Every finding on record at Saint Joseph Care Center

Based on observation, medical record review, staff and representative interview, and facility policy review, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to ensure monitoring and assessments were completed timely and appropriately for pressure ulcers and wound care was completed as ordered. This affected two residents (#5 and #61) of three reviewed for pressure wounds. The facility census was 57. Actual Harm occurred beginning on 11/04/25 to Resident #5, who was cognitively impaired, at risk for pressure ulcer development and required staff assistance for activities of daily living care, when the resident was identified to have moisture associated skin damage (MASD) to the coccyx that went unassessed and unmonitored resulting in a decline of the wound. On 12/29/25 the skin impairment was assessed by Wound Nurse Practitioner (NP) #201 to be a Stage III (a wound characterized by full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) pressure ulcer/wound measuring 1.5 centimeters (cm) length by 0.6 cm width by 0.3 cm depth. The facility failed to ensure individualized and comprehensive interventions were in place to prevent the decline in the resident's skin and identification of a Stage III pressure ulcer. Findings include:1. Review of the medical record for Resident #5 revealed an admission date of 11/06/15 with diagnoses that included Alzheimer's disease, diabetes mellitus, idiopathic progressive neuropathy, venous insufficiency, obesity due to excess calories, generalized muscle weakness, oropharyngeal phase dysphagia, and anxiety disorder. Resident #5 received hospice services effective 06/12/25 for end stage Alzheimer's disease. Review of the physician's orders dated 05/10/18 revealed orders for pressure reducing cushion to wheelchair, encourage frequent positioning, and float heels while in bed as tolerated. Review of the plan of care revised 06/29/18 revealed Resident #5 was at risk for pressure wounds. Interventions included apply house barrier cream as directed, offer to lay down after meals, use bariatric mattress, change position at least every two hours, check body with daily care, notify physician of any changes in skin integrity, encourage good oral intake, float heels while in bed, do not use briefs while resident in bed, and provide hygiene care every shift and as needed. Review of the physician's order dated 02/11/20 revealed an order to lay Resident #5 down in bed after meals for skin integrity. Review of the physician's order dated 03/11/22 revealed an order to complete a body assessment once weekly to observe for skin integrity and notify physician of any changes. Review of the care plan revised on 03/30/22 revealed Resident #5 had activities of daily living (ADL) self-care performance deficit. Interventions included utilizing Hoyer lift for transfers with two staff assist, lay resident down after meals, offering nail care on shower days, do not use briefs while resident in bed, and use custom tilt wheelchair. Review of the care plan revised on 02/05/25 revealed Resident #5 was at risk for impaired skin integrity. Interventions included educate on importance of keeping skin clean and moisturized, evaluating skin for areas of blanching or redness, keep skin clean and well lubricated, and provide skin care per facility guidelines. Review of the physician's order dated 03/21/25 revealed order for Chamosyn ointment (multi-purpose skin protectant ointment) with routine care to sacrum for moisture-associated skin damage (MASD). Review of the Braden Scale assessment dated [DATE] revealed Resident #5 was at high risk for developing pressure ulcers. Review of the Braden Scale assessment dated [DATE] revealed Resident #5 was at moderate risk for developing pressure ulcers. Review of the Braden Scale assessment dated [DATE] revealed Resident #5 was at moderate risk for developing pressure ulcers. Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #5 had Brief Interview for Mental Status (BIMS) score of 01 indicating severe cognitive impairment. Resident #5 was dependent on staff for all ADLs including bathing, bed mobility, transfers, and ambulation. Resident #5 was always incontinent of bowel and bladder. Resident #5 was at risk for developing pressure ulcers. Review of the physician's order dated 11/04/25 revealed order to cleanse open area to coccyx with normal saline (NS), pat dry, apply triad paste and cover with foam dressing daily and as needed (PRN). This order was discontinued on 12/23/25. (Please note, the facility Wound Registered Nurse (RN) #193 described the area as MASD on 11/04/25 when it was initially found however the order entered was described as an open area. There was no initial assessment to verify if the area was open or MASD.) Further review of the medical record revealed no evidence of an initial assessment to address the open area to coccyx and treatment order dated 11/04/25. There was no evidence of wound measurements being identified. Review of physician's progress note dated 11/05/25 revealed a follow up appointment for chronic medical conditions. It was noted Resident #5 had a treatment for an open area on coccyx. There was no evidence of any evaluation of the wound. Review of the nursing progress note dated 11/07/25 authored by Wound Registered Nurse (RN) #193 revealed Resident #5's coccyx wound was again moist and pink. The note included there was scant drainage from wound. Noted previous good results with triad paste and foam dressing. Plan to continue with Triad paste and foam dressing. Review of hospice interdisciplinary group (IDG) meeting notes dated 11/19/25 revealed the facility wound nurse reported a Stage II pressure wound (defined as partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) to the coccyx. The facility wound nurse reported the area comes and goes. Wound supplies were offered; however, the facility declined. Review of Resident #5's Treatment Administration Record (TAR) for November 2025 revealed skin integrity checks were completed on 11/03/25, 11/10/25, 11/17/25, 11/24/25 with no evidence of any identified findings (open areas). Review of the TAR for November 2025 revealed triad paste and dressing were applied as ordered. Review of the Braden Scale assessment dated [DATE] revealed Resident #5 was at high risk for developing pressure ulcers. Review of Resident #5's physician's progress note dated 12/03/25 revealed a follow up appointment for chronic medical conditions. It was noted Resident #5 had an ongoing treatment to open area on coccyx. There was no evidence of any evaluation of the wound. Review of the physician's order dated 12/23/25 revealed order to cleanse open area to coccyx with normal saline (NS), pat dry, apply calcium alginate and cover with foam dressing daily and PRN (as needed). Review of plan of care progress note dated 12/23/25 revealed a care conference was held with Resident #5's daughter/power of attorney (POA). It was noted Resident #5 had a wound on the coccyx and was being treated and monitored. Review of TAR for December 2025 revealed skin integrity checks were completed on 12/01/25, 12/08/25, 12/15/25, 12/22/25, and 12/29/25 with no evidence documented of any identified findings. Review of the TAR from 12/01/25 to 12/23/25 revealed triad paste and dressing were applied as ordered. The order for triad paste and dressing was discontinued on 12/23/25. Further review of the medical record revealed no evidence of assessment or monitoring of the wound including size, stage, location, or progress from 11/04/25 until 12/29/25. Review of wound care note by Wound NP #201 dated 12/29/25 revealed Resident #5 was seen for an initial consultation of a wound. Nursing reported a gradual decline of the pressure wound to Resident #5's coccyx which originally presented as a Stage II pressure wound. Wound NP #201 evaluated the wound and identified the area as an in-house acquired Stage III pressure ulcer to the coccyx measuring 1.5 cm length by 0.6 cm width by 0.3 cm depth with moderate exudate. There was noted to be pink granulating tissue across the wound bed. Wound NP #201 noted the resident had poor nutritional intake, incontinence, overall poor medical condition, poor compliance with offloading, and hospice status. However, there was no evidence to support the resident's poor compliance with off- loading and the resident was dependent on staff to manage her incontinence. On 12/30/25 at 8:55 A.M. Wound RN #193 was observed providing treatment to Resident #5's coccyx wound. The wound appeared as described in the previous assessment note. Resident #5 was noted to have cognitive impairment and was not interviewable. Interview on 12/30/25 at 9:10 A.M. with Wound RN #193 revealed Resident #5 had history of redness to her coccyx. Wound RN #193 reported generally they would treat the area for a couple weeks then it would heal up. Wound RN #193 stated Resident #5's wound did not quite heal like expected this time. Wound RN #193 reported she first noted the area to Resident #5's coccyx on 11/07/25 and reported it was an area of MASD. Wound RN #193 stated Wound NP #201 did the initial evaluation of the area on 12/29/25 and noted the area to be a Stage III pressure wound. Wound RN #193 confirmed she had no additional assessments of the coccyx wound between 11/07/25 and 12/29/25. Telephone interview on 12/30/25 at 12:41 P.M. with Hospice RN #205 revealed the facility had a wound team that managed wounds. Hospice RN #205 reported they did not always get updates on wounds for their hospice patients. Hospice RN #205 revealed the visit notes on 11/26/25 revealed Resident #5 had a red area on the resident's backside. Telephone interview on 12/30/25 at 1:05 P.M. with Physician #204 revealed he could not recall if Resident #5 had any open areas and the facility had a wound team who handled the wounds. Physician #204 revealed he would expect that a resident with a wound would be seen on a weekly basis by the wound team. Telephone interview on 12/30/25 at 1:59 P.M. with Wound NP #201 revealed Resident #5's coccyx pressure wound was discovered during incontinence care and was initially a Stage II pressure wound when discovered (Wound NP #201 was unsure when exactly Resident #5's coccyx pressure ulcer was first discovered). Wound NP #201 stated she was notified the wound was discovered last week by Wound RN #193. Wound NP #201 then indicated she was unsure when the wound was initially discovered. Wound NP #201 reported the wound looked like it had declined since the initial discovery (reported as a Stage II pressure wound) and there was granulating tissue in the wound. Wound NP #201 revealed Resident #5's skin integrity was iffy, and the resident had dual incontinence (which contributed to the breakdown). Interview on 12/31/25 at 8:18 A.M. with Certified Nursing Assistant (CNA) #118 revealed Resident #5 had a wound on her coccyx. CNA #118 indicated the nurse managed the dressing changes however CNAs would help to turn residents during wound care. CNA #118 reported Resident #5 was incontinent and was to be checked approximately every two hours. CNA #118 revealed Resident #5 was dependent on staff for all ADL care. Interview on 12/31/25 at 8:22 A.M. with RN Unit Manager (UM) #80 revealed Resident #5 had a wound on her coccyx. RN UM #80 reported Resident #5 was to be checked and changed about every two hours; however, at times she needed more frequent checks. RN UM #80 indicated staff alternated Resident #5 between the bed and her wheelchair. RN UM #80 reported Resident #5 required total assistance from staff for ADL care. Interview on 12/31/25 at 8:28 A.M. with CNA #91 revealed Resident #5 was incontinent of bowel and bladder. CNA #91 indicated Resident #5 was a heavy wetter and needed care approximately every two hours. CNA #91 indicated Resident #5 needed two staff assistance for most ADLs. CNA #91 reported she had never seen Resident #5's coccyx wound as it was covered with a dressing. A follow-up interview on 12/31/25 at 10:43 A.M. with Wound RN #193 revealed when Resident #5's wound was looking worse she called Wound NP #201 for the initial evaluation. Wound RN #193 stated she was unsure when Resident #5's pressure ulcer had worsened and in what way it had worsened. Telephone interview on 12/31/25 at 12:40 P.M. with Resident #5's POA revealed she was aware Resident #5 had a wound on her bottom. POA stated she worried about the wound and wanted to make sure the facility kept up with the wound care and keeping the resident clean and dry. Review of the facility policy Prevention of Pressure Ulcers dated September 2013 revealed the facility should have a system to assure assessments were completed timely and appropriately, changes in condition were recognized, evaluated and reported to the practitioner/physician/family, and wounds were addressed. It was noted if pressure ulcers were not treated when discovered, they quickly get larger, become very painful and often times can become infected. Review of the facility policy Pressure Ulcers/Skin Breakdown – Clinical Protocol dated March 2014 revealed nursing staff would describe, document, and report the following a full assessment (described as the location, stage, size, and presence of exudate or necrotic tissue) of the pressure wound, pain, mobility status, current treatments, and active diagnoses. During physician visits the resident would be evaluated and the progress of wound healing would be documented. Review of facility policy Pressure Ulcer Treatment dated September 2013 revealed wound information including appearance, size, drainage, and any evidence of pain or discomfort should be documented in the resident's medical record. 2. Review of Resident #61's medical record revealed the resident was admitted on [DATE] with diagnoses including nondisplaced bimalleolar fracture of the left lower leg, fibromyalgia and depression. Review of Resident #61's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #61's pressure wound care plans revealed to apply skin prep daily and leave open to air every day-shift. Review of Resident #61's Wound Care progress note dated 12/22/25 at 10:15 A.M. revealed the resident had an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) related to the cast/orthopedic brace to the left heel. The pressure ulcer measured 1.8 cm length by 1.5 cm width by undetermined depth with 100% eschar. The treatment orders included cleanse with normal saline, apply skin prep and leave open to air. Observation on 12/30/25 at 8:48 A.M. with Registered Nurse (RN) Wound Nurse #193 revealed she washed her hands, applied gloves and applied skin prep to the left heel. RN Wound Nurse #193 did not cleanse the left heel first with normal saline and was not wearing protective isolation gown while completing the resident's wound care. Interview on 12/30/25 at 8:54 A.M. with RN Wound Nurse #193 confirmed she did not wear a protective isolation gown while completing the wound care to the resident's left heel and she confirmed the resident was not placed in enhanced barrier precautions as required. RN Wound Nurse #193 also confirmed she did not cleanse the resident's left heel prior to applying the skin prep because she stated the skin prep would not stick. Review of the Pressure Ulcers/Skin Breakdown policy revised 03/2014 revealed the physician would authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressing and application of topical agents if indicated for the type of skin alteration.

