Every finding on record at Tallmadge Health & Rehab Center

Based on observation, interview, record review and review of facility policy, the facility failed to maintain accurate and timely medication records of controlled substances and other medications according to acceptable standards of practice. This affected three residents (#1, #17 and #20) of eight residents reviewed for medication administration. The facility census was 86.Findings include:1. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including arthritis, shoulder pain, and need for assistance with personal care.Review of the care plan dated 09/18/25 revealed Resident #20 had chronic pain related to arthritis with a goal of pain reduction. Interventions included administering medications as needed, monitoring complaints of pain, and record alleviating factors. Review of the physician orders revealed an order dated 06/05/25 for tramadol tablet (an opioid pain reliever) 50 milligrams (mg) as needed (prn) for moderate to severe pain every eight hours.Review of the Electronic Medication Administration Record (EMAR) dated 01/01/26 to 01/31/26 revealed documentation of tramadol 50 mg prn on the following days and times: 01/02/26 at 9:31 A.M.; 01/03/26 at 1:10 P.M.; 01/06/26 at 8:16 A.M.; 01/08/26 at 9:08 A.M.; 01/09/26 at 9:42 A.M.; 01/13/26 at 8:48 A.M.; 01/15/26 at 12:01 P.M.; 01/16/26 at 3:40 P.M.; 01/17/26 at 4:30 P.M.; 01/21/26 at 4:04 P.M.; 01/22/26 at 7:10 P.M.; 01/25/26 at 9:39 A.M.; and 01/30/26 at 6:41 P.M.Review of the facility narcotic log dated 01/04/26 to 02/18/26 revealed documentation of tramadol 50 mg prn on 01/09/26 at 10:00 P.M., 01/12/26 at 9:10 A.M., 01/18/26 at 10:00 P.M., 01/21/26 at 9:00 P.M., and 01/23/26 at 9:00 P.M. that were not documented as administered on the EMAR.An interview on 03/19/26 at 3:44 P.M. with the Director of Nursing (DON) verified the documentation findings for Resident #20 and verified when controlled substances are administered documentation should be on the EMAR and the narcotic log. 2.Review of the medical record for Resident #17 revealed an admission date of 03/09/26 with diagnoses including peripheral vascular disease, partial amputation of the right food, stroke, liver disease, and chronic kidney disease. Review of the physician orders for March 2026 for Resident #17 revealed an order for amlodipine (a medication to lower blood pressure) 10 mg once a day, apixaban (an anticoagulant) 2.5 mg once a day, metoprolol (a medication to lower blood pressure) 25 mg twice a day, and pantoprazole (a stomach acid reducer) 40 mg once a day. An observation of medication administration on 03/19/26 at 8:29 A.M. with Licensed Practical Nurse (LPN) #205 for Resident #17 revealed amlodipine 10 mg once a day, apixaban 2.5 mg once a day, metoprolol 25 mg twice a day, and pantoprazole 40 mg once a day were administered to Resident #17. LPN #205 did not sign the medications as given in the EMAR at the time of the observation.An observation on 03/19/26 at 10:38 A.M. of the EMAR for Resident #17 revealed the observed morning medications were still not documented as given.An observation on 03/19/26 at 10:44 A.M. revealed LPN #205 was seated at the nurse's station talking to coworkers and not actively charting at the computer. An interview on 03/19/26 at 10:44 A.M. with LPN #205 verified the morning medications amlodipine, apixaban, metoprolol and pantoprazole observed as administered to Resident #17 at 8:29 A.M. were still not documented as administered on the EMAR. 3.Review of the medical record for Resident #1 revealed an admission date of 05/31/22 with diagnoses including leukemia, high blood pressure, dementia with anxiety, major depressive disorder, and Alzheimer's disease.Review of the physician orders for Resident #1 revealed an order dated 06/05/25 for oxycodone (narcotic pain medication) 5 mg twice a day for moderate to severe pain and an order dated 06/05/25 for oxycodone 5 mg every twenty-four hours as needed for moderate to severe pain. Review of the care plan revised 03/13/26 for Resident #1 revealed Resident #1 had pain related to leukemia with a goal for pain reduction. Interventions to include administering medications, monitoring pain, and record alleviating factors. Review of the EMAR for Resident #1 from 01/01/26 to 01/31/26 revealed the absence of documentation for prn administration for oxycodone 5 mg. Review of the paper narcotic log from 01/04/26 to 01/18/26 revealed oxycodone 5 mg was signed out as administered on 01/18/26 at 12:45 P.M., which was not in the scheduled oxycodone A.M. medication pass of 7:00 A.M. to 11:00 A.M. or the P.M. medication pass of 7:00 P.M. to 11:00 P.M. An interview on 03/19/26 at 3:44 P.M. with the DON verified the documentation findings for Resident #1 and verified when controlled substances are administered documentation should be on the EMAR and the narcotic log. Review of the facility policy titled General Dose Preparation and Medication Administration, dated 11/15/24, revealed staff would document the administration of controlled substances in accordance with applicable law, document when medications are given, and document prn medications on appropriate forms.This deficiency represents non-compliance investigated under Complaint Number 2721104.

Based on interview, photograph review, and facility policy, the facility failed to ensure medications were stored, prepared, and administrated properly. This had the potential to affect all 47 residents residing on the 100 and 200 hall in the facility. Findings include:Review of the two photographs revealed the first photo dated 11/03/25, at 8:50 P.M. had fourteen (14) medication cups with pills in them and stacked on top of each other unlabeled, and the second photo dated 10/09/25 at 8:12 P.M. had nine (9) empty medication cups, unlabeled on the medication cart. Interview on 12/22/25 at 7:57 A.M. with Resident #22 revealed Licensed Practical Nurse (LPN) #215 is preparing medications on night shift ahead of time without labeling them and stacking them. Interview on 12/24/25 at 8:48 A.M. with Resident #23 revealed a nurse on night shift is preparing medications on ahead of time without labeling them and stacking them. Interview on 12/30/25 at 8:12 A.M. with Confidential Individual #400 confirmed the first photo with the fourteen (14) medication cups with pills in them and stacked on top of others unlabeled are from 11/03/25 at 8:50 P.M. for LPN #215 200 hall medication pass and the second photo of the nine (9) empty medication cups, unlabeled on the medication cart are from 10/09/25 at 8:12 P.M. with for LPN #215's 100 hall medication pass. On 12/24/25 at 10:39 A.M. surveyor showed the two photos to Administrator and DON. DON confirmed the first photo showed 14 medication cups with pills in them, stacked and not labeled and the second photo with nine medication cups, empty and lined up not labeled. Interview on 12/31/25 at 10:06 A.M. with Pharmacist #314 revealed medications are not to be prefilled with pills ahead of time, stacked, and unlabeled. Pharmacist #314 reported medications are to be administered one at a time. Review of facility General Dose Preparation and Medication Administration Policy, revised 11/15/24, revealed only prepare medications for one resident at a time. This deficiency represents non-compliance investigated under Complaint Number 2664936.

Based on interview, record review, and Employee Handbook review, the facility failed to ensure staff were awake at all times to effectively meet the needs of all residents. This had the potential to affect all 81 residents in the facility. Findings include:1. Review of employee personnel file for Dietary Aide (DA) #293 revealed a Disciplinary Action Form dated 12/19/25 for termination for sleeping on the job in the main lobby. Attached to the form was a statement dated 12/19/25 signed by Human Resource (HR) #230 and Administrator. HR #230 found DT #293 sleeping in the lobby and got the Administrator to witness. HR #230 woke DT #293 up and he apologized stating he did not fully intend to fall asleep but had not slept well the night before. Interview on 12/22/25 at 7:57 A.M. with Resident #22 revealed staff sleep on night shift.Interview on 12/22/25 at 1:49 P.M. with Director of Nursing (DON) confirmed DA #293 was found sleeping and was terminated.Interview on 12/24/25 at 8:48 A.M. with Resident #23 revealed staff sleep on night shift.Interview on 12/30/25 at 8:00 A.M. with Confidential Individual #400 revealed they had witnessed staff sleeping on night shift.Interview on 12/30/25 at 12:56 P.M. with Human Resource (HR) #323 confirmed Dietary aide # 277 was found asleep in the lobby. HR #323 reported she called out Administrator to witness and he was suspended on 12/19/25 pending investigation. HR #323 reported he was terminated on 12/24/25 for sleeping on the job.Interview on 01/06/26 at 11:29 A.M. with Administrator confirmed DA #293 was found sleeping on the job and terminated.2. Review of employee personnel file for Certified Nursing Assistant (CNA) # 277 revealed a Disciplinary Action Form dated 12/30/25 for termination for sleeping on the hallway. Interview on 12/22/25 at 7:57 A.M. with Resident #22 revealed staff sleeping on night shift.Interview on 12/30/25 at 8:00 A.M. with Confidential Individual #400 revealed she had witnessed staff sleeping on night shift.Interview on 12/30/25 at 9:50 A.M. via phone with Registered Nurse (RN), Midnight Supervisor # 212 confirmed (CNA) #277 was found asleep on 12/30/25 at 1:32 A.M.Interview on 12/30/25 at 1:43 P.M. with DON confirmed CNA #277 was found sleeping, suspended and would be terminated.Review of Employee Handbook, dated 01/01/24 revealed on pages 36 and 37, for critical offenses, acts considered serious in nature and will result in immediate discharge to include #17, sleeping on the Community's premises during scheduled working hours. This deficiency represents non-compliance investigated under Complaint Number 2664936.

