident's medication was reviewed and a concern was noted with the [MEDICATION(S)] 50 mg twice daily. Nurse Practitioner (NP) #10 was notified. Review of the incident log dated 04/13/21 revealed Resident #22 was recorded on the log reference to medications being reviewed and a concern was noted with [MEDICATION(S)] and NP #10 was notified. Nursing notes dated 04/14/21 revealed the resident's family returned Resident #22 from an outside appointment and had concerns about the medication list that the facility had versus the what the cardiologist's office had. NP #10 was notified and was sent the cardiology list and stated she would follow up with the Director of Nursing (DON) about the concerns. On 04/16/21, NP #10 ordered [MEDICATION(S)] 50 mg daily for [CONDITION(S)], but never discontinued the order from 03/25/21 for [MEDICATION(S)] 50 mg twice daily. On 05/02/21, Physician #11 ordered [MEDICATION(S)] 50 mg twice daily for [CONDITION(S)]. Again, the orders for [MEDICATION(S)] from 03/25/21 and 04/16/21 were not discontinued. Review of the medication administration records revealed from 04/16/21 through 05/02/21, the resident received [MEDICATION(S)] 150 mg daily, not the 100 mg per day that was ordered. Nursing notes dated 05/05/21 at 1:00 P.M. indicated Licensed Practical Nurse (LPN) #35 received a call from the facility's therapy department that the resident's oxygen saturation and heart rate were erratic. LPN #35 received a call from the laboratory which reported resident had a critical potassium level of 2.6 millimoles per liter (mmol/L); the normal is 3.5 to 5.3 mmol/L. NP #10 was consulted and ordered Resident #22 to be transported to the emergency room (ER) via 911. Nursing progress notes dated 05/05/21 at 7:48 P.M. by LPN #35 revealed Resident #22 returned from the ER with no new orders. The nurse filed the after visit summary in the resident's chart. Review of laboratory results for Resident #22 dated 05/05/21 revealed the resident had a potassium level of 2.6 mmol/L. Review of hospital ER notes for Resident #22, dated 05/05/21, revealed the resident was seen for abnormal laboratory results and diagnosed with [CONDITION(S)] (low potassium) and [CONDITION(S)] (low magnesium). The resident was discharged from the hospital with orders for [MEDICATION(S)] 50 mg twice daily and ordered to consult the physician for medications. Review of the medication administration records from 05/02/21 through 05/06/21 revealed the resident received [MEDICATION(S)] 250 mg daily. She should have been receiving only 100 mg daily per the ER orders dated 05/05/21. During an interview on 05/06/21 at 4:15 P.M., the Administrator and Regional Support Nurse #1 verified Resident #22 had three different active orders for [MEDICATION(S)] on file. Regional Support Nurse #1 stated she was not sure which order was the correct order, but she would have NP #10 reconcile the resident's medications. Regional Support Nurse #1 also verified Resident #22 was being administered the [MEDICATION(S)] at the wrong dose, as staff were implementing all three active orders. During an interview on 05/07/21 at 9:00 A.M., NP #10 stated she was called by facility on 05/06/21 to reconcile Resident #22's medications for discrepancies after surveyor intervention. NP #10 stated she reconciled Resident #22's medications on 05/07/21 and discovered resident was ordered and was being administered three different active orders for [MEDICATION(S)]. NP #10 verified Resident #22 should have only been on [MEDICATION(S)] 50 mg twice daily and she discontinued two of the active orders for [MEDICATION(S)]. NP #10 stated there were several orders for [MEDICATION(S)] ordered by her and the facility physician and something got messed up. NP #10 stated a nurse notified her on 05/05/21 that Resident #22 had shortness of breath (SOB), palpitations and anxiety and wanted to send resident to the ER. NP #10 stated she ordered resident to be transported to the ER. NP #10 stated the critical potassium level and other symptoms was a result of the medication error. Review of the facility policy titled Medication Administration Policy, dated 11/21/17, revealed medications will be administered to residents as prescribed in a manner consistent with good infection control and standards of practice. Review of the facility policy titled Medication Error Policy, dated 11/20/17, revealed nurses must adhere to the rights of medication administration by identifying resident, right medication, right dose right time, right route, and right documentation. The term medication error refers to a mistake that occurs during the medication administration process. When a mistake occurs, it's considered an error regardless of whether a resident was harmed. A medication error that doesn't cause resident harm is referred to as a potential adverse drug event (ADE) because the error was averted by the actions of the resident or clinician before the resident was affected. A potential ADE is also referred to as a near miss or close call. This is a new deficiency discovered during the post survey revisit.