Based on observation, staff interview, and policy review, the facility failed to maintain a clean and sanitary dumpster area. This had the potential to affect all residents residing in the facility. The facility census was 57.Findings include:Observation on 12/29/25 at 8:26 A.M. with Dietary Manager (DM) #74 revealed significant unbagged debris mostly consisting of used gloves surrounding the dumpster. There were also various furniture items and housewares piled up along the fence surrounding the dumpster. Interview on 12/29/25 at 8:28 A.M. with Dietary Manager #74 confirmed the area was not kept clean and free of debris. Review of the facility policy Waste Disposal (undated) revealed trash bags would be sealed prior to removing them from the facility. Trash would be deposited into a sealed container outside the premises.

Based on review of the CASPER Report 1705D (Staffing Report) for quarter three of fiscal year 2025 ([DATE]- [DATE]), review of facility nursing schedules, facility daily staffing report postings, and interview with staff, the facility failed to ensure eight consecutive hours of registered nursing coverage per day. This had the potential to affect all residents residing in the facility. The facility census was 57. Findings include:Review on [DATE] of the Centers for Medicare and Medicaid (CMS) CASPER Report 1705D for quarter three of fiscal year 2025 ([DATE]- [DATE]) revealed no Registered Nurse (RN) coverage for more than eight consecutive hours on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].Review on [DATE] of the facility daily nursing schedules revealed no RN assigned/scheduled or present working on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Further review revealed all the infraction dates were on a Saturday or Sunday.Review on [DATE] of the facility's required daily staffing report postings revealed no RN coverage on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].Interview on [DATE] at 10:56 A.M. with the Facility Scheduler (FS) #131 verified no RNs were scheduled or could show evidence of RNs working in facility for 8 or more consecutive hours on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].Interview on [DATE] at 11:04 A.M. with the facility's Human Resource Manager (HR) #197, who over sees scheduling, revealed the facility had an RN on a leave of absence in May and June of 2025. HR #197 further reported she was unaware at the time of the RN coverage requirement for eight consecutive hours per day and that when the facility became aware of this in July of 2025, they immediately remedied the situation. HR #197 further identified that the facility has hired some new RN's as well as scheduling RNs in management on a weekend rotation until staffing levels meet the 8-hour daily RN coverage.Interview on [DATE] at 11:30 A.M. with the facility Administrator revealed she was aware of the RN requirement for 8 consecutive hours per day not being followed in May and June of 2025 and once the facility became aware of the concern, they immediately began scheduling RN management on a weekend rotation until new RN's could be hired to meet this requirement.

Based on observation, staff interview, and facility policy review, the facility failed to ensure residents receiving puree diet were served the appropriate portion size and complete menu items. This affected five residents (#5, #6, #8, #9, and #11) of five identified as receiving a puree diets. The facility census was 57. Findings include:Observation on 12/30/25 at 11:00 A.M. with [NAME] #70 revealed the puree ham, green beans, and potato casserole (main menu) were served with a number 10 scoop with an ivory handle (approximately three to four ounces) and the puree Sheppard's pie (alternate menu) was served with a number 10 scoop with an ivory handle. [NAME] #70 confirmed her scoop sizes for the lunch service. Observation on 12/30/25 from 11:13 A.M. to 12:05 P.M. revealed there was no puree bread served to Residents #5, #6, #8, #9, and #11. Interview on 12/30/25 at 12:06 P.M. with [NAME] #70 confirmed she had not served puree bread and there was not puree bread available on the steamtable to serve. Review of the facility menu revealed lunch on 12/30/25 was ham, green beans, and potato casserole with choice of roll, and frosted chocolate cake. A puree diet would consist of the pureed casserole, pureed bread, and pureed cake. The alternate was beef Sheppard's pie and mashed potatoes. Review of the diet spreadsheet for lunch on 12/30/25 revealed the puree ham, green beans, and potato casserole serving size was an eight-ounce ladle and the puree beef Sheppard's pie serving size was a number six scoop (approximately five to six ounces). Interview on 12/30/25 at 12:20 P.M. with Dietary Manager #74 confirmed the portion sizes for puree main menu and alternative menu served at the lunch meal were inadequate and puree bread was not served. Review of the facility policy Portion Control undated revealed portions that were too small result in the individual not receiving the nutrients needed. Menus should be posted on tray line so dietary staff could refer to the proper portion sizes for each diet type. Dietary staff would receive training and oversight to assure appropriate portion sizes were followed.

Based on review of medical records, review of facility policies, self-reported incident review, and resident and staff interviews, the facility failed to investigate and self-report an alleged incident of verbal abuse. This affected one (#3) of one residents reviewed for abuse. The facility census was 57.Findings include:Review of the medical record of Resident #3 revealed admission to facility on 09/18/20 with diagnoses of Parkinson's disease (progressive disease affecting balance and fine motor skills), depression, atrial fibrillation (irregular heart rate), anxiety, post-traumatic stress disorder, high blood pressure, and chronic constipation.Review of Resident #3's most recent quarterly minimum data set (MDS) assessment completed on 09/25/25 revealed a brief interview for mental status score of 7 out of 15 indicating moderate cognitive impairment and a depression score of 12 indicating moderate depression. No hallucinations or delusional behaviors noted. Resident #3 required substantial assistance with bathing, transferring, and mobility. Further review revealed Resident #3 required a maximum of two persons to assist with toileting and transfer from bed to wheelchair.Review of Resident #3's treatment administration record (TAR) for October 2025 revealed on 10/26/25 a new treatment was added for the 7:00 P.M. to 7:00 A.M. shift that Resident #3 was not to have male staff providing personal care assistance.Review of the State of Ohio self reported incident (SRI) tracking software on 12/30/25 revealed no evidence of a facility SRI of verbal abuse associated with Resident #3. Interview on 12/30/25 at 3:25 P.M. with Resident #3 revealed she did not feel safe around a particular staff member who was a black male who had worked at the facility for a few months, identified as certified nurse aide (CNA) #118. Resident #3 revealed that CNA #118 had verbally insulted her and called her a liar. Resident #3 further reported that she did not trust CNA #118 nor feel safe with him providing care and she was concerned CNA #118 would take her belongings or harm her. Resident #3 reported that this incident had happened a couple months back and the facility was made aware, but they think he is great and did not fire him. Resident #3 confirmed that CNA #118 has not been providing her care recently but that CNA #118 still worked at the facility.Interview on 12/31/25 at 10:08 A.M. with CNA #118 revealed he had not provided care to Resident #3 for a couple of months since she had made some allegations of verbal abuse against him. CNA #118 reported that he self-reported to the nurse on duty a couple of months ago that he heard from other staff that Resident #3 was reporting he was calling her a liar and accusing him of taking belongs. CNA #118 reported he was told by the nurse on duty that he (CNA #118) does not provide care to Resident #3 anymore. CNA #118 reported that if he was assigned the 600 hallway in which Resident #3 resided, he would switch off with a female team member for that room. CNA #118 assists in two person transfers with the presence of another female aide. Interview on 12/31/25 at 11:50 A.M. with the facility Administrator revealed she had not ever completed an SRI related to verbal abuse for Resident #3. The Administrator further reported that she was aware that Resident #3 did not like male caregivers and they had stopped allowing male caregivers to provide care to Resident #3 for a couple of months. Further interview revealed the Administrator was aware Resident #3 did not like CNA #118 and she attributed this to Resident #3 never being married, a retired teacher, and possibly having bias about male caregivers.Review of facility policy on Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property (revised 10/22) revealed the Administrator is responsible for reporting any alleged violations of abuse to the Ohio Department of Health within 24 hours of knowledge of the incident and complete a full investigation no later than five days from the report with documented details and conclusion related to the allegations.