Based on observation, interview, and record review, the facility failed to ensure Resident #2's gastric tube was properly assessed, monitored, and cared for. This affected one resident (Resident #2) out three residents reviewed for feeding tubes. Findings include:Review of medical record for Resident #2 revealed an admission date of 08/28/25 with diagnosis included but not limited to, chronic respiratory failure, other artificial openings of gastrointestinal tract status, type 2 diabetes mellitus with diabetic neuropathy, severe protein-calorie malnutrition, gastrostomy infection, end stage renal disease, dependence on renal dialysis, dependence on respirator, and tracheostomy status.Review of the care plan dated 09/02/25 and last revised 09/11/25 revealed Resident #2 was at nutrition risk related to gastric tube related to chronic respiratory failure on ventilator, tracheostomy, and end stage renal disease (ESRD) on dialysis. Goal to include Resident #2 will be free of complications related to presence of feeding tube daily. Intervention to include provide tube site care per physician order and facility policy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had intact cognition. Resident #2 was dependent for activities of daily living (ADL) care.Review of the care plan dated 09/02/25 and last revised 09/11/25 revealed Resident #2 was at nutrition risk related to gastric tube related to chronic respiratory failure on ventilator, tracheostomy, and end stage renal disease (ESRD) on dialysis. Goal to include Resident #2 will be free of complications related to presence of feeding tube daily. Intervention to include provide tube site care per physician order and facility policy. There was no evidence of readmission on [DATE] care plan for feeding tube care.Review of the progress note dated 10/07/25 at 7:29 A.M revealed Resident 2 had two episodes of emesis, the physician was notified and ordered to send the resident to hospital for evaluation.Review of the progress note dated 10/12/25 at 6:00 P.M. revealed Resident #2 was readmitted to facility. Review of Resident #2's readmission/admission assessment dated [DATE] at 5:03 A.M. revealed the readmission/admission assessment was started and mostly incomplete. The gastrointestinal system section had nothing completed, including information on the residents gastric tube as of 10/16/25.Review of Resident #2's medical record including physician orders, progress notes, Medication Administration Record (MAR), and Treatment Administration Record (TAR) for 10/12/25 through 10/14/25 revealed no evidence for care of the feeding tube site, including monitoring of the site, and drainage: quantity, odor, and appearance.Observation and interview on 10/14/25 at 10:45 A.M. of Resident #2's J-tube on her left side revealed what looked like an ostomy bag with tube feeding coming out of site in bag which was dark brown drainage with what appeared to be granules. Resident #2 reported the peg site was from the hospital that way.Review of the physician orders for 10/15/25 revealed an order was initiated three days after readmission to change jejunostomy tube (J-tube) bag/pouch and set up as needed (PRN), every hour PRN and change J-tube ostomy bag and set up every 3 days. J-tube was a small tube inserted into the jejunum, the second part of the small intestine to provide nutrition when a person cannot eat by mouth. Review of the MARS and TARS for 10/15/25 revealed orders three days after admission to monitor J-Tube site and peri skin every shift. Special instructions to monitor for redness, tenderness, itching, burning, and/or swelling. Report changes to provider and document in a note.Interview on 10/15/25 at 6:36 A.M. with Director of Nursing (DON) confirmed there were no orders for Resident #2 for dressing changes for her J-tube site until 10/15/25. Interview on 10/15/25 at 12:10 P.M. via phone with Physician #301 confirmed Resident 2 should have routine care for the J-tube site.Interview on 10/16/25 at 8:16 A.M. with Licensed Practical Nurse (LPN) #303 confirmed all residents with feeding tubes, to include J-tube should have orders for the care. LPN #303 confirmed after reviewing Resident #2's orders, to include discontinued orders she did not have any orders for the care of her J-tube site on her readmission to facility on 10/12/25, 10/13/25 and 1014/25. LPN #303 reported orders for the J-tube site were put in on 10/15/25.Interview on 10/16/25 at 9:09 A.M. with Assistant Director of Nursing (ADON) #282 confirmed Resident #2 did not have any orders on her readmission for 10/12/25, 10/13/25, and 10/14/25 for her J-tube site care. ADON #282 confirmed an order for Resident #2's J- tube site care was put in on 10/15/25 and she provided the care on that day.Interview on 10/16/25 at 3:22 P.M. with DON confirmed the readmission assessment for Resident #2 was not initiated until 10/13/25 at 5:03 A.M. DON confirmed the reassessment initiated on 10/13/25 at 5:23 A.M. by LPN #232 was mostly incomplete and the section for gastrointestinal system had nothing documented, including nothing for the J-tube site. Interview on 10/16/25 at 3:28 P.M. with LPN #227 confirmed the admission/readmission is to be initiated promptly by the admitting nurse and completed before leaving work. Interview on 10/16/25 at 3:28 P.M. with RN #294 confirmed the admission/readmission is to be initiated promptly by the admitting nurse or nurse on next shift and completed before timely. RN #294 confirmed, by pulling up Resident #2's readmission assessment, it was not timely, initiated on 10/13/25 and not completed, with many incomplete sections to include the gastrointestinal system. RN #294 confirmed 4 days later is not timely. Review of facility policy, Enteral Feeding Tube(s) Policy revised 11/19/24, revealed site care, to include enteral tube entrance sites will be monitored daily and observed for the following, erythema or edema, and drainage: quantity, odor, and appearance. Review of facility policy, admission re-admission Process, revised 03/19/25, revealed admissions/readmissions will have required assessment/documents initiated promptly. This deficiency represents non-compliance investigated under Complaint Number OH002638099.