Based on observation, record review, and interview, the facility failed to honor resident food preferences. This affected two residents (#17 and #43) of three residents reviewed for nutrition. Findings include:1. Review of Resident #17's medical record revealed the resident was initially admitted on [DATE] with diagnoses including chronic pulmonary edema, congestive heart failure, and muscle weakness. Review of Resident #17's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #17's nutrition care plan revealed an intervention dated 12/11/25 to provide substitutions for any food/fluid dislikes. Review of Resident #17's physician orders revealed an order dated 12/15/25 for four ounces of a nutritional supplement twice a day for decreased meal intake. Observation on 12/30/25 at 7:52 A.M. of Resident #17 revealed she received breakfast. She received milk, juice, orange juice, and water on tray with eggs and toast. A Certified Nursing Assistant (CNA) brought the resident ginger ale. Review of the current day's menu on 12/30/25 at 7:54 A.M. revealed a choice of cereal, cheese scrambled eggs, and toast. Interview on 12/30/25 at 7:59 A.M. with Resident #17 revealed she would eat cold cereal but not hot cereal. She indicated at times she was tired of eggs but today they were fine. Resident #17 reported she did not like cheese on her eggs. Interview 12/30/25 at 8:05 A.M. with Licensed Practical Nurse (LPN) #90 revealed everyone gets the same breakfast daily. LPN #90 confirmed she was going to get Resident #17 cold cereal since there was none on her tray. LPN #90 reported Resident #17 declined cereal when she was asked when she received her breakfast tray. Review of the Meal Identification and Preference Card Policy, undated, revealed a meal identification and food preferences card will be used properly identify each individual's needs including food and beverage preferences. 2. Review of Resident #43's medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including depression, Alzheimer's disease and weakness. Review of Resident #43's physician orders revealed orders dated 11/26/25 for a regular diet, mechanical soft texture with a thin consistency and a four ounce high calorie supplement. Review of Resident #43's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderate cognitive impairment. Resident #43 was not able to answer questions appropriately. Review of Resident #43's nutrition care plan revealed an intervention dated 12/05/25 for the diet as ordered which included a regular diet, mechanical soft texture with thin liquids. Review of Resident #43's dinner meal ticket revealed a baked potato with butter only, chocolate pudding, grilled cheese and a chocolate mighty shake (nutritional shake). Review of Resident #43's meal ticket for breakfast 12/30/25 revealed beverages included eight ounces of 2% milk, four ounces of orange juice, eight ounces of water and the resident's preferences included four ounces of chocolate supplement with meals. Interview on 12/29/25 at 4:42 P.M. with Registered Dietitian (RD) #202 revealed the resident's daughter filled out the menus and the resident received a supplement with each meal. RD #202 confirmed the resident liked the chocolate flavored supplement and accepted the supplement at 100%. Observation on 12/29/25 at 5:00 P.M. revealed Resident #43's dinner tray consisted of grilled cheese, a cut up baked potato, orange juice, strawberry gelatin and two cookies. The resident did not have a mighty/nutritional shake on her tray and the chocolate pudding was missing from the tray. Interview on 12/29/25 at 5:05 P.M. with RD #202 confirmed Resident #43's meal tray did not have the chocolate pudding per the resident's preferences and daughter's request. Observation on 12/30/25 at 7:33 A.M. revealed Resident #43's meal tray consisted of oatmeal with brown sugar, scrambled eggs, toast and vanilla mighty/nutritional shake (not chocolate per preference). Interview on 12/30/25 at 7:45 A.M. with Speech Therapist (ST) #203 confirmed Resident #43 was supposed to have a chocolate mighty shake and she was served a vanilla mighty shake. Interview on 12/30/25 at 7:58 A.M. with Dietary Manager (DM) #74 confirmed Resident #43's preferences included four ounces of chocolate supplement with meals and chocolate pudding and the resident did not receive the chocolate supplement because the facility was out of chocolate mighty shakes. She added chocolate syrup to the mighty shake and stated the kitchen staff should have added chocolate syrup per the resident's preferences. Observation on 12/30/25 at 11:13 A.M. of facility lunch meal service revealed Resident #43's lunch tray had a strawberry flavored nutritional supplement delivered on her tray. Review of the tray ticket specified chocolate flavor was preferred for nutritional supplement. It was later observed DM #74 returned to the kitchen for a vanilla flavored nutritional supplement for Resident #43 that she added chocolate syrup to. Interview on 12/30/25 at 11:15 A.M. with DM #74 revealed the facility ran out of chocolate flavored nutritional shakes; however, had gotten them on the food delivery truck that day. DM #74 indicated the chocolate flavored supplements were still frozen that were delivered today. DM #74 indicated she would have expected the staff to honor the preference and add chocolate syrup to the vanilla supplement.

Based on observation, record review, and interviews the facility failed to ensure a resident had interventions in place for monitoring of congestive heart failure. This affected one resident (#17) of one resident reviewed for congestive heart failure (CHF). Findings include: Review of Resident #17's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic pulmonary edema and chronic CHF.Review of Resident #17's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had debility and cardiorespiratory conditions that included chronic pulmonary edema and heart failure.Review of Resident #17's care plan for nutrition/hydration related to CHF and pulmonary edema revealed an intervention dated 12/15/25 for daily weights as ordered for CHF monitoring. Review of Resident #17's physician orders revealed an order dated 12/13/25 for daily weights due to CHF.Review of Resident #17's weights from 12/13/25 to 12/30/25 revealed Resident #17 was missing daily weights on 12/16/25, 12/22/25, and 12/26/25.Review of Resident #17's progress note dated 12/28/25 revealed Resident #17 complained of shortness of breath. Resident's oxygen level was 87% on room air. The left upper lung was noted to have audible crackles and wheezing noted in the right upper lung. Resident #17 was placed on two liters of oxygen and breathing treatment administered.Review of Resident #17's progress note dated 12/28/25 revealed the resident was ordered a one-time dose of potassium, a one-time dose of Lasix, labs, and a chest x-ray.Interview on 12/30/25 at 1:38 P.M. with the Director of Nursing (DON) confirmed Resident #17 had daily weights missing and she would discuss the need for weights to be completed with the staff. Review of the policy weighing and measuring the resident, dated March 2011, revealed the purposes of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident. Report information in accordance with facility policy and professional standards of practice.

Based on observation, record review, and interviews the facility failed to ensure residents had accurate care plans. This affected two residents (#10 and #45) of 22 residents reviewed for accurate care planning.Findings include:1. Review of Resident #45's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including muscle weakness, history of falling, and acquired absence of the right leg below the knee.Review of Resident #45's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of Resident #45's fall care plans revealed an intervention dated 11/10/25 for dycem to the recliner for safety. The care plans did not reflect the dycem to the wheelchair.Review of Resident #45's physician orders revealed an order dated 11/10/25 for dycem to the wheelchair; and an order dated 12/24/25 for dycem to the recliner. No directions were specified for the order.Interview on 12/29/25 at 4:15 P.M. with Resident #45 confirmed he did not like the dycem non-slip mat to the wheelchair or recliner and had staff remove it.Interview on 12/30/25 at 9:19 A.M. with the Director of Nursing (DON) revealed Resident #45 should have dycem in his recliner as that was a fall intervention. She stated she was unaware it was removed and she would address the intervention. Interview on 12/31/25 at 10:43 A.M. with the DON revealed Resident #45 was talked to and he did not want the dycem in place and it should have been removed from the physician orders and care plan. Review of fall policy, dated March 2018, revealed the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.2. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of unspecified displaced fracture of left humerus, need for assistance with personal care, muscle weakness, and polyarthritis.Review of Resident #10's admission MDS 3.0 assessment dated [DATE] revealed Resident #10 had no pressure areas but currently at risk for skin impairments. Resident #10 needed partial/moderate assistance with rolling left to right, sit to lying, and lying to sitting on the side of bed.Review of Resident #10's wound note, dated 12/08/25, revealed she had a Stage 2 pressure area to her left and right buttock.Review of Resident #10's physician order, dated 12/22/25, revealed to cleanse the wound with normal saline, apply collagen to open areas, and cover with a foam dressing daily and as needed.Review of Resident #10's skin care plan revealed she was at risk for skin impairment, but no actual skin impairment care plan was in place.Interview on 12/29/25 at 10:20 A.M. with Resident #10 revealed she's had wounds to her buttock for a long time and concerned they haven't healed. She stated the staff changed the dressings daily and assisted her as needed due to her left shoulder fracture.Interview on 12/30/25 at 3:19 P.M. with Registered Nurse (RN) #193 revealed Resident #10 had a remaining wound to her left buttock but her right buttock was healed. RN #193 revealed a Certified Nursing Assistant (CNA) found the open areas to Resident #10's buttock on 12/08/25 possibly during a shower. That same day the wound nurse practitioner assessed the wounds and ordered Triad cream and a foam dressing to be applied daily. The current treatment was to apply collagen and a foam dressing daily. RN #193 confirmed Resident #10 did not have an actual skin impairment care plan, she only had an at risk for skin impairment care plan.Review of the Care Plan Policy, dated 2011, revealed the plan of care included instructions needed to provide effective, person-center care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the residents. The care plan was updated as needed.

Based on review of medical records, facility policy review, self-reported incident review, and resident and staff interviews, the facility failed to investigate an alleged incident of staff to resident verbal abuse. This affected one (#3) of one resident reviewed for abuse. The facility census was 57.Findings Include: Review of the medical record of Resident #3 revealed admission to facility on 09/18/20 with diagnoses of Parkinson's disease (progressive disease affecting balance and fine motor skills), depression, atrial fibrillation (irregular heart rate), anxiety, post-traumatic stress disorder, high blood pressure, and chronic constipation. Review of Resident #3's most recent quarterly minimum data set (MDS) assessment completed on 09/25/25 revealed a brief interview for mental status score of 7 out of 15 indicating moderate cognitive impairment and a depression score of 12 indicating moderate depression. No hallucinations or delusional behaviors noted. Resident #3 required substantial assistance with bathing, transferring, and mobility. Further review revealed Resident #3 required a maximum of two persons to assist with toileting and transfer from bed to wheelchair.Review of Resident #3's treatment administration record (TAR) for October 2025 revealed on 10/26/25 a new treatment was added for the 7:00 P.M. shift that Resident #3 was not to have male staff providing personal care assistance. Review of Resident #3's current care plan and Kardex revealed no care plans or task reflecting resident preference for no male care givers. Review of the State of Ohio self-reported incident (SRI) tracking software on 12/30/25 revealed no evidence of a facility self-reported incident (SRI) of verbal abuse associated with Resident #03. Interview on 12/30/25 at 3:25 P.M. with Resident #3 revealed she did not feel safe around a particular staff member who was a black male who had worked at the facility for a few months (identified as certified nurse aide (CAN) #118). Resident #3 revealed that CNA #118 had verbally insulted her and called her a liar. Resident #3 further reported that she did not trust CNA #118 nor feel safe with him providing care and she was concerned CNA #118 would take her belongings or harm her. Resident #3 reported that this incident had happened a couple months back and the facility was made aware, but they think he is a great and did not fire him. Resident #3 confirmed that CNA #118 has not been providing her care recently, but that CNA #118 still worked at the facility.Interview on 12/31/25 at 10:08 A.M. with CNA #118 revealed he had not provided care to Resident #3 for a couple of months since she had made some allegations of verbal abuse against him. CNA #118 reported that he self-reported to the nurse on duty a couple of months ago that he heard from other staff that Resident #3 was reporting he was calling her a liar and accusing him of taking belongs. CNA #118 reported he was told by the nurse on duty that he should not provide care to Resident #3 anymore. CNA #118 reported that if he was assigned the 600 hallway, in which Resident #3 resided, he would switch off with a female team member for that room. CNA #118 identified that he assists in two person transfers with the presence of another female aide. Interview on 12/31/25 at 11:50 A.M. with the facility Administrator revealed she had not ever completed an SRI or investigation related to allegation of verbal abuse for Resident #3. The Administrator further reported that she was aware that Resident #3 did not like male caregivers and they had stopped allowing male caregivers to provide care to Resident #3 for a couple of months. Further interview revealed the Administrator was aware Resident #3 did not like CNA #118 and she attributed this to Resident #3 never being married, a retired teacher, and possibly having bias about male caregivers. Review of facility policy on Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property (revised on 10/22) revealed the Administrator is responsible for reporting any alleged violations of abuse to the Ohio Department of Health within 24 hours of knowledge of the incident and complete a full investigation no later than five days from the report with documented details and conclusion related to the allegations.

Based on observation, record review, and interview, the facility failed to ensure appropriate enhanced barrier precaution signage was in place and appropriate isolation gowns were used when completing wound care. This affected two (#5 and #61) of three residents reviewed for pressure ulcer wounds.Findings include:1. Review of the medical record for Resident #5 revealed an admission date of 11/06/15 and diagnoses included Alzheimer's disease, diabetes mellitus, idiopathic progressive neuropathy, venous insufficiency, obesity due to excess calories, generalized muscle weakness, oropharyngeal phase dysphagia, and anxiety disorder. Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #5 had Brief Interview for Mental Status (BIMS) score of 01 indicating severe cognitive impairment. Review of the physician's order dated 12/23/25 revealed order to cleanse open area to coccyx with normal saline (NS), pat dry, apply calcium alginate and cover with foam dressing daily and PRN. Review of wound care note dated 12/29/25 revealed Resident #5 was seen for an initial consultation of a wound. Resident #5 had an in-house acquired stage three pressure ulcer to the coccyx measuring 1. 5 centimeters (cm) length by 0.6 cm width by 0.3 cm depth with moderate exudate. There was noted to be pink granulating tissue across the wound bed. Observation on 12/30/25 at 8:55 A.M. with Registered Nurse (RN) Wound Nurse #193 revealed RN Wound Nurse #193 was not wearing protective isolation gown while completing wound care to Resident #5's coccyx pressure wound. Interview on 12/30/25 at 9:01 A.M. with RN Wound Nurse #193 confirmed she did not wear a protective isolation gown while completing wound care to Resident #5's coccyx wound and confirmed the resident was not placed in enhanced barrier precautions with signage to indicate precautions were needed. 2. Review of Resident #61's medical record revealed the resident was admitted on [DATE] with diagnoses including nondisplaced bimalleolar fracture of the left lower leg, fibromyalgia and depression. Review of Resident #61's admission MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #61's pressure wound care plans revealed to apply skin prep daily and leave open to air daily on dayshift. Review of Resident #61's Wound Care progress note dated 12/22/25 at 10:15 A.M. revealed the resident had an unstageable pressure ulcer related to the cast/orthopedic brace to the left heel which measured 1.8 cm length by 1.5 cm width by undetermined depth with 100% eschar. The treatment orders included an order to cleanse with normal saline, apply skin prep and leave open to air. Observation on 12/30/25 at 8:48 A.M. with RN Wound Nurse #193 revealed she washed her hands, applied gloves and applied skin prep to the left heel. RN Wound Nurse #193 did not cleanse the left heel first with normal saline and was not wearing protective isolation gown while completing the resident's wound care. Interview on 12/30/25 at 8:54 A.M. with RN Wound Nurse #193 confirmed she did not wear a protective isolation gown while completing the wound care to the resident's left heel and she confirmed the resident was not placed in enhanced barrier precautions with signage placed on the resident's door. Review of the Enhanced Barrier Precaution policy dated 2001 indicated enhanced barrier precautions (EBPs) were utilized to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents. EBPs were indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Wounds generally include chronic wounds such as pressure ulcers, diabetic foot ulcers, venous stasis ulcers, and unhealed surgical wounds.

Based on observation, record review, and interview, the facility failed to ensure comprehensive assessments were complete and accurate. This affected four (#4, #5, #22, and #43) of 22 residents reviewed for accurate comprehensive assessments. Findings include:1. Review of Resident #43's medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including depression, Alzheimer's disease and repeated falls. Review of Resident #43's physician orders revealed an order dated 11/26/25 for cefdinir oral capsule 300 milligrams (mg) give one capsule by mouth two times a day for an urinary tract infection (UTI). Review of Resident #43's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] (with a seven-day look back from 11/27/25 to 12/03/25) revealed the resident exhibited moderate cognitive impairment, was on an hypnotic and not on an antibiotic. Review of Resident #43's medication administration records (MARs) and treatment administration records (TARs) revealed the last dose administered was on 11/27/25 upon rising. The MARs did not reflect the resident received a hypnotic during the seven-day look back period. Interview on 12/20/25 at 10:30 A.M. with the Director of Nursing (DON) confirmed the above findings. 2. Review of Resident #4's medical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses including mild cognitive impairment, unspecified dementia and difficulty in walking. Review of Resident #4's Quarterly MDS 3.0 assessment dated [DATE] (with a look back period period between 11/28/25 to 12/05/25) revealed the resident exhibited severe cognitive impairment, the resident received a hypnotic and an antianxiety. Review of Resident #4's physician orders and MARs did not reveal evidence the resident was ordered and/or received a hypnotic medication or an anxiety medication. Email interview on 12/30/25 at 2:45 P.M. with the Administrator confirmed the above findings. 3. Record review revealed Resident #22 was admitted to the facility on [DATE] and her diagnoses included dementia, dysphagia, abnormalities of gait/mobility, acute kidney failure, hypertension, diabetes, major depressive disorder, spinal stenosis, chronic kidney disease (CKD)-stage2, anemia, and anxiety disorder. She was alert and oriented to person, place, and time (A&Ox3). She was given hearing aides on 04/04/25. Record review of Resident #22's Minimum Data Set 3.0 (MDS) from 06/04/25, 09/04/25, and 12/05/25 revealed the use of hearing aides was not noted. Interview on 12/30/25 at 2:00 P.M. with the Director Of Nursing (DON) confirmed the MDS's from 06/04/25, 09/04/25, and 12/05/25 did not contain evidence of Resident #22 using hearing aides. 4. Review of the medical record for Resident #5 revealed an admission date of 11/06/15 and diagnoses included Alzheimer's disease, diabetes mellitus, idiopathic progressive neuropathy, venous insufficiency, obesity due to excess calories, generalized muscle weakness, oropharyngeal phase dysphagia, and anxiety disorder. Review of the Medicare Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #5 was at risk for developing pressure ulcers/injuries. Resident #5 had one or more unhealed pressure ulcers/injuries. There was no stage selected for unhealed pressure ulcer/injuries. Further review of the medical record revealed no evidence of any pressure wounds at the time of the assessment or seven-day lookback period. Interview on 12/31/25 at 10:43 A.M. with the Director of Nursing (DON) confirmed Resident #5 did not have any pressure wounds at the time of the lookback period and the MDS section was marked in error.

Based on closed record review, review of a facility fall investigation, interviews and review of the facility policies, the facility failed to ensure adequate, individualized and effective fall risk interventions were in place to prevent a fall with injury for Resident #60, a resident at risk for falls. This affected one resident (#60) of three residents reviewed for falls. The facility census was 51. Actual Harm occurred on 03/10/25 when Resident #60 sustained an unwitnessed fall out of bed resulting in a fractured left arm, a laceration to the right side of her forehead, and a bruise to her right cheek. Prior to the incident, the resident had been having behaviors which staff identified as terminal agitation. The facility failed to ensure adequate, individualized and effective fall risk interventions were in place prior to the fall with injury to meet the resident's total care and safety needs. Findings include: Review of the closed medical record for Resident #60 revealed an admitted [DATE] and a discharge date of [DATE]. Resident #60 had diagnoses including atrial fibrillation, anxiety disorder, morbid obesity, and acute kidney failure. Review of a fall risk assessment dated [DATE] (completed on admission), revealed Resident #60 was assessed to be at high risk for falls. However, no additional fall risk assessments were completed until 03/11/25, following a fall with injury that occurred on 03/10/25. (At the time of the assessment on 03/11/25, Resident #60 was assessed to be at high risk for falls). Review of the initial care plan dated 11/25/20 revealed Resident #60 was at risk for falls. Interventions (also dated 11/25/20) included completing fall risk assessments and providing ongoing review for the resident's safety needs. NO new updates or fall related focus areas were identified after this time. Review of the physician's orders revealed Resident #60 was admitted to hospice services on 01/28/25. Review of the medication administration record revealed Resident #60 had an order for Morphine sulfate (opioid pain medication) one milliliter every four hours for pain. She also had an order for Ativan (antianxiety medication) one tablet by mouth every four hours for anxiety and restlessness. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 had intact cognition. The assessment revealed Resident #60 required moderate to extensive (staff) assistance for all activities of daily living. Resident #60 was always incontinent of urine and occasionally incontinent of bowel. Resident #60 was identified as a fall risk due to taking anti-anxiety medications daily during the seven-day assessment reference period. Review of a nursing progress note dated 03/10/25 at 5:47 A.M. revealed Resident #60's daughter put the call light on and was stating her mother was trying to take her clothes off and get out of bed. Resident #60 was asking about her grandmother. The note revealed the nurse educated Resident #60's daughter about terminal agitation, and the nurse was going to administer a dose of Ativan, but Resident #60 calmed down. Record review revealed no new safety or fall risk interventions were implemented or considered at this time. Review of a nursing progress note dated 03/10/25 at 9:41 P.M. revealed Resident #60's daughter walked into the resident's room and ran out screaming stating her mother was on the floor. The nurse entered the room, Resident #60's bed was in a high position, and she (the resident) was lying on the ground on her stomach with her head, shoulders, and arms under the bed. A small amount of blood was visualized on the floor next to Resident #60. Vital signs were assessed, and Resident #60 was reporting pain in her left arm and head. The hospice agency was notified, and an x-ray of the left shoulder was ordered. Emergency responders assisted to help Resident #60 back into bed. At the time of the incident, the resident's family made the decision not to send the resident to the emergency room . Review of the left shoulder x-ray dated 03/11/25 for Resident #60 revealed an acute displaced fracture of the left humorous metaphysis. Review of a facility unwitnessed fall investigation dated 03/10/25 revealed Resident #60's family (daughter) walked into her room and ran out stating her mother was on the floor. Resident #60 was found on the floor lying on her stomach with head shoulders and arms under the bed. Resident #60's bed was in a high position. A small amount of blood was on the floor next to the resident. Initial assessment of Resident #60 revealed she was oriented to person, situation, and place. Her predisposing factors included she had periods of confusion, was incontinent, a recent change in cognition, weakness, gait imbalance, and impaired memory. Review of a witness statement from Certified Nursing Assistant (CNA) #499, (no longer employed at the facility), revealed she changed Resident #60 a little after 8:00 P.M. (on 03/10/25) that day. Resident #60 was still urinating, so she informed her she would return. CNA #499 then went back to change her again, and she put the bed in the lowest position and put the resident's bed remote in the drawer of her bedside table. CNA #499 then went to care for other residents until she heard the nurse calling for her. (However, Resident #60's sister was in the room on 03/10/25 from 7:00 P.M. to 8:40 P.M. and stated no staff came into the room while she was visiting). Resident #60 was lying on the floor and due to her position, it was difficult to assess her. Resident #60's family was very upset with CNA #499, so the nurse had her stay in the hallway with her. Review of a statement from Nurse Manager #505 revealed she arrived on the unit on 03/10/25 at 9:57 P.M. Two nurses were in Resident #60's room attempting to assess her. The nurses informed her that the emergency medical services team was in route. Nurse Manager #505 then notified the hospice agency and the Director of Nursing (DON). Blood was coming from Resident #60 on the right side of her forehead and after the area was cleaned, a small laceration was discovered that eventually stopped bleeding. Resident #60's right cheek had some bruising as well, and she was complaining of left shoulder pain. Resident #60's family agreed to not send the resident out but an order for a left shoulder x-ray was obtained and neurological checks were instituted. Interview on 04/17/25 at 9:40 A.M. with the Administrator revealed the facility had investigated Resident #60's fall. She reported prior to the fall, the aide had left Resident #60's bed in the lowest position (she was unsure of the time this occurred) and put the bed remote (used to raise and lower the bed) in the bedside drawer, which was a hospice recommendation. The Administrator revealed Resident #60 unfortunately experienced end of life psychosis and raised her bed because she preferred it that way and fell out. She reported the resident's daughter did find Resident #60 on the ground. The Administrator also revealed Resident #60 had some behaviors of removing all of her clothing and trying to walk. Resident #60 was not left alone after she was found on the ground and a staff member, and the daughter were present with her the whole time she was on the ground. Interview on 04/17/25 at 10:25 A.M. with the Director of Nursing (DON) confirmed there was only ever a fall risk assessment for Resident #60 on admission in the year 2020, and the facility never re-assessed the resident until 03/11/25 after she fell . She confirmed the family did not want to send the resident to the hospital, but she did receive an x-ray in the facility of her left shoulder, which showed a left humerus fracture (as a result of the fall). During the interview, the DON also confirmed Resident #60's fall prevention care interventions had not been updated since the resident's admission on 11/25/20 as noted above even though the resident was at risk for falls and demonstrated behaviors that increased her fall risk and safety needs prior to the fall with fracture that occurred on 03/10/25. A telephone interview on 04/17/25 at 11:18 A.M. with Resident #60's daughter revealed the resident's sister was the person who found the resident lying on the floor all bloody on 03/10/25. She reported her sister immediately called her, and she was at the facility within five minutes. Resident #60's daughter reported her mother had behaviors of trying to get out of bed and remove her clothing for a couple of nights prior to the incident, and at that time, hospice staff made a recommendation to keep the resident's bed in the lowest position. When she arrived at the facility, she reported that her mother was lying on her belly on the right side of the bed. There was blood all over the floor and the wall. She reported that the bedside table where the bed remote was placed in an open drawer was also on the right side of the bed next to Resident #60's head. Resident #60 had suffered a laceration to her head, and her daughter reported the next day her right eye was swollen shut. Resident #60's daughter also confirmed Resident #60 suffered a right shoulder and arm fracture due to the fall, but the family chose not to send the resident to the emergency room because her mother was terminal and not doing well. Resident #60's daughter reported they (the whole family) already knew the resident was nearing the end of her life but voiced concerns the resident had to suffer so much (as a result of the fall/fracture) before she passed away. A telephone interview on 04/17/25 at 3:65 P.M. with Resident #60's sister revealed she was at the facility on 03/10/25 from approximately 7:00 P.M. until 8:40 P.M. when she left. She reported during this visit, Resident #60 was in and out of consciousness, but was sleeping when she left. Resident #60's sister reported that no staff member came into the room during her visit on this date/time. She also reported the resident's bed was also raised in a high position when she was visiting which she stated surprised her because the (hospice) staff had left handwritten notes next to the resident's bed stating to leave the bed in the lowest position. Resident #60's sister reported she did not question staff about her bed being in the highest position because she was so distraught watching her sister go in and out of consciousness. Resident #60's sister reported she could not confirm where the bed remote was because she did not pay attention to that. Resident #60's sister reported after she left at 8:40 P.M., she did return to the facility at which time Resident #60 was lying on the ground on her stomach on the right side of the bed complaining about her left shoulder and had a cut and bruises to the right side of her face. A telephone interview on 04/21/25 at 8:45 A.M. with Licensed Practical Nurse (LPN) #506 revealed she was the nurse on duty on 03/10/25, the night Resident #60 fell . She reported she was two doors down passing medications to other residents when she saw Resident #60's family enter the resident's room. The resident's family then came out screaming the resident was on the floor. She reported Resident #60 was lying on her stomach half under the bed and half outside the bed. LPN #506 reported that when she went to assess Resident #60, the resident screamed, I fell and don't touch me, my arm is broken. LPN #506 confirmed the bed remote was on the floor next to Resident #60 at that time. LPN #506 reported she did not know how the bed ended up in the highest position but stated Resident #60 preferred it that way, but since Resident #60 was at the end of life and not always with it, staff decided to keep the bed in the lowest position. Review of the visitor sign-in logs from 03/10/25 revealed that Resident #60's sister signed in at 7:00 P.M. and signed out at 8:40 P.M. Review of the facility policy Falls and Fall Risk, Managing, revised March 2018, revealed based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident conditions that might contribute to the risk of falls include delirium and other cognitive impairment and medication side effects of medication. The staff with the input of the attending physician, would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. This deficiency represents noncompliance investigated under Master Complaint Number OH00164791 and Complaint Number OH00164470.