Based on closed record review, policy review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer program to ensure necessary and timely interventions were initiated for Resident #96 who was identified to have skin breakdown in the hospital just prior to admission. The facility also failed to timely identify changes in skin integrity and implement necessary wound care to promote wound healing and prevent infection.Actual harm occurred on 07/31/25 when Resident #96, who was dependent on staff for activities of daily living, was transferred to the hospital due to a change in condition. The resident was subsequently assessed by hospital staff to have an unstageable sacral wound with a significant amount of purulence in the tissue consistent with a necrotizing soft tissue infection. Hospital staff also documented the resident had a pressure injury to the right buttock, a pressure injury to the right heel (assessed to be black), a pressure injury to the upper posterior right leg (assessed to be a suspected deep tissue pressure injury). Prior to the hospital identification and assessment, there was no evidence the facility had knowledge of these areas or an active treatment plan in place to prevent, monitor and promote healing. This affected one resident (#96) of three residents reviewed for wound/pressure ulcers.Findings include:Review of Resident #96's medical record revealed an After Visit Summary for a hospital stay from 06/30/25 through 07/08/25 that reflected Resident #96 had a coccyx (active) pressure injury (identified on 07/05/25). On 07/06/25 the coccyx pressure area was non-blanchable (skin discoloration that did not fade or turn white when pressed, indicating bleeding under the skin rather than increased blood flow. This type of discoloration was a significant clinical sign that required immediate medical attention, as it could signal developing pressure injuries), had erythema (abnormal redness of the skin, caused by dilation and irritation of the superficial capillaries), sloughing (sloughing in pressure injuries referred to the presence of dead tissue, appearing as yellow, tan, gray, or green stringy material that covered the wound bed. This tissue consisted of protein fibers and dead skin cells and impeded healing by obscuring the wounds true depth and staging) and was pink. The peri-wound was blanchable, had erythema and was fragile. The hospital record noted treatment to the coccyx pressure area included cleansing, a moisture barrier ointment and foam dressing. Review of Resident #96's closed medical record revealed an admission date of 07/08/25 with diagnoses including malignant neoplasm of the ascending colon, secondary neoplasm of the liver and intrahepatic bile duct, severe protein calorie malnutrition and type two diabetes mellitus with diabetic polyneuropathy. On 07/31/25 Resident #96 was transported to the hospital emergency department (ED), admitted to the hospital and did not return to the facility. Review of Resident #96's facility admission Observation dated 07/08/25 at 6:19 P.M. documented Resident #96 had no alterations in skin. The admission observation failed to include identification of the pressure injury to the resident's coccyx identified on 07/05/25 during the resident's hospitalization or treatment that was in place to the area. Resident #96's Braden Scale assessment dated [DATE] revealed the resident was at high risk for developing pressure ulcers, injuries.Review of Resident #96's care plan dated 07/08/25 included Resident #96 was at risk for pressure ulcers related to his diagnoses. The goal developed was for Resident #96's skin to remain intact. Interventions included to conduct a systematic skin inspection weekly and as needed (pay particular attention to the bony prominences) and report signs of skin breakdown (sore, tender, red, or broken areas). The plan of care failed to include evidence of the pressure injury to the resident's coccyx identified on 07/05/25 during the resident's hospitalization or evidence ongoing treatment was in place to the area. Review of Resident #96's Weekly Observation dated 07/08/25 revealed there were no skin issues noted. Review of Resident #96's Observations dated 07/08/25 through 07/31/25 did not reveal evidence additional Weekly Observations were completed. In addition, review of the Observations dated 07/08/25 through 07/31/25 revealed no evidence Assistant Director of Nursing (ADON) #275 had completed a skin assessment during this time.Review of Resident #96's physician orders dated 07/08/25 revealed pressure reducing/reduction orders to float heels when in bed as tolerated, every shift (day shift and night shift). Provide pressure reducing cushion to chair and document cushion in place in the chair. Provide pressure reducing mattress to the bed and document that mattress was in place. Turn and reposition in bed as tolerated every shift, every day shift and night shift. Review of Resident #96's medical record including progress notes, General Administration Records, Treatment Administration Records, Medication Administration Records and Point of Care aide charting dated 07/08/25 through 07/31/25 revealed no documented evidence Resident #96 was turned and repositioned when he was in bed. In addition, there was no documented evidence of pressure reducing cushion was placed on his chair, a pressure reducing mattress was on his bed or his heels were floated when he was in bed.Review of a facility Wound Summary Report dated 07/08/25 through 07/31/25 revealed it did not include Resident #96 had any type of wounds/pressure ulcers.Review of Resident #96's Wound Management records dated 07/08/25 through 07/31/25 revealed no evidence Resident #96 had any type of wounds/pressure ulcers.Review of Resident #96's shower sheets dated 07/11/25, 07/14/25, 07/16/25, 07/18/25, 07/22/21, 07/25/25 and 07/28/25 revealed no documented evidence of any type of pressure ulcers, or any reddened or open areas to the resident's coccyx. Review of Resident #96's admission Minimum Data Set assessment dated [DATE] revealed Resident #96 was cognitively intact. The assessment revealed Resident #96 was dependent (on staff) for toileting hygiene, lower body dressing and the ability to move from lying on the back to sitting on the side of the bed. Resident #96 required substantial to maximal (staff) assistance with bathing, upper body dressing, and the ability to roll from lying on his back to the left and right side and return to lying on his back. Resident #96 was occasionally incontinent of urine and always incontinent of bowel. The assessment revealed Resident #96 was at risk of developing pressure ulcers, injuries. Review of Resident #96's physician orders dated 07/16/25 revealed PATH (skilled nursing documentation) observation to be completed every shift, twice a day. Review of Resident #96's PATH observation documentation dated 07/16/25 through 07/30/25 revealed observations were not completed two times a day as ordered. There was no PATH documentation on 07/19/25 or 07/20/25. On 07/21/25 there was one PATH observation. There were no PATH observations documented on 07/23/25, 07/24/25, 07/25/25, 07/27/25, 07/28/25, or 07/29/25. On 07/26/25 and 07/30/25 there was only one PATH observation documented.Review of Resident #96's PATH observations from 07/16/25 through 07/30/25 revealed the nurses documented Resident #96's skin was intact and he did not have an order for a dressing. However, review of Resident #96's Point of Care History dated 07/16/25 at 1:43 P.M., documented by State Tested Nursing Assistant (STNA) #295, revealed Resident #96 had an open area on his buttock and a dressing on his buttock. On 07/19/25 at 9:55 A.M. STNA #295 documented Resident #96 had an open area on his buttock and a dressing on his buttock. On 07/28/25 at 10:13 A.M. and 07/30/25 at 9:09 A.M., STNA #295 documented Resident #96 had a dressing on his buttock. Resident #96's Occupational Therapy Treatment Encounter Note dated 07/23/25 revealed Resident #96 complained of coccyx pain and nursing was aware. Resident #96 had poor tolerance for sitting in a wheelchair, had slouched posture with hips very close to the edge of the seat. Resident #96 reported it was due to pain of the coccyx and Resident #96 refused to stay in the chair following the session and was assisted to his bed. The note was signed by Occupational Therapist (OT) #410 on 07/23/25 at 12:54 P.M. Review of Resident #96's progress notes dated 07/22/25 at 12:13 P.M. through 07/24/25 revealed no written evidence Resident #96 was having pain in his coccyx during therapy or evidence interventions were attempted related to the pain or to determine the source of the pain.Review of a transportation schedule revealed Resident #96 was transported by the facility to a physician appointment on 07/31/25 at 11:00 A.M.However, review of the corresponding nursing progress note dated 07/31/25 revealed no documentation was completed on this date related to the resident leaving to go to the appointment, the resident's condition at the time he left and/or the resident's status. There was no additional entry/documentation to reflect the resident was transferred from the physician appointment to the emergency room and subsequently admitted to the hospital and/or why. Review of Resident #96's ED to Hospital admission paperwork dated 07/31/25 included Resident #96's arrival time was 07/31/25 at 11:27 A.M. Resident #96 had an appointment at the hospital cancer center, was unresponsive and hypoxic and was transported to the ED. A nasal trumpet (a soft flexible tube inserted into a nostril to keep the airway open) was placed and Resident #96 was put on a non-rebreather mask (delivers high concentrations of oxygen to patients who are experiencing severe respiratory distress but do not require mechanical ventilation) and his oxygen saturations began to increase. Resident #96 was minimally responsive on arrival. Resident #96's reason for the visit included hypoxia, sepsis, an unstageable pressure injury of the sacral region, a wound of the sacral region, initial encounter, a wound of the sacral region subsequent encounter. Further review of the hospital record revealed on 07/05/25 at 8:00 A.M. an unstageable pressure injury of the coccyx was first assessed. On 07/08/25 at 9:20 A.M. Resident #96 was assessed to have a Deep Tissue pressure injury to the right buttock (active) which was first assessed on this date. On 07/08/25 at 9:20 A.M. Resident #96 had a Deep Tissue Pressure Injury of the right heel. On 08/01/25 at 8:00 A.M. Resident #96 had a right, upper posterior leg Deep Tissue Injury. Review of a hospital operative note dated 08/05/25 revealed Resident #96 had an unstageable sacral wound. Resident #96 had an excisional debridement (skin subcutaneous tissue muscle fascia) necrotizing soft tissue infection of the sacrum and measurements included length of 11.0 centimeters (cm) with a width of 16 cm. There was a significant amount of purulence in the tissue consistent with a necrotizing soft tissue infection. The postoperative diagnosis was necrotizing soft tissue infection of the sacrum.Review of Resident #96's After Visit Summary for a hospital visit dated 07/31/25 through 08/17/25 included Resident #96 had a wound identified on 07/05/25 as a pressure injury to the coccyx (active). On 08/01/25 at 3:50 P.M. the coccyx was documented to be necrotic. The area was cleansed and a foam dressing was applied. The number of days the wound had been present was listed as 28. Resident #96 had a pressure injury of the right buttock (active) identified on 07/08/25. The number of days listed that the pressure injury was present was 25. A pressure injury of the right heel (active) was identified on 07/08/25. On 08/01/25 at 1:26 P.M. the right heel was assessed and was described as black. The treatment was site care. Number of days present was 25. An upper posterior right leg pressure injury (active) was identified on 08/01/25 at 1:27 P.M. The upper posterior right leg pressure injury was described as purple (a purple or maroon color in a pressure injury, also known as a suspected deep tissue pressure injury indicated damage to the underlying soft tissue even if the skin was intact). The treatment was site care. The number of days was one.Interview on 09/24/25 at 11:55 A.M. with Resident #96's spouse (Wife #425) revealed she thought Resident #96 had a sore starting on his backside when he was admitted to the facility and he had a bed sore on his heel. Wife #425 stated someone at the hospital gave her a white bottle with medication that needed put on Resident #96's sores, and she gave the medication to a nurse at the facility and told her it needed put on the sores. Wife #425 could not remember what nurse at the facility she gave the medication to and did not know the name of the medication in the white bottle. On 07/31/25 Resident #96 had an appointment at the hospital to see an oncologist, but when he got there he was in a bad state, unresponsive, and he was taken to the ED. Wife #425 stated when Resident #96 was re-admitted to the hospital on [DATE] he had a deep wound on his backside, he needed surgery, and the surgeon told her it was one of the worst wounds he had seen. The wound was very deep and going into his spine. Wife #425 indicated she asked Resident #96 more than once if his wounds were being treated and she told the nurse the wounds were not being treated. Wife #425 stated Resident #96 was not changed timely and layed in feces for hours. One time Wife #425 stated she charged down to the nurse's station and was told they would be right in, but they did not come in. Wife #425 stated she told the social worker and she made sure Resident #96's incontinence brief was changed. Wife #425 stated Resident #96 had a lot of different aides and none took care of him consistently.Interview on 09/24/25 at 4:13 P.M. with OT #410 revealed she gave Resident #96 a shower, but did not remember details of any abnormal skin areas. OT #410 revealed Resident #96 was very frail and thin and did not spend much time out of bed.Interview on 09/24/25 at 5:06 P.M. of Nurse #247 revealed she did not remember Resident #96.Interview on 09/25/25 at 11:32 A.M. with the Director of Nursing (DON) revealed she was unaware Resident #96 had any wounds when he was admitted to the facility or during his stay at the facility. Interview on 09/25/25 at 11:33 A.M. with Assistant Director of Nursing (ADON) #275 revealed after residents were admitted to the facility a Team review of the resident was completed. The Team reviewed paperwork and made sure everything on the discharge summary was addressed and followed up if everything was not addressed. ADON #275 stated she did not remember Resident #96 having any wounds and when she evaluated him, she denied any awareness of wounds.During an interview on 09/25/25 at 12:03 P.M. with Regional Director of Operations (RDO) #400, RDO #400 reviewed Resident #96's hospital paperwork (prior to admission) and verified the resident had a non-blanchable area on his coccyx. RDO #400 stated the coccyx area healed before Resident #96 was admitted to the facility, and Resident #96 did not have any pressure injuries when he was admitted to the facility. RDO #400 stated the nurses documented Resident #96 did not have any open areas of the skin while he resided at the facility.Interview on 09/28/25 at 2:57 P.M. with Certified Nursing Assistant (CNA) #253 revealed she took care of Resident #96 during the resident's stay and he had a reddened area right at the top of his tailbone that was approximately an inch in diameter. CNA #253 stated she could not remember if it had any other colors in it. Resident #96 had an abdominal (ABD) dressing covering the area on his tailbone. CNA #253 indicated sometimes the dressing came off when it was soiled and she always notified the nurses when this happened, and the nurse would put another dressing over the tailbone. CNA #253 stated the aides tell the nurses when residents including Resident #96 had open areas on their skin. CNA #253 indicated Resident #96 complained of pain, but she could not remember how severe the pain was. During the interview, CNA #253 stated residents including Resident #96 did not get turned and repositioned every two hours like they were supposed to by the staff, and she did not know why.Interview on 09/25/25 at 12:52 P.M. with Nurse #247 revealed she reviewed Resident #96's medical record after her conversation with the surveyor on 09/24/25 at 5:06 P.M. Nurse #247 then revealed she had admitted Resident #96 to the facility on [DATE]. The nurse revealed Resident #96 was admitted on [DATE] and he did not have skin issues or wound treatment orders when he was admitted . Nurse #247 revealed she was again working on 07/31/25 when Resident #96 was transported to his physician appointment, but she did not remember details of Resident #96 leaving for his appointment. Nurse #247 confirmed there was no evidence in Resident #96's progress notes that he left the faciity on [DATE] for an appointment, did not return, or was admitted to the hospital. Nurse #247 stated she could not remember why she did not document any of those things.Interview on 09/29/25 at 10:42 A.M. with CNA #273 revealed on 07/31/25 she transported Resident #96 to his appointment. CNA #273 stated she did not know Resident #96 very well but thought he seemed like his normal self. The CNA revealed it was raining and an employee at the Oncology Center assisted Resident #96 into the building. CNA #273 indicated she contacted the Oncology Center to check on Resident #96 and was told he was taken to the ED.During an interview on 09/29/25 at 11:17 A.M. Nurse #420 revealed wound treatments were not completed timely and sometimes not at all. Nurse #420 indicated Resident #96 had a wound, but she did not know the details because she was not assigned to care for him. Nurse #420 did not reveal how she knew Resident #96 had a wound. The nurse revealed there was a lack of education for the nurses and many of the nurses were more interested in socializing with each other rather than taking care of the residents. Nurse #420 stated she brought her concerns regarding wound treatments not completed timely to the Administrator and Director of Nursing but got nowhere. Nurse #420 stated she was told by other nurses that she was taking too long when she admitted residents and did not need to do a full skin assessment for each admission.Interview on 09/29/25 at 12:07 P.M. with the DON revealed PATH observations should be completed one time a day, and she had orders written for two times a day so that the PATH observation would be completed at least one time a day. The DON confirmed Resident #96's PATH observations were not completed at least one time a day from 07/08/25 through 07/30/25. The DON confirmed Resident #96 did not have Weekly Observations completed for skin evaluation and stated it was not required to have Weekly Observations of skin. The DON confirmed Resident #96's medical record including progress notes, General Administration Records, Treatment Administration Records, Medication Administration Records and Point of Care aide charting dated 07/08/25 through 07/31/25 revealed no documented evidence Resident #96 was turned and repositioned when he was in bed. In addition, there was no documented evidence of pressure reducing cushion was placed on his chair, a pressure reducing mattress was on his bed or his heels were floated when he was in bed. The DON stated she did not know why there was no evidence these things were completed because there were orders in Resident #96's record, and she believed staff were completing these things. When told Resident #96 had documentation in the Point of Care aide charting on 07/16/25, 07/19/25, 07/28/25 and 07/30/25 that Resident #96 had open areas and dressings on his buttock the DON stated she would look into it. Interview on 09/29/25 at 2:49 P.M. with CNA #296 revealed she took care of Resident #96 while he resided at the facility. The CNA revealed Resident #96 did not like the aides to do much for him and stayed in his bed a lot. CNA #296 stated Resident #96 had a red area on his butt and the aides put cream on it. CNA #296 indicated she always told the nurses about Resident #96's red area and was told to apply cream. CNA #296 stated Resident #96 had the red area on his buttock, but she did not remember if he had a skin issue on the heel. CNA #296 stated we always report to the nurses when we see something.Interview on 09/29/25 at 3:08 P.M. with the Administrator revealed if a resident was admitted to the hospital, she feels like there should be documentation they left and came back (included in the medical record). During the interview, the Administrator revealed Resident #96's wife mentioned the resident did not get his incontinence brief changed timely and told the social worker who made sure he was changed right away. The Administrator denied Resident #96's hospital discharge instructions had treatment orders (even though the hospital after summary included the use of a moisture barrier ointment and a foam dressing). The Administrator stated she would expect nurses to obtain a treatment order if they observed Resident #96's wound.Interview on 09/29/25 at 4:00 P.M. with RDO #400 and the DON confirmed Resident #96's Point of Care History dated 07/16/25 at 1:43 P.M. documented Resident #96 had an open area on his buttock and a dressing on his buttock. On 07/19/25 at 9:55 A.M. Resident #96 had an open area on his buttock and a dressing on his buttock. On 07/28/25 at 10:13 A.M. and 07/30/25 at 9:09 A.M. Resident #96 had a dressing on his buttock. RDO #400 stated the open areas and dressings were only documented by one aide, and felt the aide could have made a mistake. RDO #400 stated the nurses documented there were no skin issues. Review of the facility policy titled Pressure Injury Prevention and Treatment Policy revised 09/18/23 included residents admitted with existing pressure injuries would receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. New pressure injuries would not develop unless the individual's clinical condition demonstrated they were unavoidable. Pressure injuries identified would be assessed initially and at least weekly thereafter, until closed. All assessments would include location and stage, size, exudate, pain, wound bed, appearance of surrounding tissue and any evidence of infection. Pressure injuries identified would be documented and orders obtained from providers for treatment.This deficiency represents non-compliance Complaint Number 2624905, 2609502, 1404959, 1404954, and 1404955.