Based on review of the medical record, review of the call light audit reports, and interview with the staff the facility failed to answer call lights timely for Resident #10 and #58. This affected two residents (Resident #10 and #58) of three residents reviewed for call light response times. The facility census was 57. Findings included: 1. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] . Diagnoses included urinary tract infection, sepsis, weakness, and cognitive communication deficit. She was discharged to home on 05/31/24. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #58 had moderately impaired cognition. She needed some help with self-care and required substantial assistance with toilet transfers. Review of the call light audit report revealed Resident #58 had a call light activated for 48 minutes on 05/26/24 at 8:58 A.M. and a call light that was activated for 42 minutes on 05/28/24. On 08/22/24 at 9:42 A.M. an interview with Family Member #300 revealed her mother's call light was on for over 40 minutes a couple times and that was unacceptable. She stated she told the Administrator about it. 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, neurological dysfunction of the bladder, diabetes, kidney disease, congenital dilatation of the esophagus and arthritis. Review of the Admission MDS assessment dated [DATE] revealed Resident #10 had intact cognition. Review of the call light audit record revealed on 08/19/24 Resident #10 had her call light activated for 56 minutes. On 08/22/24 at 9:25 A.M. an interview with Resident #10 revealed turnaround time was terrible because this week she had to wait 45 minutes to an hour to get her call light answered more than one time. She stated it was in the morning. She stated she usually got up in the chair to eat breakfast but they had not gotten her up yet so she turned her call light on. She stated after about 20 minutes they brought her breakfast tray in and set in over on the table where she could not reach it and it was another 35 to 40 minutes before they finally came in to get her up in the chair. She stated her breakfast was cold by then. She stated it happened two more time that day. She stated she understands 10 to 15 minutes but 45 minutes to an hour was ridiculous amount of time to wait until her call light was answered by staff. On 08/22/24 at 11:55 A.M. an interview with the Director of Nursing (DON) confirmed the long call light for Resident #10 and #58 on the call light audit report. She stated she would look into why they were so long. This deficiency represents non-compliance investigated under Complaint Number OH00155664.

Based on observation, interview, and policy review the facility failed to ensure foods were labeled, dated, and discarded when expired. This had the potential to affect all 51 residents in the facility. Findings Include: Observation of the main kitchen and resident refrigerators on [DATE] starting at 8:59 A.M. with Dietary Manager (DM) #235 revealed the following areas of concern: In the dry storage area in the main kitchen, there was an expired case of tortillas dated [DATE]. In the juice and supplement cooler in the main kitchen, there were multiple containers of yogurt and juice that were out of date. On the Division One unit, there were two containers of takeout food without a date or name. On the Rehab unit, there was takeout with Resident #26's name and a date of [DATE]. There was also an undated container of takeout with a resident name that was no longer in the facility as of [DATE]. Interviews with DM #235 verified the out-of-date foods at the time of observation. DM #235 stated resident food was to have a date and resident name and was to be discarded three days after the date listed on the item. DM #235 stated dietary staff would go through the refrigerators once a week to discard out-of-date food but indicated this process was not documented anywhere. Review of an undated policy and procedure manual revealed leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within seven days or discarded as per the 2022 Federal Food Code. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their use by dates or discarded. Review of the policy, Food Brought in By Family/Visitors, revised [DATE], revealed food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility-prepared food. Containers are labeled with the resident's name, the item, and the use by date. Nursing staff will discard perishable foods on or before the use by date. The nursing or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example past due package dates).

Based on interview and record review the facility failed to initiate care plans for hospice care and medication monitoring. This affected six residents (#7, #14, #17, #23, #37 and #39) out of 18 residents reviewed for care planning. The facility census was 51. Findings Include: 1. Review of the medical record for Resident #17 revealed an admitted [DATE]. Diagnoses included respiratory failure, chronic kidney disease, Multiple Sclerosis, and localized swelling. Review of Resident #17's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact, was dependent for mobility, and received anticoagulant medication. Review of Resident #17's March 2024 physician orders revealed an order dated 06/23/23 for Eliquis (anticoagulant or blood thinning medication) with directions to give 2.5 milligrams (mg) by mouth two times a day for blood clots. Review of Resident #17's care plan dated 12/27/23 revealed no evidence that the resident was receiving anticoagulant medication. Interview on 03/11/24 at 4:34 P.M. the facility's Director of Nursing (DON) confirmed the facility had not developed a care plan for the use of Resident #17's anticoagulant medication. 2. Review of the medical record for Resident #23 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, fibromyalgia, atrial fibrillation, and hypertension. Review of Resident #23's quarterly MDS assessment dated [DATE] revealed the resident was moderately impaired, had heart failure, and received anticoagulant medication. Review of Resident #23's March 2024 physician orders revealed an order Eliquis Tablet 2.5 MG with directions to give 0.5 tablet by mouth two times a day for atrial fibrillation. Review of Resident #23's Care Plan dated 01/24/24 revealed no evidence that the resident was receiving anticoagulant medication. Interview on 03/11/24 at 4:34 P.M. the facility's DON confirmed the facility was not monitoring for side effects related to Resident #23's anticoagulant medication. 3. Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute chronic respiratory failure, upper respiratory failure, emphysema, chronic obstructive pulmonary disease, anxiety, vertebra fracture, and dysphagia. Review of Resident #14's physician orders dated 01/24/24 revealed admission to hospice services for emphysema. Review of Resident #14's care plan revealed no focus areas, goals, or interventions for the hospice care and services. On 03/12/24 at 12:44 P.M. an interview with MDS Licensed Practical Nurse #265 confirmed Resident #14's care plan did not reflect the new hospice order. No goals or interventions were documented in the plan of care. 38522 4. Review of Resident #7's medical record revealed an admitted [DATE] with diagnoses including Crohn's disease, mild cognitive impairment, venous insufficiency, hypertension, hyperlipidemia, and personal history of other venous thrombosis and embolism. Review of a quarterly MDS assessment dated [DATE] revealed Resident #7 had mild cognitive impairment and received an anticoagulant. Review of Resident #7's March 2024 physician's orders revealed an order dated 02/15/23 for Xarelto oral tablet 20 mg daily for deep vein thrombosis (DVT). Review of Resident #7's plan of care revealed no evidence Resident #7 received an anticoagulant. Interview on 03/12/24 at 11:00 A.M. with the DON verified there was no care plan in place for Resident #7's anticoagulant. 5. Review of Resident #37's medical record revealed an admitted [DATE] with diagnoses including hyperkalemia, obesity, moderate protein-calorie malnutrition, and cognitive communication deficit. Review of Resident #37's annual MDS assessment dated [DATE] revealed Resident #37 had moderate cognitive impairment and received antianxiety and antidepressant medications. Review of Resident #37's current physician's orders revealed an order dated 03/27/23 for mirtazapine tablet 15 milligrams (mg) give one tablet by mouth at bedtime for increase appetite and an order dated 07/19/23 for Vistaril oral capsule 25 mg give one capsule by mouth every dayshift for anxiousness, give one dose 30 minutes before dressing change. Review of Resident #37's plan of care revealed no evidence Resident #37 received antianxiety and antidepressant medications. Interview on 03/13/24 at 10:12 A.M. with the DON verified there was no care plan in place for Resident #37's antianxiety and antidepressant medications. 6. Review of Resident #39's medical record revealed an admitted [DATE] with diagnoses including Alzheimer's disease, depression, cognitive communication deficit, chronic kidney disease, and hypertension. Review of Resident #39's admission/5-day MDS assessment dated [DATE] revealed Resident #39 was cognitively impaired and received antipsychotic, antianxiety, and antidepressant medications. Review of Resident #39's current physician's orders revealed an order dated 02/05/24 for citalopram hydrobromide oral tablet 10 mg give two tablet by mouth one time a day for depression; an order dated 02/05/24 for lorazepam oral tablet 0.5 mg give one tablet every four hours as needed for anxiety; an order dated 02/05/24 for Risperdal oral tablet 0.5 mg give one tablet by mouth at bedtime due to psychosis; and an order dated 02/18/24 for Ativan oral tablet 0.5 mg by mouth at bedtime for anxiety/agitation. Continued review of Resident #39's plan of care revealed no evidence Resident #39 received antianxiety, antipsychotic, and antidepressant medications. Interview on 03/12/24 at 4:30 P.M. with the DON verified there was no care plan in place for Resident #39's antianxiety, antipsychotic, and antidepressant medications.

Based on interview, record review, and policy review the facility failed to monitor residents using anticoagulant medications. This affected three residents (#7, #17 and #23) out of seven residents reviewed for medications. The facility census was 51. Findings Include: 1. Review of the medical record for Resident #17 revealed an admitted [DATE]. Diagnoses included respiratory failure, chronic kidney disease, Multiple Sclerosis, and localized swelling. Review of Resident #17's admission Minimum Data Set assessment dated [DATE] revealed the resident was cognitively intact, was dependent for mobility, and received anticoagulant medication. Review of the Resident #17's March 2023 physician orders revealed an order dated 06/23/23 for Eliquis (anticoagulant or blood thinning medication) with directions to give 2.5 milligrams (mg) by mouth two times a day for blood clots. Continued review revealed the facility had no orders in place to monitor the resident for side effects related to her high-risk medication. Continued review of the resident medical record including Point of Care system for state tested nursing aides and the residents care plan revealed the facility did not have any evidence of monitoring for the resident's anticoagulant medication. Interview on 03/11/24 at 4:34 P.M. the facility's Director of Nursing (DON) confirmed the facility was not monitoring for side effects related to Resident #17's anticoagulant medication. 2. Review of the medical record for Resident #23 revealed an admitted [DATE]. Diagnoses included Parkinson's disease, fibromyalgia, atrial fibrillation, and hypertension. Review of Resident #23's quarterly MDS assessment dated [DATE] revealed the resident was moderately impaired, had heart failure, and received anticoagulant medication. Review of Resident #23's March 2024 physician orders revealed an order Eliquis Tablet (anticoagulant) 2.5 mg with directions to give 0.5 tablet by mouth two times a day for atrial fibrillation. Continued review revealed the facility had no orders in place to monitor the resident for side effects related to her high-risk medication. Continued review of the resident medical record including Point of Care system for state tested nursing aides and the residents care plan revealed the facility did not have any evidence of monitoring for the resident's anticoagulant medication. Interview on 03/11/24 at 4:34 P.M. the facility's DON confirmed the facility was not monitoring for side effects related to Resident #23's anticoagulant medication. 38522 3. Review of Resident #7's medical record revealed an admitted [DATE] with diagnoses including Crohn's disease, mild cognitive impairment, venous insufficiency, hypertension, hyperlipidemia, and personal history of other venous thrombosis and embolism. Review of a quarterly MDS assessment dated [DATE] revealed Resident #7 had mild cognitive impairment and received an anticoagulant. Review of Resident #7's March 2024 physician's orders revealed an order dated 02/15/23 for Xarelto oral tablet 20 mg daily for deep vein thrombosis (DVT). There was no order for staff to monitor for side effects of this anticoagulant medication. Continued review of Resident #7s medical record including Medication Administration Records (MARs), Treatment Administration Records (TARs) and the plan of care revealed no evidence of monitoring for side effects related to Resident #7s anticoagulant. Interview on 03/12/24 at 7:55 A.M with Licensed Practical Nurse (LPN) #263 revealed for anticoagulants she would monitor for bruising or bleeding. When asked where documentation was to be done for this monitoring, LPN #263 acknowledged there was not an order on the TAR for staff to document this and was unaware of any other location where this information could be documented. Interview on 03/12/24 at 10:35 A.M. with LPN #266 revealed she would look for cuts and bruises and if a resident was bleeding to get the bleeding under control for a resident receiving an anticoagulant. When asked where monitoring documentation was placed, LPN #266 stated a progress note could be made but there was not a routine location for the monitoring to be signed off, such as on the TAR. Interview on 03/12/24 at 10:44 A.M. with State tested Nursing Assistant (STNA) #270 revealed they had some skin documentation in the point of care system and but nothing routine to prompt checking for bruising and bleeding. STNA #270 showed the surveyor during the interview the point of care interface which was the same for all residents for skin observation and staff could select scratch, discoloration, red area, skin tear, open area, resident not available, and resident refuse. STNA #270 indicated if there was a bruise they had to report this information to the nurse. Interview on 03/12/24 at 11:00 A.M. with the DON verified there was no monitoring in place for Resident #7's anticoagulant. Review of the facility policy, Anticoagulation-Clinical Protocol, dated November 2018, revealed the staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant.

Based on observation, interview, record review, and policy reviewed the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) into Resident #36's Enhanced Barrier Precautions (EBP) room and completed appropriate hand washing during incontinence care for Resident #36. This affected one resident (#36) out of three residents reviewed for transmission-based precautions. This had the potential to affect all ten residents (#5, #20, #36, #7, #37, #4, #9, #1, #103, and #29) on the 500-hall where Resident #36 resided. The facility census was 51. Findings Include: Review of the medical record for Resident #36 revealed an admitted [DATE]. Diagnoses included hydronephrosis with renal and ureteral calculous obstruction, urinary tract infection, and Multiple Sclerosis. Review of Resident #36's admission Minimum Data Set assessment dated [DATE] revealed the resident was cognitively intact, required substantial maximum assistance for toileting. Review of Resident #36 physician order dated 03/10/24 revealed an order for the resident to be on EBP every shift for extended-spectrum beta-lactamases (ESBL) for urinary tract infection (UTI). Observation on 03/12/24 at 1:32 P.M. revealed a sign on Resident #36's door indicating the resident was on EBP with instructions that everyone must clean hands including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high contact resident care activities which include dressing, bathing, transferring, changing linens, providing hygiene, and changing briefs, or assisting with toileting. At this time State tested Nursing Aide (STNA) #283 and STNA # 271 walked into Resident #36's room without applying a gown. The staff members washed their hands, gathered supplies, and applied gloves. STNA #283 transferred Resident #36 from her recliner chair to her bed using a Hoyer (mechanical) lift. She then repositioned her on the bed. STNA #283 removed the resident's pants and brief, she used a washcloth with water and soap to clean the resident's perineal area, clean water, and a washcloth to rinse the area, and another clean washcloth to dry the area. STNA #283 and STNA #271 positioned the resident on her right side and cleansed her buttocks with soap and water, rinsed with clean water, and then dried her buttocks with a clean washcloth. STNA #283 grabbed a bottle of incontinence cream, squeezed it into her gloved hand and used her hand to apply the cream on the resident's buttocks. She then moved the resident to her back and applied the remaining cream on the resident's perineal area with the same gloved hand. She attached the brief, pulled up the resident's pants and used the remote to transfer the resident back to her recliner before removing her gloves and washing her hands. STNA #283 and STNA #271 completed the incontinence care without donning gowns as indicated on the signage outside of the residents' rooms. Interview on 03/12/24 at 1:45 P.M. STNA #283 revealed she did not complete any hand washing or change her gloves from the start of Resident 36's incontinence care until the resident was seated back in her recliner. She also stated she did not know that she was required to follow the sign on the outside of Resident #36's door because she knew the resident did not have a clotridiodes difficile (C. Diff) infection. Interview on 03/12/24 at 2:15 P.M. the Director of Nursing confirmed Resident #36 is on EBP and all staff who were providing direct care were required to wear a gown and gloves. Review of the undated facility policy Hand Washing/Hand hygiene revealed indications for hand hygiene included after contact with blood, body fluids, or contaminated surfaces, before moving from work on a soiled body site to a clean body site on the same resident. Review of the undated Enhanced Barrier Precautions policy revealed EBP is used as an infection prevention and control intervention to reduce the spread of multi-drug residence organism's tor residents. EBP employs targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gowns are applied prior to performing the high contact resident care activities. Examples of high contact resident care activities requiring the use of gown and gloves for EBP include dressing, bathing, transferring, providing hygiene, changing briefs, or assisting with toileting. EBP are indicated for resident infected or colonized with ESBL producing enterobacterales. This deficiency is an example of continued noncompliance from the survey completed on 03/04/24.

Based on record review, interview, and facility policy review the facility failed to ensure monitoring for medication effects and potential adverse consequences was completed for residents who were receiving psychotropic medications. This affected two residents (#37 and #39) out of five residents reviewed for unnecessary medications. The facility census was 51 residents. Findings Include: 1. Review of Resident #37's medical record revealed an admitted [DATE] and diagnoses including hyperkalemia, obesity, moderate protein-calorie malnutrition, and cognitive communication deficit. Review of Resident #37's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had moderate cognitive impairment and received antianxiety and antidepressant medications. Review of Resident #37's current physician's orders revealed an order dated 03/27/23 for mirtazapine tablet 15 milligrams (mg) give one tablet by mouth at bedtime for increase appetite and an order dated 07/19/23 for Vistaril oral capsule 25 mg give one capsule by mouth every dayshift for anxiousness, give one dose 30 minutes before dressing change. There were no orders for staff to monitor for side effects for these medications. Continued review of Resident #37's medical record including Medication Administration Records (MARs), Treatment Administration Records (TARs), and the plan of care revealed no evidence of monitoring for side effects related to her antianxiety and antidepressant medications. Interview on 03/13/24 at 10:12 A.M. with the Director of Nursing (DON) confirmed the lack of medication monitoring relative to Resident #37's antianxiety and antidepressant medications. 2. Review of Resident #39's medical record revealed an admitted [DATE] and diagnoses including Alzheimer's disease, depression, cognitive communication deficit, chronic kidney disease, and hypertension. Review of Resident #39's admission/5-day MDS 3.0 assessment dated [DATE] revealed Resident #39 was cognitively impaired and received antipsychotic, antianxiety, and antidepressant medications. Review of Resident #39's current physician's orders revealed an order dated 02/05/24 for citalopram hydrobromide oral tablet 10 mg give two tablet by mouth one time a day for depression; an order dated 02/05/24 for lorazepam oral tablet 0.5 mg give one tablet every four hours as needed for anxiety; an order dated 02/05/24 for Risperdal oral tablet 0.5 mg give one tablet by mouth at bedtime due to psychosis; and an order dated 02/18/24 for Ativan oral tablet 0.5 mg by mouth at bedtime for anxiety/agitation. There were no orders for staff to monitor for side effects for these medications. Continued review of Resident #39's medical record including MARs, TARs and the plan of care revealed no evidence of monitoring for side effects related to her antianxiety, antipsychotic, and antidepressant medications. Interview on 03/12/24 at 4:30 P.M. with the DON confirmed the lack of medication monitoring relative to Resident #39's antianxiety, antipsychotic, and antidepressant medications. Review of the facility policy, Psychotropic Medication Use, dated July 2022, revealed residents receiving psychotropic medications are monitored for adverse consequences including anticholinergics effects, cardiovascular effects, metabolic effects, neurologic effects, and psychosocial effects.