Based on observation, interview, record review, hospital record review, and interview, the facility failed to ensure Resident #39 received proper care and assistance in managing his ostomy and tube feed needs. This affected one resident (Resident #39) of three residents reviewed for dependent resident care.Findings include:Review of Resident #39's medical record revealed an admission date of 03/31/25 and a return date of 08/31/25. Resident #39's diagnoses included acute and chronic respiratory failure with hypoxia, Rett's syndrome, Todd's paralysis (post epileptic), and epileptic seizures related to external causes, not intractable, with status epilepticus.Review of Resident #39's Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status was not completed because he was rarely or never understood. Resident #39 was dependent for activity of daily living (ADL), the ability to roll from lying on his back to the left and right side and return to lying on back on the bed, and chair-to-bed-to-chair transfers. Resident #39 had a wheelchair. Resident #39 had a catheter and an ostomy. Resident #39 had medically complex conditions. Review of Resident #39's care plan revised 08/12/25 revealed Resident #39 had self-care deficits related to acute and chronic respiratory failure, seizure disorder and other diagnoses. Resident #39's needs would be met through the next review. Interventions included Resident #39 was dependent on two staff and used a mechanical lift; last check and change on last rounds on night shift.Review of Resident #39's Enteral Administration History dated 08/01/25 through 08/31/25 revealed enteral feeding tube site care, once a day, clean tube feeding site and apply split gauze to area daily was documented it was completed every day as ordered including 08/31/25. Review of Resident #39's nursing orders dated 08/05/25 revealed orders for skin checks weekly and as needed.Review of Resident #39's physician orders dated 08/05/25 revealed orders for Calmoseptine (menthol-zinc oxide) 0.44 -20.6 percent, apply to GJ (gastrojejunostomy) irritation as needed.Review of Resident #39's nursing orders dated 08/05/25 revealed orders to change colostomy skin barrier appliance (wafer) as needed for leakage or detachment.Review of Resident #39's nursing orders dated 08/05/25 revealed orders to change colostomy bag, pouch and set up as needed.Review of Resident #39's nursing orders dated 08/05/25 revealed orders to monitor stoma site and peristomal skin every shift, monitor for redness, tenderness, itching, burning, and, or swelling. Report changes to provider and document in a note, every day shift and night shift.Review of Resident #39's progress notes dated 08/26/25 through 08/31/25 did not reveal evidence Resident #39's right lower abdominal area was very red and irritated.Review of Resident #39's Treatment Administration History dated 08/26/25 revealed the weekly skin check was marked it was done but there was no evidence a weekly skin check observation was completed.Review of Resident #39's Treatment Administration History dated 08/31/25 revealed there was no evidence Resident #39's colostomy skin barrier appliance was changed due to it being detached from the ostomy. There was no evidence Resident #39's colostomy bag, pouch and set-up was changed due to it being detached from the ostomy.Review of Resident #39's Treatment Administration History dated 08/05/25 through 08/31/25 did not reveal evidence Calmoseptine ointment was applied for GJ irritation.Review of the facility assignment sheets dated 08/31/25 from 7:00 A.M. through 7:00 P.M. revealed Nurse #229 was assigned to care for Resident #39.Review of Resident #39's Treatment Administration History dated 08/31/25 on day shift documented by Nurse #229 revealed Resident #39's stoma site and peristomal skin did not have redness, tenderness, itching, burning or swelling. Review of Resident #39's progress notes dated 08/31/25 at 9:35 A.M. revealed the respiratory therapist (RT) called Nurse #229 to Resident #39's room. Nurse #229 found Resident #39's tube (G-tube) was out and he needed to go to the local hospital ED for a new tube.Review of Resident #39's progress notes dated 08/31/25 at 9:35 A.M. through 08/31/25 at 10:33 A.M. did not reveal evidence Resident #39's ostomy bag was detached from his ostomy site and needed replaced. There was no evidence Resident #39's tube feeding was draining onto Resident #39 and the floor of his room.Review of Resident #39's progress notes dated 08/31/25 at 10:33 A.M. revealed Resident #39 was transported via EMS to the ED.Review of Resident #39's hospital ED progress notes dated 08/31/25 at 11:41 A.M. revealed Resident #39 arrived at the hospital ED via EMS from the facility. It was reported that Resident #39's G-tube was out and the facility was unaware when it became dislodged. The EMS staff stated when they arrived at the facility Resident #39 was covered in feed from the feeding tube and no ostomy bag was on the ostomy. The EMS staff asked the facility to place a bag on the ostomy and Resident #39 arrived at the hospital ED with an ostomy bag laid on top of the ostomy and the ostomy bag was not attached. The bag was not attached to the ostomy and gastric contents from the ostomy were leaking over Resident #39's skin, into Resident #39's diaper (incontinence brief) and on his abdominal binder. Resident #39's binder was saturated. The G-tube had brown contents leaking from the site onto the skin. Pictures were obtained by the physician. Resident #39 was bathed, given a clean incontinence brief and clean gown. A dressing was applied around the G-tube site. A new ostomy bag was placed to Resident #39's ostomy. Resident #39's skin on his right lower abdomen was extremely red and irritated. The physician checked placement of Resident #39's G-tube. The RT was notified Resident #39 had a trach. Resident #39 was covered with warm blankets. On 08/31/25 at 3:43 P.M. Resident #39 was discharged to the facility and was awake, alert and appropriate for baseline at discharge.Review of Resident #39's hospital ED physician provider notes dated 08/31/25 revealed Resident #39 had a history of multiple chronic medical problems who presented with his G-tube displaced. Resident #39 arrived via EMS with concerns for neglect at his home health care facility. On EMS arrival to Resident #39's room at the facility his feeding tube was noted to be dislodged. The timing of the dislodgement was unknown. A drain of unknown purpose was found leaking into a basin. Resident #39's ostomy bag was not in place, with leakage noted and Resident #39 was covered in feces and stomach contents. There was tube feed spillage on the floor and feces on his bed. Resident #39's room at the facility was described as being without stimulation such as toys or a television. This was a recurrent issue regarding Resident #39's care at the facility. Additional comments included Resident #39 had an ostomy with a [NAME] button in place draining yellow-green fluid onto the abdominal wall. The balloon was filled with 5 cc of fluid. There were crusties on the stoma and the ostomy site was covered by an ostomy bag without any adhesive. Liquid stool was expelled from the stoma onto the abdominal wall. Stoma site appeared irritated and there was erythematous satellite lesions surrounding the stoma on the abdomen. Review of Resident #39's hospital ED notes dated 08/31/25 revealed Resident #39's final diagnoses included candida dermatitis, leaking percutaneous endoscopic gastrostomy tube (PEG), irritant contact dermatitis associated with digestive stoma, and medical neglect of an adult by a caregiver. Start Calmoseptine (menthol-zinc oxide) 0.44-20.6 percent ointment, apply to affected areas on abdominal wall twice daily for at least two weeks, and nystatin 100000 units per gram ointment, apply to red areas on abdominal wall twice daily for at least two weeks.Review of Resident #39's progress notes dated 08/31/25 at 4:20 P.M. revealed Resident #39 returned to the facility and had a new tube (G-tube) placed.Observation on 09/24/25 at 2:55 P.M. of Resident #39 revealed the door was closed to his room and there was an Enhanced Barrier Precaution sign on the door. The surveyor knocked on the door, opened the door and as the door was opened a very unpleasant, strong odor was noticed. A large puddle of greenish-yellow material was noted on the floor under Resident #39's padded wheelchair. Resident #39 was alone in the room with no staff present and was sitting in a padded wheelchair. The padded wheelchair was positioned so Resident #39 was sitting in a tilted backward position. Fresh drip marks were seen on the back of the padded wheelchair and the drips led to the puddle on the floor. A long tube could be seen that appeared to come from Resident #39's abdominal area and the long tube was attached to a small bag that was laying in a basin, and the basin was placed on the floor. The bag had a small amount of thick yellowish material in it. Tube feeding was being administered via a pump through another tube leading to Resident #39's abdomen. Nurse #430 entered Resident #39's room and stated the J-tube (jejunostomy) was used for tube feeding and the other tube was gastric contents. Nurse #430 confirmed there was a large puddle of yellowish-green material on the floor under Resident #39's wheelchair. Nurse #430 lifted Resident #39's shirt, an abdominal binder was observed and a tube could be seen under the abdominal binder but it was unclear where it originated. About six inches from the abdominal binder a pillow case could be seen and it was wrapped around the tube draining gastric contents. The pillowcase was saturated with greenish-yellow material. Certified Nursing Assistant (CNA) #296 stated Resident #39 was at activities and Activity Director (AD) #227 brought him back to his room and closed the door. CNA #296 stated the door to Resident #39's room should not be closed unless care was being provided. Nurse #430 stated she did not wrap a pillowcase around the tube draining gastric contents and she thought the night nurse stayed over and wrapped it. Nurse #430 stated the night nurse told her the tube was leaking, but Nurse #430 did not think the tube was leaking as much as it was and she had not checked it since around 12:00 P.M. Assistant Director of Nursing (ADON) #275 entered Resident #39's room and indicated the tube draining gastric contents was a venting drain. Resident #39 was assisted into his bed using a mechanical lift, and the wheelchair seat was wet on the left side near where the venting drain was leaking. Resident #39's pants and shirt were wet from the drainage, and his incontinence brief was soaked with the yellowish-green drainage. CNA #296 stated she wrapped Resident #39's tube with the pillowcase in the morning because it was leaking, and it was not the night nurse who wrapped it. Observation revealed Resident #39's right lower abdomen and penis were very red and irritated looking. Nurse #430 confirmed the areas were red and indicated it always looks like that. When asked if there was any treatment ordered Nurse #430 was unclear in her answer and stated he is always digging and fidgety. ADON #275 left the room to get supplies to change the venting tube tubing, returned and changed the tubing. Resident #39 was unable to be assisted back to his wheelchair due to the mechanical lift pad was wet with the yellowish-green drainage and there were no clean mechanical lift pads available.Interview on 09/24/25 at 3:26 P.M. of AD #227 revealed Resident #39 did not attend activities today (09/24/25) because in the morning around 10:30 A.M. when she went to his room to assist him to activities he needed his medication and was unable to come. AD #227 stated she tried to get him for the afternoon activity around 1:45 P.M. but his door was closed and she thought he was having care provided and AD #227 left without entering Resident #39's room. Interview on 09/24/24 at 3:45 P.M. of Nurse #430 revealed Resident #39 had a G-tube and that was the tube that was long and connected to a bag that was placed in the basin on the floor, and the G-tube was leaking gastric contents onto Resident #39, his clothes, his incontinence brief, his abdominal binder, the wheelchair and the floor. Nurse #430 stated Resident #39 had a J-tube (jejunostomy tube) that was connected to the tube feeding, and he had a colostomy. Nurse #430 stated Resident #39 scratched himself and caused redness to the abdomen and penis, and there was no treatment ordered for the reddened areas.Interview on 09/25/25 at 1:23 P.M. of Nurse #229 revealed she did not remember caring for Resident #39 on 08/31/25 when his G-tube became dislodged, his ostomy bag was not attached to the ostomy site, and he was transported to the hospital.Interview on 09/25/25 at 5:15 P.M. of Nurse Practitioner (NP) #435 revealed she was not aware Resident #39 had redness of his lower abdomen and penis and was not notified the areas were red. NP #435 stated she was not surprised the areas were red because he had a G-tube and a colostomy. NP #435 stated Resident #39 had a colostomy, a trach, and a J and G tube. There was one tube inserted into Resident #39's abdomen and it had two ports. The G-tube was for gastric emptying and the J-tube was connected to tube feeding.Review of the facility policy titled Ostomy Care Procedure revised 09/19/24 included nursing personnel with demonstrated competence may provide routine ostomy site care. Changing the ostomy system included to remove and empty the used pouch, remove the wafer by gently and gradually loosening around the adhesive area, and gently cleanse the peristomal area with warm tap water and wash cloth, do not use soap. Pat the stoma and skin dry, and measure the stoma size using the measuring guide. It was important to fit the opening closely to the size of the stoma so little peristomal skin was exposed. Trace the pattern of the size of the opening on the wafer backing and cut the opening to size. Apply skin prep to the peristomal skin, remove adhesive wafer back and apply firmly to the peristomal skin. Attach the new bag to the [NAME] and close the end of the pouch with the closure device. Document per policy.Review of the facility policy titled Enteral Feeding Tube Policy revised 11/19/24 included licensed clinicians with demonstrated competence may administer enteral feedings and provide tube, site care. At each access of the tube for installation of fluids, nutrition, or medications, verification of placement would be conducted using the following methods: evaluate the clinical presentation of the residents including respiratory status, complaints of nausea, vomiting, feelings of fullness or excessive belching, or unusual abdominal distention. Observation of the volume and character of gastric aspirate. Do not use the tube if there was any doubt about its correct placement and contact the physician, provider for guidance. Enteral tube entrance [NAME] would be monitored daily and observed for erythema, edema, drainage including quantity, odor, appearance. Nurses should monitor the condition of the tube with each use and inform the physician if the tube becomes unusable, leaks or might need replacement. This deficiency represents non-compliance investigated under Complaint Number 2609502, 1404959, 1404954, and 1404958.