Based on interview, record review, and policy review the facility failed to obtain an ordered culture and sensitivity prior to starting antibiotic therapy for Resident #23. This affected one resident (#23) out of five residents reviewed for antibiotic stewardship. The facility census was 51. Findings Include: Review of the medical record for Resident #23 revealed an admitted [DATE]. Diagnoses include Parkinson's disease, fibromyalgia, and hypertension. Review of Resident #23's nursing note dated 12/12/23 at 9:46 A.M. revealed the physician saw the resident on rounds. The resident complained of constipation and abdominal discomfort due to constipation. The physician examined the resident's abdomen and bowel sounds. The resident complained of burning with urination. A urinalysis, lab, and antibiotic were ordered. Review of Resident #23's physician orders revealed an order dated 12/13/23 to straight catheter for urinalysis and culture and sensitive for dysuria and abdominal discomfort. Also noted was an order on 12/13/23 for the resident to start Cefdinir 300 milligrams (mg) (an antibiotic) with directions to take the medication two times a day for infection/dysuria until 12/29/23. Review of Resident #23 Medication Administration Record revealed she received Cefdinir 300 mg from 12/13/23 through 12/29/23. Review of Resident #23 December 2023 lab work revealed the facility did not obtain Resident #23's ordered urinalysis with a culture and sensitivity. Review of the facility Infection Screening Evaluation, dated 12/12/23, revealed the resident did not meet McGeer's criteria for Urinary Tract Infection. Interview on 03/12/24 at 9:40 A.M. the Director of Nursing confirmed the facility missed the order to complete Resident #23's urinalysis with a culture and sensitivity. She stated the facility did not follow correct antibiotic stewardship practices by administering Resident #23 Cefdinir 300 mg twice daily and she did not meet McGeers criteria for a urinary tract infection. Review of the facility policy, Surveillance for infections, revised 09/2017, revealed nursing staff will monitor residents for signs and symptoms that may suggest infection. When an infection or colonization with epidemiologically important organisms is suspected cultures may be sent, if appropriate, to contracted laboratory for identification or confirmation. Cultures will be further screened for sensitive to antimicrobial medications to help determine treatment options.

Based on review of the infection control logs, review of facility policy and interviews with staff, the facility failed to maintain proper surveillance of all infections in the facility. This had the potential to affect all 51 residents in the facility. Findings include: Review of the infection control log from 11/20/23 to 02/20/24 revealed no documentation of infections from 01/01/24 to 02/20/24. On 02/20/24 at 11:51 A.M. an interview with the Administrator revealed they facility did not have any surveillance of infections documented for January and February 2024 due to the infection control nurse, who just quit her job at the facility the prior week, had not been doing them. On 02/26/24 at 12:27 P.M. an interview with Registered Nurse # 210 revealed she had been the facility's infection control nurse, however, she was never trained to do the infection control log so she never created them for January and February 2024. She stated she had asked several times to be shown how to do the logs but was never shown how to do them. Review of the facility policy titled, Surveillance for Infection, dated 09/17, revealed the infection preventionist would conduct ongoing surveillance for healthcare-associated infections and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. This deficiency represents non-compliance identified during the investigation of Complaint Number OH00151177.

Based on observation, interview, record review, and facility policy review the facility failed to ensure ordered interventions were in place and functional to prevent falls for Resident #44. Actual Harm resulted when Resident #44 sustained a [MEDICAL CONDITION] after an unsupervised transfer and fall on 07/29/20. This affected one of four residents reviewed for falls (Residents #44, #45, #47 and #49). The facility census was 42. Findings include: Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent significant change Minimum Data Set 3.0 (MDS) assessment, dated 07/22/20, revealed Resident #44 was cognitively impaired and required extensive assistance of one or two staff for most activities of daily living including transfers and toileting. The assessment indicated the resident had not had a fall since the last assessment. Review of the care plan for falls initiated 01/25/17 and updated through 10/25/20 revealed she was at risk for falls due to increased confusion, decreased mobility and poor safety awareness. She also would intentionally place herself on the floor at times. Interventions included redirection, floor mats beside the bed, a low, extra wide bed to allow for more movement, gripper socks and assistance or encouragement to use the bathroom. A non-sound pressure alarm that triggered the resident's call light was ordered on [DATE]. Review of nursing notes dated 06/13/20 at 4:45 A.M. revealed Resident #44 was found on the floor. The pressure alarm was sounding through the call light and the resident was not injured. An intervention was put in place to assist the resident to the bathroom if she awakens through the night. Resident #44 had a hospital stay from 06/26/20 through 06/28/20 and on return to the facility, she was placed in a different room due to the need to quarantine for COVID 19. She later developed symptoms of COVID 19 and was kept in the quarantine unit until the testing was negative and symptoms resolved. She was transferred to a room out of the quarantine unit on 07/28/20. Review of a nursing note dated 07/29/20 at 2:34 A.M. revealed the resident was found on the floor in front of a recliner and stated she had walked from the bathroom and fell . The note indicated the resident complained of pain to her hips and elbow. An order was obtained for x-rays of both hips, the pelvis and left elbow. Review of the x-ray results obtained on 07/29/20 (no time indicated) revealed Resident #44 had an acute, impacted, right, subcapital femoral neck fracture ([MEDICAL CONDITION]). A nursing note dated 07/29/20 at 7:15 A.M. revealed the nurse practitioner was notified of the x-ray results and the resident was sent to the hospital for evaluation. Review of the fall investigation for the incident on 07/29/20 revealed a statement by State tested Nursing Assistant (STNA) #100, dated 07/29/20. STNA #100 stated she had been in and out of the resident's room several times for the resident unplugging the bed alarm setting off the call light. The statement indicated the resident was checked and changed (incontinence care) at 1:30 A.M. and at 2:15 A.M. a door slam was heard. The STNA statement indicated the resident slammed the bathroom door while falling. Review of the nursing notes dated 08/18/20 at 11:40 A.M. revealed the resident returned to the facility with bruising to the right elbow and staples noted to the right outer thigh after surgery to repair her [MEDICAL CONDITION]. An interview by phone with STNA #100 on 08/19/20 at 1:36 P.M. revealed she had been told the resident was more confused than usual on 07/28/20 due to the room change. She stated the resident had been playing with the bed alarm several times through the night and had set off the alarm by disconnecting it from the wall. She stated she had reset the alarm several times but it did not alarm when the resident got up before the fall. She stated she was alerted to the fall by hearing the bathroom door slam. She verified she had not talked to the nurse about the resident's behavior that night of disconnecting the alarm. An interview with Licensed Practical Nurse (LPN) #200, on 08/19/20 at 1:45 P.M. revealed she was the nurse working the night the resident was found on the floor with the fracture. She stated she was not aware of the resident's increased confusion and behaviors related to disconnecting the bed alarm. She stated if she would have known about the behavior of disconnecting the alarm, she would have explored other interventions to alert staff to unsupervised transfers, such as moving the alarm out of her reach or to the other side of her bed, as she (the resident) always laid on one side. She verified the resident stated she had gotten up, gone to the bathroom and fell as she made her way back to bed. Further review revealed the fall investigation also included statements from STNA #101 and #102, whose statements were written on 07/29/20. Both indicated they were in a dining room near the resident's room and heard a door slam, which alerted them the resident had fallen. An interview with Registered Nurse (RN) #300 on 08/19/20 at 2:00 P.M. confirmed Resident #44 had increased confusion due to a room change and according to the fall investigation and interviews, had been found by the nursing staff to have set off the alarm to her bed by manipulating the cords earlier that evening prior to the fall. RN #300 stated the resident was able to disconnect the cords, which resulted in the alarm not going off when she got up, walked to the bathroom unassisted, and fell on her return to bed, subsequently fracturing her hip. RN #300 confirmed there had been no other interventions put in place to more closely monitor Resident #44 on that night, even though staff were aware she was restless and had been manipulating the alarm. Observation of a non-sound bed alarm with RN #300 on 08/19/20 at 2:10 P.M. in an empty room revealed the alarm consisted of a pad which would be placed under the resident's top sheet with a cord coming from the pad to a box. Another cord connected the box to the call light. RN #300 verified the cord to the pad would have come out under the sheet and could have been placed so the resident could not see the cord or have access to the cord or the box to prevent her from disabling the alarm. RN #300 also verified if the resident had been anxious and focused on the alarm, staff should have ensured other measures were put in place to prevent unassisted transfers. She further verified the fall resulted in a [MEDICAL CONDITION] that required surgery. Resident #44 was observed in her room and bed on 08/19/20 at 2:30 P.M. She appeared comfortable but was confused and not interviewable. A cord for the non-sound alarm was noted coming from under the resident and attached to the call light. Review of the facility fall policy, revised March 2018, revealed staff should monitor the residents response to interventions to reduce the incidence of falls and reconsider the interventions if necessary.

Based on record review and interview the facility failed to ensure Resident #88 was provided adequate assistance during a staff assisted transfer using a mechanical lift. Actual harm occurred when Resident #88 sustained a fall from the mechanical lift resulting in nasal fractures and lacerations. This affected one resident (Resident #88) of four residents reviewed for falls. Findings include: Review of Resident #88's medical record revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Record review revealed the resident was dependent on staff for activities of daily living including bed mobility and transferring. The resident was non-ambulatory due to the [DIAGNOSES REDACTED].#88's fall risk care plan revealed the resident was at risk for falls. Interventions included the use of a mechanical lift with assist of at least two staff members for transfers. Review of the medical record revealed on 10/16/16 Resident #88 was being transferred with a mechanical lift by two staff members when the lift tipped over and Resident #88 landed on top of the mechanical lift. Resident #88 was sent out to the hospital due to pain in his nose and lacerations to his nose and ear. Resident #88 returned from the hospital with a [DIAGNOSES REDACTED]. Interview with Resident #88 on 12/07/16 at 2:35 P.M., revealed that approximately six weeks ago he sustained injuries when the mechanical lift tipped over when he was being transferred from bed to his wheelchair. Interview with STNA #15 on 12/08/16 at 10:25 A.M., revealed herself and STNA #16 were transferring Resident #88 in the mechanical lift from his bed to his wheelchair when the mechanical lift tipped over when the resident was suspended in the air causing the resident to land on top of the lift. The STNA stated she was unsure how the incident actually happened. Interview with STNA #16 on 12/08/16 at 10:40 A.M., revealed she was assisting STNA #15 transferring Resident #88 in the mechanical lift from his bed to his wheelchair when the mechanical lift tipped over when the resident was suspended in the air causing the resident to land on top of the lift. The STNA stated she was unsure how the incident actually happened. Review of the fall investigation completed by the facility identified that the assistance device (mechanical lift) was not being used according to manufacturer's specifications at the time the resident sustained [REDACTED]. Review of the investigative form revealed no additional documentation related to how the facility concluded the lift was not being used according to manufacturer's specifications. On 12/08/16 at 10:45 A.M. interview with the director of nursing (DON) verified Resident #88, who was dependent on staff for transfers sustained a fall from a mechanical lift while being transferred which resulted in a fractured nose and facial lacerations. The DON stated the facility concluded that for the fall to have occurred, the mechanical lift was not being used properly. This deficiency substantiates Master Complaint Number OH 324 and Complaint Number OH 295.