Based on observation, interview, tasting of meal test tray, and facility policy review, the facility failed to ensure meals provided were palatable and served at an appetizing temperature. This affected seven residents (Resident #10, #21, #26, #28, #30, #41, and #69) and had the potential to affect all 82 residents receiving meals from the facility. The facility identified three residents (#25, #65, and #281) who received nothing by mouth and did not receive food from the facility kitchen. The facility census was 85. Findings include: Interview on 03/17/25 at 10:44 A.M. with Resident #21 revealed the food is frequently cold and the coffee is cold. Interview on 03/17/25 at 1:16 P.M. with Resident #10 revealed the food tasted horrible and stated other residents have said they can't eat it as the food made them nauseous. Interview on 03/17/25 at 1:37 P.M. with Resident #28 revealed the facility frequently served cold food, especially on the weekends, and the food tasted terrible. Resident #28 stated staff do not use the plate warmer, instead they place food on the plate and cover it. Resident #28 stated she had brought her concerns to management about the food and meals being repetitive during past care conferences, but no changes had been made. Interview on 03/17/25 at 2:03 P.M. with Resident #30 revealed meals are frequently cold. Interview on 03/17/25 at 3:09 P.M. with Resident #26 revealed the breakfast tray is usually cold. Interview on 03/18/25 at 9:27 A.M. with Resident #69 revealed she did not eat breakfast as it was cold and really did not taste good. Resident #69 stated the food frequently tasted bad and the resident is not really interested in eating the facility's food. Interview on 03/19/25 at 9:36 A.M. with a family member of Resident #41 revealed sometimes her food is not served hot and does not look appealing. Observation on 03/18/25 at 7:42 A.M. with [NAME] #542 revealed the following food temperatures prior to the start of tray line: oatmeal 190 degrees Fahrenheit (F), pureed eggs 158 degrees F, pureed oatmeal 166 degrees F, egg spinach frittata 190 degrees F, egg and cheese omelet 152 degrees F and bacon 140 degrees F. Continued observation revealed the tray line started at 7:50 A.M. No sanitation concerns were observed. Observation of the egg spinach frittata revealed it was not firm and did not hold shape upon being plated. Tray line ended at 8:27 A.M. A test tray went with the 300 resident hall cart. The last tray was passed on the 300 hall at 8:42 A.M. Observation of test tray with Food Service Manager #542 on 03/18/25 at 8:42 A.M. revealed the following temperatures: coffee 154 degrees F, milk 40 degrees F, oatmeal 114 degrees F, egg spinach frittata 115 degrees F, pureed eggs 111 degrees F, pureed oatmeal 106 degrees F, egg and cheese omelet 105 degrees F. Appearance of the test trays food items revealed the egg spinach frittata appeared mushy and had moisture around it. Upon tasting the egg spinach frittata, pureed oatmeal, and egg and cheese omelet, the items were not warm enough for preference. Interview with Food Service Manager #542 at the time of the tasting confirmed the items were not as warm as she would have preferred, and the spinach frittata was not as firm as it could have been. Review of the facility food committee meeting minutes dated 01/23/25 revealed a concern related to cold coffee. Review of the 12/31/24 revised facility policy called; Dining Experience at Mealtimes Policy revealed the facility will provide attractive, nourishing, and palatable meals that minimize negative health outcomes. Foods will be served at a palatable temperature.

Based on observation, interview and facility policy review, the facility failed to ensure resident refrigerators were maintained in a safe and sanitary condition, free from expired food. This affected one (Resident #10) of three resident refrigerators observed. The facility identified 29 residents with refrigerators in their rooms. The facility census was 85. Findings include: Review of the facility resident council meeting minutes dated [DATE] revealed a concern related to resident refrigerator having items that are not being labeled or dated and should only be kept for three days and then discarded. Observation and interview on [DATE] at 12:36 P.M. with the Administrator of Resident #10's room refrigerator revealed the following concerns: - A 16-ounce (oz.) bottle of Italian dressing with an expiration date of [DATE]. - A 16-oz. bottle of honey mustard dressing with an expiration date of [DATE]. - A 16-oz. bottle of ranch dressing with an expiration date of [DATE]. - A 32-oz. bottle of strawberry jam with an expiration date of [DATE]. -A 16-oz. opened bag of mild cheddar shredded cheese that appeared moldy and had some liquid in it with an expiration date of [DATE]. - An open and undated saran-wrapped chunk of Swiss cheese that had visible mold. At the time of the observation, the Administrator confirmed the findings. The Administrator stated facility management and nursing staff are to be checking the resident room refrigerators to ensure they are cleaned and expired items are discarded. Interview on [DATE] at 12:36 P.M. with the Administrator confirmed facility leadership talked with residents at the [DATE] resident council meeting about staff-identified concerns with residents having food in their room refrigerators. The Administrator stated staff would be monitoring resident refrigerators to ensure items were labeled, dated, and discarded timely for resident safety. Administrator confirmed more monitoring was needed. Review of the facility policy called; Food Brought in from outside the facility dated [DATE] revealed resident room refrigerator foods must be labeled and dated to ensure proper rotation by expiration dates. Designated employees will check food labels and date marking daily. Resident refrigerators and freezers will be kept clean and in working order.

Based on observation, interview, medical record review, observation of resident council, review of resident rights, and review of the formal complaint from residents at the facility, the facility failed to ensure residents were treated with dignity and respect. This affected four residents (#3, #69, #285, #28) of four residents reviewed for dignity. The facility census was 85. Findings include: Review of the formal complaint filed by several residents on 11/24/24 revealed the residents felt like staff members were immature, untrained, lacked common sense, and were not compassionate, yet were hired to care for the elderly. The resident questioned why can't staff be friendly or smile, and noted small talk would be nice. The residents further noted they wanted staff to quit being uncaring and unfriendly, and wanted staff to stop talking down to residents and family members. The written complaint revealed some residents in wheelchairs feel belittled by staff. The complaint went on to say the facility staff, especially nursing and Certified Nursing Assistants (CNA), were very intimidating. The complaint also noted staff wear ear buds, and they feel like this could be considered a privacy violation. Observation of a resident council meeting on 03/20/25 at 1:26 P.M. with 15 residents present revealed resident concerns included staff were still wearing ear buds while working, staff would enter their rooms and would say what do you want. The residents noted there was a lack of respect towards residents, and nurses sat at the desk and would not answer the call lights. 1. Review of the medical record for Resident #3 revealed an admitted [DATE]. Diagnoses included type one diabetes mellitus with diabetic polyneuropathy, obesity, Aspergers syndrome, and post-traumatic stress disorder, and needs assistance with personal care. Continued review revealed she was cognitively intact. Interview on 03/18/25 at 9:52 A.M. Resident #3 reported CNA #557 does not assist with undoing brief and pulling brief up/down, does not assist with ambulation to the bathroom and stands off to the side telling her she should be able to do more for herself. The resident stated CNA #557 made negative comments to her about not doing more for herself. Resident #3 stated she felt like CNA #557 neglected to provide care, and felt the negative comments were hurtful. Interview on 03/24/25 at 4:46 P.M. with the Administrator revealed CNA#557 was suspended on 03/18/25. The Administrator reported CNA #557 does not normally take care of Resident #3, but did care for her one day last week. She continued the CNA wanted her to walk to the bathroom, and would sometimes take the wheelchair out of the bathroom as she wanted the resident to walk back out. The CNA reported she knew the resident walks back, but sometimes she did not want to. The Administrator revealed CNA #557 would receive a teachable moment related to if resident doesn't want to walk, she has the right to use her wheelchair. 2. Review of the medical record for Resident #69 revealed admitted [DATE]. Diagnoses included acute and chronic respiratory failure with hypercapnia, congenital central alveolar hypoventilation syndrome, and tracheotomy status. The record indicated the resident was cognitively intact. Review of Resident #69's care plan dated 10/28/24 revealed the resident had self-care deficits and was limited in ability to transfer self-related to acute on chronic respiratory failure with hypercapnia, ventilator associated pneumonia, congenital central alveolar hypoventilation, bilateral knee pain, tracheostomy, dependence of respirator, chronic respiratory failure with hypercapnia and hypoxia, oxygen tubing and anemia. Interventions include providing assistance of one staff for transfers and ambulation with platform walker and wheelchair follow and praise resident for efforts. Interview on 03/18/25 at 9:04 A.M. with Resident #69 revealed the resident reported CNA #574 did not speak kindly to her and was rude while she provided care. Interview on 03/25/25 at 11:25 A.M. with CNA #574 revealed the she was a fast-paced worker, and when they are pulled into a split assignment, it was hard to get everything done. She stated she does have to tell residents that she will come back at a later time. CNA #574 stated residents say they feel like a burden or feel like she is rushing them because they are short-staffed. CNA #574 went on to say Resident #69 had been sick recently and needed more assistance. She stated that now that she is better, CNA #574 was trying to get Resident #69 to be more independent, but she was used to the extra assistance. Interview on 03/24/25 at 4:02 P.M. with the Administrator revealed after speaking with Resident #69, the resident wanted CNA #574 to spend more time during care with her. She stated she spoke with CNA #574 and provided her a teachable moment about slowing down, not appearing rushed, and to spend extra time with residents who desire it. 3. Review of the medical record for Resident #285 revealed an admitted [DATE]. Diagnoses included nondisplaced trimalleolar fracture of right lower leg, subsequent encounter for closed fracture with routine healing, Type two diabetes mellitus with hyperglycemia, chronic obstructive pulmonary disease, unspecified, and major depressive disorder, recurrent, unspecified. Her record indicated she was cognitively intact. Interview on 03/17/25 at 9:33 A.M. with Resident #285 revealed the resident was tearful when she reported on her first night in the facility, a (unnamed) CNA on second shift belittled her. She feels as if it was mental abuse. Resident #285 stated she reported the incident to someone but did not know it was. The resident went on to say when she came to the facility, she was sick with bad diarrhea and the (unnamed) CNA got upset with her. She stated the (unnamed) CNA told her to stop going to the bathroom because she was going to be at lunch. She rolled her eyes and threw something against the wall. The resident reported this scared her. The resident stated she never wanted that (unnamed) CNA to come into her room again. Resident #285 stated she was afraid of her coming in again. Interview on 03/24/25 at 4:23 P.M. with the Administrator revealed she determined that CNA #546 was the CNA that was assigned to the resident and met the description given to her. The CNA was placed on administrative leave on 03/17/25 while they investigated the complaint. She stated after speaking with CNA #546, it was revealed that CNA #546 did tell the residents that if she went to the bathroom again, she wouldn't be able to change her until after she was back from lunch. The CNA denied throwing anything. The Administrator revealed CNA #546 would be provided a teachable moment related to not offering medical options to residents. Telephone interview on 03/25/25 at 2:46 P.M. with CNA #546 reported that when she worked a split assignment between two halls it was hard to get all the work done. She reported that the nurses usually do not answer call lights at night. She went on to say residents felt rushed because the hall is full. She stated when Resident #285 was newly admitted , she hit her call light five times between 7:00 P.M. and 8:00 P.M. The resident kept saying she needed changed, and she told Resident #285 I'm changing people it'll be a minute. CNA #546 stated later that night, she was about to go on her lunch break, when Resident #285 called again. CNA #546 told her that she wouldn't be back in for approximately 30 minutes, and she would come in after her lunch. 4. Observation on 03/17/25 at 7:25 A.M. revealed CNA #556 delivered a meal tray to a resident with ear buds in her ears. Observation on 03/17/25 at 10:00 A.M. revealed Registered Nurse (RN) #641 had an ear bud in their ear. Observation on 03/17/25 at 2:10 P.M. revealed LPN #546 had an ear bud present in her ear. Interview on 03/17/25 at 1:51 P.M. with Resident #28 reported that sometimes staff come in with their ear pods on while they are talking on the phone. Resident #28 stated she was not okay with that. Resident #28 stated staff wearing ear buds were rude and believed it was a privacy issue. Interview on 03/24/25 at 5:07 P.M. with the Administrator revealed staff are not allowed to wear ear buds while at work. The Administrator stated she would pull staff aside and tell them to remove the ear buds when she sees them doing this. Review of the Ohio Revised Code, Resident Right effective October 03, 2023 revealed the rights of residents of a home shall include, but are not limited to, the following: the right to be free from physical, verbal, mental, and emotional abuse and to be treated at all times with courtesy, respect, and full recognition of dignity and individuality; The right to have all reasonable requests and inquiries responded to promptly. This deficiency represents non-compliance investigated under Complaint Number OH00162488.

Based on record review, observation, interview, and facility policy review, the facility failed to ensure Resident #23's Thrombo-Embolic Deterrent (TED) hose (compression stockings) were in place as ordered and failed to ensure monitoring was completed for Resident #63's biliary drain. This affected two residents (#23 and #63) out of six residents reviewed for skin conditions. The facility census was 85. Findings include: 1. Review of the medical record for Resident #63 revealed an admitted [DATE]. Diagnoses included metabolic encephalopathy, acute kidney failure with tubular necrosis, dependence on renal dialysis, and hypertensive heart and chronic kidney disease without heart failure. The resident was admitted with a right biliary drain (a medical device used to drain bile from the liver or gallbladder. It consists of a thin, flexible tube that is inserted into the bile duct to collect and remove bile). Review of Resident #63's care plan dated 02/05/25 revealed she did not have a care plan addressing her biliary drain. Review of Resident #63's progress notes revealed she was admitted to the hospital from 02/21/25 to 03/01/25 with influenza type A. Review of Resident #63's January 2025 physician orders revealed orders to document biliary drain output twice a day, and to monitor the residents biliary drain site for signs and symptoms of infection. The orders were received on 01/11/25 and were discontinued by 02/24/25. Continued review of the March 2025 physician orders revealed the resident did not have any orders related to monitoring the biliary drain site or recording its output. Review of Resident #63's Medication Administration Record, skin assessments, and progress notes revealed no evidence that the facility was monitoring the resident biliary drain site or output after 02/21/25. Review of Resident #63's nursing progress note dated 03/21/25 at 7:54 P.M. revealed the resident's family reported that the resident was having pain at the site of her drain. Upon assessment, the area around resident's drain was slightly swollen, tender to touch with slight redness around the area. Vitals were obtained and the resident was noted with a temperature of 100.2 degrees Fahrenheit (F). The family was at bedside and wanted the resident to be sent to the emergency room . A call was placed to the Nurse Practitioner who recommended the resident be sent out. Emergency medical services came to transport resident to the hospital. The family was at bedside and aware. Review of Resident #63's hospital paperwork dated 03/21/25 revealed she was admitted with clostridium difficile (c-diff) and cholecystitis. Phone interview on 03/20/25 at 1:55 P.M. with Family Member #632 revealed Resident #63 had a biliary drain since November 2024. Yesterday, (03/19/25) the family member noticed it appeared that the tubing did not appear to be clean, the drainage appeared chunky, did not appear to have been flushed, and the amount in the bag did not appear to be different from several days prior. She asked the CNA if she had dumped it, and the CNA stated there had not been a reason since the amount had not changed. Family Member #632 stated the resident had gotten sick yesterday, and last night she complained of pain in that area, and she reported her pain was a seven (indicating seven on a scale of zero to 10, zero indicating no pain and 10 the worst pain). The family member spoke with the nurse last night, the nurse assessed the resident and stated her abdomen was in pain. She stated the resident went out to the hospital in February 2025 for Influenza A and since coming back, it was discovered upon discussion with the nurse last night that there were no orders for cleaning, draining, or documenting the amount of drainage for the biliary drain following the residents readmission from hospital. The nurse contacted the Nurse Practitioner, and orders were received and an order for an ultrasound was ordered. Interview on 03/24/25 at 5:19 P.M. the Director of Nursing revealed Resident #63 went to the hospital in February 2025 and when she came back to the facility, the hospital paperwork did not provide orders for her biliary drain. She stated because of this, the nurse did not initiate the residents' previous drain orders. She confirmed the facility did not have any documented evidence where the residents drain was monitored since her admission back to the facility on [DATE]. She stated that her expectation would be for the nurses to monitor the drain twice daily and monitor the resident's output twice a day. 45442 2. Review of the medical record for Resident #23 revealed an admitted [DATE]. Diagnoses included but were not limited to chronic obstructive pulmonary disease, epileptic seizures, congestive heart failure, peripheral vascular disease, and abnormalities of gait and mobility. Review of the 01/17/25 quarterly Minimum Data Set (MDS) 3.0 for Resident #23 revealed he was cognitively intact and required moderate assistance for dressing, toileting and transfers. Review of the 11/01/24 physician order for Resident #23 revealed an order to put on Thrombo-Embolic Deterrent (TED) hose (compression stockings) every morning and they were to be taken off at night. Review of the physician order dated 01/22/24 for Resident #23 revealed an order for weekly skin checks and as needed. Review of the care plan last reviewed on 01/29/25 for Resident #23 revealed an alteration in cardiovascular status related to congestive heart failure, cardiomyopathy, presence of a pacemaker, hypertension, and hyperlipidemia. Interventions listed were TED hose on in the morning and off at night. Review of the March 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #23 revealed each day in March 2025 indicated the residents TED hose were on as ordered, including on 03/18/25. Review of the nursing progress notes from 12/01/24 to 03/18/25 did not reveal any TED hose refusals. Review of the weekly skin assessments from December 2024 to March 2025 for Resident #23 revealed skin assessments were completed on 12/08/24, 12/15/24, 01/26/25, 02/09/25, 02/23/25, and 03/23/25. Interview on 03/17/25 at 1:06 P.M. with Resident #23 revealed both feet were swollen and he did not feel the staff monitored his edema. Observation on 03/18/25 at 2:31 P.M. of Resident #23 revealed his TED hose were not on. Interview at the time of the observation with Resident #23 revealed staff did not offer to put TED hose on the resident this morning and had not offered to put them on in a long time. Interview on 03/18/25 at 2:46 P.M. with Licensed Practical Nurse (LPN) #586 confirmed Resident #23 did not have his TED hose on and stated it was an accident that the 03/18/25 MAR/TAR indicated them as being on and that it shouldn't have been checked off as completed. Interview on 03/24/25 at 2:47 P.M. with LPN #586 also confirmed weekly skin checks for Resident #23 were not completed weekly as physician ordered. Review of the 02/08/21 revised facility policy titled Application of Anti-Emboli Stockings/TED Hose revealed anti-embolic stocking will be applied according to providers orders. The policy revealed if possible, anti-emboli stoking should be applied in the morning, prior to the resident getting out of bed, and to remove and reapply stockings according to providers orders (usually left off at night).

Based on observation, interview, record review, and policy review, the facility failed to ensure Resident #7 was safely transferred using a mechanical lift. This affected one resident (#7) of three residents reviewed for accidents. The facility census was 85. Findings include: Review of the medical record for Resident #7 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), Alzheimer's disease, unspecified, and type two diabetes mellitus with hyperglycemia. The resident was noted to have a severe cognitive impairment. Review of Resident #7's March 2025 physician orders revealed an order dated 05/15/24 for Hoyer (mechanical) lift (a mobile, wheeled device used to safely lift and transfer individuals with limited mobility) with assist of two staff for all transfers. Review of Resident #7's comprehensive care plan date 02/27/25 revealed the resident had self care deficits related to COPD, Alzheimer's, dementia, diabetics, atherosclerotic heart disease, and cognitive communication deficit. One intervention stated the resident was dependent on two staff with the use of a mechanical lift for all transfers. Observation of video recordings submitted anonymously to the Ohio Department of Health via email revealed a video clip dated 01/27/25 starting at 4:39 P.M. lasting one minute and 50 seconds showing Certified Nursing Assistant (CNA) #633 using a mechanical lift to transfer Resident #7 from her wheelchair into the bed independently. There was not a second staff member present in the video. Interview on 03/25/25 at 2:14 P.M. the Administrator confirmed the facility staff member was observed on video unsafely transferring Resident #7 independently. Review of the facility policy titled Mechanical Lift Policy dated 01/07/22 revealed two staff persons were required for total body lifts.

Based on interview, medical record review, and policy review, the facility failed to establish a baseline weight for Resident #73. This affected one resident (#73) of four residents reviewed for nutrition. The facility census was 85. Findings include: Review of the medical record for Resident #73 revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified fracture of third thoracic vertebra, subsequent encounter for fracture with routine healing, and dysphagia following cerebral infarction. Review of Resident #73's physician orders revealed an order dated 11/30/24 to 01/03/25 to obtain weight upon admission, then weekly for four weeks. Additional orders dated 03/03/25 called for Resident #73 to receive a magic cup (fortified ice-cream type supplement) four ounces (oz) daily with lunch and dinner, and for a regular diet, pureed texture, with a 1500 milliliter (ml) daily fluid restriction. Review of Resident #73's Admission nutrition assessment dated [DATE] revealed the resident was on a pureed diet with a 1500 ml daily fluid restriction. His weight was listed as 164 pounds (lbs), a BMI of 23.5, and his ideal body weight was noted to be 164 lbs. The assessment stated to monitor weekly weights, intakes, skin, and labs. Review of Resident #73's care plan revised 03/03/25 revealed the resident had increased nutrition/hydration risk related to hemiplegia, fracture right clavicle, fracture of vertebra, hypertension, alcohol abuse, aphasia, dysarthria, dysphagia, and significant weight loss of one month. A listed goal stated the resident will be free of significant weight changes every month. Interventions included provide diet per order,monitor weight per protocol, monitor need for increased nutritional intervention related to diagnosis, medications and listed problems, monitor dietary intake Review of Resident #73's weights revealed the following weights: - 12/16/24 a weight of 163.4 lbs - 01/06/25 a weight of 163.4 lbs - 01/30/25 a weight of 145.5 lbs - 02/06/25 a weight of 145.5 lbs - 03/03/25 a weight of 144.8 lbs The recorded weights indicated Resident #73 had a 10.95 percent weight loss from December 2024 to January 2025. Interview on 03/18/25 at 9:55 A.M. with Resident #73 revealed the resident reported he had lost a lot of weight recently and was unsure why. Interview on 03/19/25 at 9:45 A.M. with Dietitian #610 revealed all residents are ordered weekly weights upon admission to establish a baseline weight. Dietician #610 stated weights were not always consistently obtained due to staffing, but the issue was improving. Interview on 03/27/25 at 10:38 A.M. with Regional Registered Dietitian #627 verified the facility failed to establish a baseline weight for Resident #73 by obtaining an initial weight and weekly weights following. She stated it is her expectation that a baseline weight should be obtained within 48 hours of admission. She reported without the facility obtaining a baseline weight she is unable to determine if the resident had a true weight loss. Review of the policy Resident Weight Policy last revised on 12/12/23 revealed weights will be obtained routinely in order to monitor nutritional health over time. Each residents weight will be determined upon admission/readmission to the facility, weekly for the first four weeks after admission/readmission and monthly or more often if risk is identified or as ordered. Nursing is responsible for obtaining weights. Review of the facility policy, Resident Change in Condition Policy last revised 06/27/24 revealed the physician, provider and resident/family/responsible party will be notified when there has been a significant weight loss of five percent in 30 days, or 10 percent in 180 days.