Based on observation, record review, and interview, the facility failed to implement interventions to prevent an unstageable pressure ulcer and failed to assess and monitor the skin condition for one resident (Resident #117) who was assessed to be at risk for developing pressure ulcers. Actual harm occurred when Resident #117 developed an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer on the left heel. This affected one of three residents reviewed for pressure ulcers. The facility census was 90. Findings include: Resident #117 was admitted with [DIAGNOSES REDACTED]. Review of the pressure ulcer risk assessment dated [DATE] indicated Resident #117 was at moderate risk for the development of a pressure ulcer. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #117 was admitted without any pressure ulcers and required extensive assistance with activities of daily living. Review of the weekly skin integrity review completed by state-tested nurse aides (STNAs) revealed Resident #117 had no pressure areas on 05/28/15 through 06/18/15. Review of the medical record revealed no evidence of any skin monitoring from 06/18/15 through 07/03/15. Review of the progress notes dated 07/03/15 revealed a black and blue area was discovered to the bottom of Resident #117's left heel. Review of the weekly pressure ulcer progress report dated 07/03/15 revealed a black and blue area was discovered on the bottom of Resident #117's left heel that was staged as a deep tissue injury. Review of physician orders [REDACTED]. Pressure redistribution boots were ordered to bilateral heels. Review of the weekly pressure ulcer progress report dated 07/10/15 indicated the area was brown and black and unstageable. The note from 07/17/15 indicated the area was pink and brown and a Stage II pressure ulcer. The weekly pressure ulcer progress report continued to indicate the pressure ulcer on the resident's left heel was a Stage II until 08/23/15. Further review of the weekly pressure ulcer progress reports revealed no evidence of assessments /monitoring of the left heel from 08/23/15 through 09/15/15. On 09/15/15 the ulcer was documented as a brown unstageable pressure ulcer. Review of the MDS 3.0 assessment dated [DATE] indicated Resident #117 had a Stage II pressure ulcer. Review of the risk for pressure ulcer development care plan initiated, revised 10/26/15, revealed Resident #117 had an unstageable left heel pressure ulcer on 08/17/15 which resolved on 10/20/15. Observation made on 11/05/15 at 9:50 A.M. revealed Resident #117 was in bed. Licensed Practical Nurse (LPN) #17 began to apply a dressing to the left heel pressure ulcer. LPN #17 stated the scab came off the area since the last dressing change. The pressure ulcer presented as a Stage III with pink and yellow tissue in the wound bed and flaky skin surrounding the wound. LPN #17 measured the wound and stated it was 1.5 centimeters (cm) in length, 3.0 cm in width and 0.2 cm deep. LPN #17 cleansed the wound with normal saline wound wash, patted dry, applied Hydrogel saturated 2x2 gauze, applied an ABD and secured with Kerlix and tape. An interview with LPN #17 on 11/05/15 at 11:00 A.M. verified the facility had no evidence of wound assessments from 08/23/15 through 09/15/15. LPN #17 also verified the wound documentation regarding Resident #117's left heel was not consistent and there were several discrepancies. LPN #17 verified the documentation indicated the left heel pressure ulcer was not discovered until it was a black and blue area on the bottom of the left heel. LPN #17 verified discrepancies in the wound documentation indicating the ulcer was unstageable and also a Stage II.

Based on observation, interview, and record review, the facility failed to ensure timely and adequate treatments for a skin condition for one resident (Resident #19). Actual harm occurred when Resident #19 had complaints of severe itching, episodes of yelling, moaning, and digging vigorously at skin causing blood blisters, for nearly two months with no physician notification or appropriate treatment. This affected one (Resident #19) of three resident's reviewed for skin conditions. The facility failed to ensure a [MEDICAL TREATMENT] site was monitored as ordered. This affected one (Resident #91) of one resident reviewed for [MEDICAL TREATMENT] care. The facility census was 90. Findings include: 1. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Review of a nurse ' s note dated 09/8/15 at 3:45 A.M. revealed Resident #19 was yelling out from her bed. The nurse entered the room to see the resident scratching her abdomen. The nurse asked what was wrong, and the resident stated she had very bad itching of her skin. House lotion was applied and pain medication was given for discomfort which was effective. There was no documented evidence the physician was notified or the resident's skin was assessed. Review of a nurse ' s note dated 09/11/15 at 1:59 A.M. revealed Resident #19 was yelling out in her bed help me. The nurse entered the room, and the resident stated she itched on her back and arms. Over the counter lotion was applied, and the resident stated it helped a little. The resident was offered a pain pill for discomfort from scratching but refused. The nurse left the room and the resident immediately started to holler help again. There was no documented evidence to indicate the physician was notified or the resident ' s skin was assessed. Review of a nurse ' s note dated 09/22/15 at 4:01 A.M. revealed the resident was crying out while in bed. The nurse asked the resident what was wrong and the resident stated I don't know also stated that she was itchy. Lotion was applied and the resident was medicated for discomfort. There continued to be no documented evidence that the physician was notified of the ongoing complaints of itching or an assessment of the resident's skin. Review of a nurse ' s note dated 09/24/15 at 5:48 A.M. revealed Resident #19 complained at the beginning of the shift that she was itching. Lotion was applied to the back and arms. The note indicated Resident #19 rested quietly until 3:00 A.M. and then began to yell out. Resident #19 again complained of itching, lotion applied again with good results. There continued to be no documented evidence the physician was notified of the ongoing complaints of itching or an assessment of the resident's skin. Review of a nurses note dated 09/29/15 at 9:09 P.M. revealed new orders were received to apply lotion such as [MEDICATION NAME] or [MEDICATION NAME] to dry skin on arms/legs daily and for the resident to have [MEDICATION NAME] (an [MEDICATION NAME] medication) 10 milligrams (mg) daily due to complaints of itching. The order for lotion was not a new order. Review of a nurse ' s note dated 09/30/15 at 7:36 A.M. revealed Resident #19 had complaints of generalized itching. The resident was noted to be scratching at self. Lotion was again applied with slight relief. There was no documented evidence that the physician was notified of the ongoing complaints of itching or an assessment of the resident's skin. A review of a nurse ' s note dated 10/6/15 at 2:24 A.M. revealed Resident #19 was heard moaning in her bed. The nurse approached the resident to see what was wrong. The resident stated I itch and it's worse than ever. The nurse applied moisturizer to the resident's extremities and torso. There continued to be no documented evidence that the physician was notified of the ongoing complaints of itching or an assessment of the resident's skin. Review of a nurses note dated 10/22/15 at 12:59 A.M. revealed Resident #19 was yelling out in bed help me, oh someone help me. The nurse entered the resident's room, and the resident was digging at her skin with her fingernails stating that she itched all over. Lotion was applied to extremities and torso and the resident responded why does it have to itch so badly? There continued to be no documented evidence that the physician was notified of the ongoing complaints of itching or an assessment of the resident's skin. Review of a nurse ' s note dated 10/22/15 at 4:10 A.M. revealed the resident was moaning in her room and yelling out help me. The resident stated she was itching all over again. Lotion was applied and the resident was quiet. There continued to be no documented evidence that the physician was notified of the ongoing complaints of itching or an assessment of the resident's skin. Review of a nurse ' s note dated 10/30/15 at 2:43 A.M. revealed Resident #19 was yelling in room help me and moaning. The nurse entered the resident's room to see Resident #19 vigorously digging at her arms with her fingernails stating I itch all over, why I itch? Lotion was again applied to extremities and torso with no relief. There continued to be no documented evidence that the physician was notified of the ongoing complaints of itching or an assessment of the resident's skin. Review of a nurses note dated 10/31/15 at 2:20 A.M. revealed the resident was yelling help me and oh God while lying in bed. The nurse entered Resident #19's room and the resident was awake asking why she was itching so much while digging at the skin on her left arm. Her left arm was purple in color and had two dime size blood blisters that were raised 0.5 centimeters (cm). The nurse applied lotion to extremities and torso with no relief. There continued to be no documented evidence to indicate the physician was notified of the ongoing complaints of itching. Observations on 11/02/15 at 3:00 P.M. revealed Resident #19 had a pin point rash with scratch marks on her abdomen, chest, groin, upper thighs and back. State tested Nursing Assistant (STNA) #10 verified the rash and stated the staff was applying [MEDICATION NAME] cream to those areas. Resident #19 was observed scratching and stated she was very itchy in the places where the rash was noted. Review of a nurse ' s note dated 11/03/15 at 10:19 A.M. revealed there was a new order for a topical treatment. Review of a nurse's note dated 11/03/15 at 9:55 P.M. revealed [MEDICATION NAME] cream (a topical treatment for [REDACTED]. On 11/06/15 at 9:50 A.M. an interview with Licensed Practical Nurse (LPN) #14 verified Resident #19 had complaints of severe itching, episodes of yelling, moaning, and digging vigorously at skin causing blood blisters for nearly two months with no physician notification or new treatment with the exception of [MEDICATION NAME] 10 mg daily on 09/29/15, which did not provide relief. LPN #14 verified Resident #19's rash was not assessed at any time. 2. Resident #91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact, required limited assistance with bed mobility, transfers, ambulation, dressing, hygiene, and toilet use and supervision for eating. Review of the July, 2015 physician's orders [REDACTED].#91 received [MEDICAL TREATMENT] on Tuesday/Thursday/Saturday at 7:15 A.M. The order indicated to monitor the [MEDICAL TREATMENT] site for redness, warmth, tenderness or [MEDICAL CONDITION] every shift for any bleeding, apply pressure and contact [MEDICAL TREATMENT] center if bleeding was observed. Review of the physician's orders [REDACTED]. Review of the plan of care dated 05/21/14 revealed Resident #91 required [MEDICAL TREATMENT] related to [MEDICAL CONDITION]. The plan of care goal indicated the resident will have immediate intervention should any signs and symptoms of complications from [MEDICAL TREATMENT] occur through the review date. Interventions included [MEDICAL TREATMENT] days are scheduled for Tuesdays, Thursdays, and Saturdays and to observe the [MEDICAL TREATMENT] site for redness, warmth, tenderness or [MEDICAL CONDITION] every shift. Observe/document/report to medical doctor as needed any signs and symptoms of infection to the access site such as redness, warmth or tenderness. Review of the medical record revealed no documented evidence to indicate nursing staff observed the [MEDICAL TREATMENT] site for redness, warmth, tenderness or [MEDICAL CONDITION] every shift. Interview with the director of nursing (DON) on 11/05/15 at 10:54 A.M. verified there was no documented evidence to indicate nursing observed the [MEDICAL TREATMENT] site for redness, warmth, tenderness or [MEDICAL CONDITION] every shift.