Based on record review and staff interview, the facility failed to ensure pharmacy recommendations were timely reviewed and addressed by the provider. This affected two residents (#30 and #67) of five residents reviewed for unnecessary medications. The facility census was 85. Findings include: Review of Resident #67's medical records revealed an admitted [DATE]. Diagnoses included diabetes and congestive heart failure. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 had impaired cognition. Review of physician orders for March 2025 revealed Resident #67 was ordered metformin (oral diabetic medication) 500 milligrams (mg) once daily. Review of pharmacy recommendation dated 01/23/25 revealed a recommendation to monitor blood work to assess for kidney function on the next convenient lab day, and every six months thereafter. Review of Resident #67's medical records revealed lab work was not completed until 03/11/25. Interview on 03/26/25 at 3:08 P.M. with the Director of Nursing (DON) confirmed Resident #67's pharmacy recommendation was dated 01/23/25 and confirmed Resident #67's lab work was not completed until 03/11/25. 42015 2. Review of the medical record for Resident #30 revealed an admitted [DATE]. Diagnoses included end stage renal disease, generalized anxiety disorder, and major depressive disorder. Review of Resident #30's quarterly Minimum Data Set, dated dated dated [DATE] revealed the resident was cognitively intact and had no symptoms of depression. Review of Resident #30's physician ordered revealed an active order dated 12/18/23 for sertraline 50 mg by mouth one time a day for depression and an active order for mirtazapine 7.5 mg by mouth every night at bedtime for depression. Review of Resident #30's pharmacy recommendation dated 09/25/24 revealed the resident received two antidepressants for depression: mirtazapine 7.5 mg at bedtime and sertraline 50 mg in the morning. The recommendation stated to please reduce one of these medications, if possible, with the end goal of discontinuation. Continued reviewed revealed the physician did not address the recommendation. Interview on 03/27/25 at 2:47 P.M. with the Administrator confirmed there was no evidence where the physician addressed the pharmacy recommendation.

Based on interviews, observation, record review, facility policy review, review of pharmacy destruction logs, review of facility policy, and review of Ohio Revised Code, the facility failed to ensure medications were returned to the pharmacy timely following discharge and narcotics were destroyed in a timely manner. In addition, the facility failed to ensure Resident #21 received routine medications per physician orders. This affected Resident #21 and had the potential to affect all residents residing in the facility. The facility census was 85. Findings include: 1. Review of Resident #800's closed medical records revealed an admitted [DATE] and a deceased date of [DATE]. Review of Resident #801's closed medical records revealed an admitted [DATE] and a deceased date of [DATE]. Review of Resident #802's closed medical records revealed an admitted [DATE] and deceased date of [DATE]. Review of Resident #803's closed medical records revealed an admitted [DATE] and a discharge date of [DATE]. Review of Resident #804's closed medical records revealed an admitted [DATE] and a deceased date of [DATE]. Resident #804 was ordered oxycodone (narcotic pain medication) 5 milligrams (mg). Review of Resident #805's closed medical records revealed an admitted [DATE] and a discharge date of [DATE]. Resident #805 was ordered oxycodone 5 mg. Review of Resident #806's closed medical records revealed an admitted [DATE] and a discharge date of [DATE]. Resident #806 was ordered lorazepam (controlled substance to treat anxiety) 0.5 mg. Review of Resident #807's closed medical records revealed an admitted [DATE] and deceased date of [DATE]. Resident #807 was ordered oxycodone 5 mg, morphine (narcotic pain medication) 20 mg and lorazepam 0.5 mg. Observation and interview on [DATE] at 8:33 A.M. with the Director of Nursing (DON) of the facility medication rooms revealed no excess medications present. The DON stated unused medications were sent back to the pharmacy twice weekly. The DON denied she had any narcotics in the facility that were not being used and stated that narcotics had been destroyed. The DON stated there were some medications in the nursing office that were in the process of being sent back to the pharmacy. Observation of the nursing office on [DATE] at 9:12 A.M. with the Assistant Director of Nursing (ADON) revealed four boxes of several cards of unused medications. ADON stated she was assisting with getting the medications sent back to the pharmacy. Observation revealed several medication cards in the bins for Residents #800, #801, #802 and #803, and ADON stated those residents no longer resided in the facility. Interview on [DATE] at 1:30 P.M. with Regional Registered Nurse (RRN) #628 revealed the DON had stated she had unused narcotics in the facility that should have been destroyed. RRN #628 stated she had wasted the unused narcotics with the DON on [DATE] after she had been informed the narcotics had not been destroyed previously. RRN #628 stated unused narcotics should be destroyed as soon as possible after a resident is discharged or the medication is not longer being used. Review of controlled substance inventory form revealed Resident #804, #805, #806 and #807's controlled substance medications were destroyed on [DATE]. Review of facility policy titled Discontinued Medication Procedure revised [DATE] revealed items eligible for return were to be returned to the pharmacy within 48 hours or as soon as practicably possible. Review of facility policy titled Disposal/Destruction of Expired or Discontinued Medication revised [DATE] revealed facility should dispose of discontinued medication after a residents discharge or death in a timely fashion, no longer than 90 days after the medication was discontinued. Review of Ohio Revised Code 4729:5 effective date [DATE]: (6) Controlled substances shall be destroyed pursuant to this paragraph no later than ten days from the date the patient's controlled substance medication is removed from the medication cart or storage area. 2. Review of Resident #21's medical record revealed an admitted [DATE] with the diagnosis including diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had intact cognition. Review of the physician orders for [DATE] revealed Resident #21 was ordered Ozempic (diabetic/weight loss injection) 2 milligrams (mg), once daily on Mondays. Review of Resident #21's Medication Administration Record (MAR) for [DATE] revealed a dose of Ozempic was given on [DATE] and [DATE]. Review of the pharmacy delivery slip dated [DATE] revealed Resident #21 had an Ozempic injection pen which contained 8 milligrams/3 milliliters of medication (4 doses of the ordered medication). Review of the progress note dated [DATE] timed 5:16 P.M. revealed they were awaiting a pharmacy delivery for Resident #21's Ozempic and to place the medication on hold until medication was delivered which was scheduled for [DATE]. Review of the progress note dated [DATE] time 3:59 P.M. revealed the facility had agreed to pay for Resident #21's Ozempic. Interview on [DATE] at 9:23 A.M. with Resident #21 revealed he had not received his ordered Ozempic once a week as he was supposed to. Resident #21 stated the medication was supposed to be administered on Saturdays, however he had not received it and stated he had been told he would need to change the day it was administered because the medication was unavailable and stated he had been told the medication could not be reordered until [DATE]. Resident #21 stated he believed someone had taken the medication for their own personal use for weight loss because the facility was having a weight loss contest. Interview on [DATE] at 12:33 P.M. with the Director of Nursing (DON) confirmed the pharmacy delivery slip dated [DATE] revealed Resident #21 had an Ozempic pen that contained 8 mg/3 mL. The DON further confirmed Resident #21's physician orders were for 2 mg once daily on Mondays and that the injection pen contained a total of 4 doses. She stated she was unsure why the medication was not available to be given on [DATE] and further confirmed the dose documented on [DATE] was prior to the medication being delivered on [DATE]. This deficiency represents non-compliance investigated under Complaint Numbers OH00162488 and OH00162160.

Based on interview and record review the facility failed to ensure dialysis communication forms had been completed before and after dialysis treatments. This affected one resident (#10) of two residents reviewed for dialysis communication. The facility census was 85. Findings include: Review of Resident #10's medical records revealed an admitted [DATE]. Diagnoses included end stage renal disease (ESRD) and dialysis dependent. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had intact cognition. Review of Resident #10's care plan dated 01/30/25 had ESRD and required dialysis Monday through Friday. Review of Resident #10's physician orders for March 2025 revealed to obtain Resident #10's weight post-dialysis and notify the physician of weight or losses of three pounds. Review of Resident #10's dialysis communication forms for February 2025 and March 2025 revealed dialysis communication forms were only completed for 02/04/25, 02/07/25, 02/10/25, 02/13/25, 02/20/25, 02/21/25, 02/24/24, 02/25/25, 02/27/25, 03/03/25, 03/04/25, 03/06/25, 03/11/25, 03/14/24, 03/17/25 and 03/21/25. Review of progress note dated 03/05/25 timed 2:24 P.M. authored by Licensed Practical Nurse (LPN) #587 revealed Resident #10 had refused dialysis. Progress note did not include notification to the physician of refusal. Interview on 03/25/25 at 12:23 P.M. with Director of Nursing (DON) confirmed missing dialysis communication forms and stated dialysis communication forms were to be filled out before and after dialysis treatments. The DON stated if a resident refused dialysis treatments, a progress note was to be written.

Based on medical record review, observation, and interview, the facility failed to ensure Resident #287's midline intravenous access site dressing changes were completed per physician order. This affected one resident (#287) out of one residents reviewed for intravenous therapy. The facility identified four residents receiving intravenous therapy. The facility census was 85. Findings include: Review of Resident #287's medical record revealed an admitted [DATE]. Diagnoses included osteomyelitis (bone infection), respiratory failure and quadriplegia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #287 had intact cognition. Resident #287 was dependent for toileting, bathing and personal hygiene. Review of physician orders for March 2025 revealed orders dated 03/07/25 to observe Resident #287's midline intravenous access site every shift and change the transparent dressing and securement device every seven days and also as needed (PRN). Review of Resident #287's care plan revealed no documented evidence of a care plan related to the residents midline. Review of Medication Administration Record (MAR) and Treatment Administration Record (TAR) for March 2025 revealed documentation that Resident #287's midline dressing change had been completed on 03/09/25, 03/10/25, 03/11/25, 03/12/25, 03/13/25, 03/14/25, 03/15/25, 03/17/25, 03/23/25, 03/24/25, 03/25/25 and 03/26/25. Observation on 03/26/25 at 10:39 A.M. with Licensed Practical Nurse (LPN) #587 revealed Resident #287's midline dressing to her left upper arm had a date of 03/05/25 and there was dried blood around the insertion site. LPN #587 confirmed the date of 03/05/25 and stated midline dressings were to be changed every seven days and also PRN. Interview on 03/26/25 at 3:08 P.M. with Director of Nursing (DON) confirmed Resident #287's MAR and TAR for March 2025 had included inaccurate documentation of Resident #287's midline dressing being changed and stated nurses should not document treatments they had not completed. The DON further revealed the facility had not updated the residents care plan since the midline was placed.

Based on medical record review and staff interview, the facility failed to ensure appropriate follow up with a specialty physician related to an antibiotic medication. This affected one resident (#296) out of two residents reviewed for death. The facility census was 85. Findings include: Review of Resident #296's closed medical records revealed an admitted [DATE] and a discharge date of [DATE], with the diagnosis of bladder cancer. Review of the care plan dated 01/31/25 revealed Resident #296 had a diagnoses of cancer and was receiving chemotherapy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #296 had impaired cognition. It also noted that Resident #296 was independent with self care and had received antibiotics in the previous seven days. Review of Resident #296's physician orders for February 2025 revealed to follow up with infectious disease regarding antibiotic orders and to fax laboratory results every week, Cefazolin (intravenous antibiotic) 2 grams every eight hours from (02/03/25 to 02/19/25), Cefazolin 1 gram twice a day was ordered from 02/20/25 to 02/20/25 and Cefazolin 2 grams was ordered three times a day from 02/20/25 to 02/28/25. Review of Medication Administration Record (MAR) for February 2025 revealed the resident received Cefazolin 2 grams three times per day (12:00 A.M., 8:00 A.M., and 4:00 P.M.) from 02/04/25 until 02/19/25, besides during the 8:00 A.M. shift on 02/06/25, 02/13/25, 02/15/25, 02/17/25, and 02/18/25 when the medications were not signed off as received. On 02/19/25 at 4:00 P.M. and 02/20/25 at 12:00 A.M., the medication was documented as being on hold. On 02/20/25 at 8:00 A.M. Cefazolin 1 gm was documented as given. On 02/20/25 at 4:00 P.M., the Cefazolin 2 gm three times per day resumed until 02/24/25 when the resident received the last dose at 12:00 A.M. Review of Resident #296's laboratory (lab) results dated 02/14/25 revealed the residents kidney labs were high. The Blood Urea Nitrogen (BUN) level was 74 milligrams per deciliter (mg/dL)(normal ranges from 7 to 25 mg/dL), the Creatinine level was 2.4 mg/dL (normal ranges from 0.6 to 1.2 mg/dL), and the GFR was 32 milliliters (ml) per minute (normal range was to be greater than 60 mL/min). The lab results indicated the kidney function was worsening from the previous labs received on 02/11/25. The lab results from 02/11/25 revealed BUN level was 67 mg/dL, the Creatinine level was 2.1 mg/dL, and the GFR was 37 ml per minute. Review of Resident #296's progress note dated 02/19/25 timed 1:15 P.M. authored by LPN #518 revealed she had received a call from the pharmacy regarding Resident #296's lab work related to his kidney function. The pharmacy had advised to change Resident #296's antibiotic dosages due to decreased kidney function. The progress note stated the nurse practitioner had been called and she advised staff to follow the pharmacy recommendations. The progress note also stated the orders had not been changed and the information had been relayed to the oncoming nurse. Review of Resident #296's progress note dated 02/19/25 timed 11:00 P.M. authored by LPN #535 revealed she had been informed that Resident #296's antibiotic had been placed on hold due to abnormal kidney function. LPN #535 had contacted the pharmacy who had recommended a lower dose of antibiotic which was 1 gram every 12 hours, instead of 2 grams every eight hours. The progress note stated the nurse practitioner had been notified and stated Resident #296's laboratory results were supposed to have been faxed to infectious disease because they were to handle Resident #296's antibiotics. The progress note stated the nurse practitioner informed them to go ahead with the pharmacy recommendations until infectious disease had placed orders. Review of progress note dated 02/20/25 timed 11:19 A.M. authored by LPN #514 revealed she had spoken with the nurse practitioner to clarify Resident #296's antibiotic orders and Resident #296 was to continue with 2 grams Cefazolin until they received clarification from infectious disease. There were no further notes indicating if the infectious disease physician was contacted or notified. Interview on 03/27/25 at 12:16 P.M. with LPN #518 revealed she recalled the pharmacy calling and had made recommendations to decrease Resident #296's antibiotics due to his decrease kidney function. LPN #518 stated she had informed the DON and stated the DON was supposed to have contacted infectious disease and stated she had passed the information on to the oncoming nurse. Interview on 03/27/25 at 3:14 P.M. with Administrator revealed she was unable to locate orders from infectious disease regarding Resident #296's antibiotic orders. Telephone interview on 03/27/25 at 3:21 P.M. with Nurse Practitioner (NP) #629 revealed she could not recall if she had given orders for Resident #296's antibiotics, however she had advised the nurses to contact infectious disease for orders. This deficiency represents non-compliance investigated under Complaint Number OH00162160.

Based on interview and record review the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) for Resident #56 was accurately completed upon the resident's admission to the facility. This affected one resident (#56) of one resident reviewed for PASARR. The facility census was 85. Findings include: Review of the medical record for Resident #56 revealed an admitted [DATE]. Diagnoses included traumatic subdural hemorrhage without loss of consciousness, Post Traumatic Stress Disorder (PTSD), anxiety, and dementia. The record indicated the residents had moderate cognitive impairment. Review of Resident #56's PASARR dated 12/13/24, the day after admission to the facility, revealed the PASARR was completed due to no previous PASARR records. The PASARR did not include the residents' diagnoses of PTSD, anxiety, or dementia. Interview on 03/19/25 at 1:25 P.M. Social Service Designee #579 verified when Resident #56 was admitted to the facility she did not have a PASARR. She stated she completed the PASARR but not include the resident diagnoses of PTSD, anxiety, or dementia.

Based on interviews, medical record review, personnel file review, and policy review, the facility failed to implement their abuse policy by failing to immediately remove a staff member accused of emotional abuse during the investigation. This affected one resident (#3) of four residents reviewed for abuse and neglect. A second example of no actual harm with the potential for minimal harm occurred when the facility failed to ensure reference checks were completed on new employees upon hire. This had the potential to affect all residents residing in the facility. The facility census was 85. Findings include: 1. Review of the medical record for Resident #3 revealed an admitted [DATE]. Diagnoses included type one diabetes mellitus with diabetic polyneuropathy, obesity, Aspergers syndrome, and post-traumatic stress disorder, and needs assistance with personal care. Continued review revealed she was cognitively intact. Review of Resident #3's nursing progress note dated 02/23/25 at 8:30 P.M. revealed Licensed Practical Nurse (LPN) #543 stated Resident #3's brother came to the nurse and stated Certified Nursing Assistant (CNA) #584 was mean to Resident #3. The nurse and the resident's brother went to Resident #3's room, and found the resident crying due to fear that CNA #584 would be mean to her again. Resident #3 stated CNA #584 had been mean to her a few times when she wanted to go to the bathroom. The note indicated LPN #543 had explained to Resident #3 and her brother that the nurse would switch CNA #584's assignment with another CNA, so Resident #3 would feel safe and not worry about care that night. The resident and her brother agreed and stated they wanted to speak with management about the situation. The note indicated the Director of Nursing (DON) was notified and explained what happened, and the note indicated the DON stated she would speak with Resident #3 the next day. Interview on 03/19/25 at 10:45 A.M. with Resident #3 revealed the last five or so times, that CNA #584 cared for her, she was not nice to her. Resident #3 reported when she put on her call light, CNA# 584 would come in and say she was short-staffed and had 16 other residents to take care of. CNA #584 would tell Resident #3 she didn't have time to run down to her room and take her to the bathroom. CNA #584 would continuously tell her to squeeze it all out because she could not keep running down to take her to the bathroom. Resident #3 stated at times she would urinate herself because she was fearful of how CNA #584 would treat her. Resident #3 stated one day she finally had enough and called her brother hysterically because she knew she would be working with CNA #584 that night. Resident #3 stated her brother had to come in and settle her down. She stated the Administrator was aware and ensured her that CNA #584 would not be working with her anymore. When asked how CNA #584 made her feel, Resident #3 reported that she thought CNA #584 was mentally abusive to her. Telephone interview on 03/25/25 at 6:10 P.M. with Family Member #630 reported he had heard CNA #584 say inappropriate things to Resident #3, including telling her that she [CNA #584] did not have time to keep coming to Resident #3's room and taking her to the bathroom as the facility was short staffed. Family Member #630 reported he heard CNA #584 state to Resident #3 to push all her urine out now because she was too busy to keep coming to the resident's room. Family Member #630 would then see CNA #584 seated at the nurse's station on her phone. He reported Resident #3 had called him crying over the treatment she received from CNA #584. His sister was afraid to voice concerns due to staff retaliation, and instead, let it all build up and she would eventually break down. He requested CNA #584 to not work with her anymore. He reported the Administrator told him if his sister kept complaining, then no one would be left to take care of her. Family Member #630 reported he thought that was a rude comment. Review of the Disciplinary Action Form initially dated 02/24/25 revealed CNA #584 was disciplined on 03/06/25 due to a resident and her brother stating CNA #584 used poor customer service skills when caring for the resident, the CNA was said to have stated on several evenings she was busy, she was short staffed, and told the resident to urinate completely because she could not toilet the resident over and over during the shift. Counseling included not rushing residents or telling them you were busy or understaffed. Review of schedules showed the shifts were not understaffed. Residents do not want to feel like they are a burden to staff. Review of the staffing schedules revealed on Sunday 02/23/25 CNA #584 was scheduled to work on the 100 and 200 halls from 7:00 P.M. to 7:00 A.M (Resident #3 resided on the 100 hall) Review of staff time punches for this day revealed she clocked in at 7:00 P.M. and out at 7:30 A.M. on 02/24/25. Interview on 03/24/25 at 4:46 P.M. the facility Administrator verified that the facility did not follow their abuse policy. She revealed that had it been reported in the way that was relayed in the nurses note, or reported that the resident felt she was emotionally abused, CNA #584 would have been removed and not allowed to remain working in the facility while an investigation was conducted. Review of the facility policy, Ohio Resident Abuse Policy dated 07/11/24 revealed the facility will not tolerate abuse, neglect, mistreatment, exploration of residents, and misappropriation of resident property by anyone. Facility staff must immediately report all such allegations to the administrator/abuse coordinator. The facility administrator/abuse coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with procedures in this policy. If a staff member is accused or suspected of abuse, neglect, mistreatment, or exploration, the facility immediately remove the staff member from the resident care area and requests a written statement from accused staff member. The accused staff members will remain under direct supervision until the statement is complete and or law enforcement arrives if applicable. The accused staff member will then be removed from the facility and the schedule pending the outcome of the investigation. 2. Review of the personal files for facility staff revealed eight sampled staff members did not receive references checks before being employed by the facility and having resident contact. These included: 1. Certified Nursing Assistant (CNA) #584 hired on 02/16/22. 2. CNA #546 hired on 03/25/24. 3. CNA #574 hired on 04/15/24. 4. CNA #557 hired on 06/28/23. 5. Admissions Coordinator #524 hired on 09/03/24. 6. Registered Nurse #512 hired on 06/26/24. 7. Laundry aide #612 hired on 03/21/24. 8. Respiratory Director #513 hired on 09/12/24. Interview on 03/26/25 at 10:33 A.M. with Human Resource Coordinator #517 confirmed the facility did not obtain reference checks prior to employing the above staff members. Review of the facility policy, Ohio Resident Abuse Policy dated 07/11/24 revealed as part of the facility screening procedure included that the facility will generally attempt to obtain references from two prior employers for each applicant. This deficiency represents non-compliance investigated under Complaint Number OH00162488.

Based on interview, record review, and review of email correspondence, the facility failed to ensure resident concerns were addressed in manner that provided a resolution to their concerns. This affected two residents (#10 and #21) of four residents reviewed for concerns. The facility census was 85. Findings include: Interview on 03/20/25 at 9:23 A.M. with Resident #21 revealed he was the president of resident council and stated he had many residents who had expressed concerns related to their care. Resident #21 stated he had shared those concerns with the Administrator and the Director of Nursing (DON), however, their concerns had not been addressed and they had not seen any changes. Resident #21 stated he had sent his letter of concerns to the corporate office, and stated he had not received or seen any resolution or effort to address the residents' numerous concerns. Resident #21 further stated when he had brought issues to the Administrator, she would then go to the staff members he had complained about and then those staff members would ignore him and not assist him with care. An observation on 03/20/25 at 1:26 P.M. of the resident council meeting revealed several residents, including Residents #10 and #21, were present for the meeting. Residents had expressed various concerns that included laundry, maintenance, nursing, and administration and stated their concerns have been ongoing with no resolution. Interview on 03/24/25 at 11:09 A.M. with Administrator revealed she had spoken with Resident#10 and Resident #21 regarding their concerns and stated she had been aware of a letter that was sent to the corporate office. Administrator stated she had addressed their concerns, however they had continued to make complaints. Interview on 03/26/25 at 2:07 P.M. with Licensed Practical Nurse (LPN) #514 revealed she had spoken with Resident #10 on occasions regarding her concerns. LPN #514 stated she had advised Resident #10 to discuss her concerns further with the Administrator and the DON. LPN #514 stated she was unaware of the outcome of the residents concerns. Review of submitted letter to the corporate office authored by Residents #10 and #21, and signed by numerous other residents, revealed several concerns that included staff treatment, housekeeping, poor food quality, and nursing concerns. Review of email received by the corporate office dated 11/25/24 and timed 10:37 A.M. revealed the corporation had confirmed they had received resident concerns that stated management at the facility isn't taking the issues seriously. This deficiency represents non-compliance investigated under Complaint Number OH00162488.

Based on record review, review of hospital documentation, review of staff schedules, staff interview and policy review, the facility failed to develop and implement a comprehensive and effective pain management program for Resident #90, at the time of admission including adequate and accurate assessment and administration of physician ordered pain medication resulting in a re-hospitalization for the resident due to unrelieved pain. Actual harm occurred on 08/16/24 following Resident #90's admission to the facility for post-operative care when the resident experienced excruciating pain, was yelling out in pain and requesting pain medication that was not timely addressed. The resident was subsequently transferred to the hospital and readmitted due to abdominal pain. This affected one resident (#90) of three residents reviewed for pain management. The facility census was 75. Findings include: Review of the medical record for Resident #90 revealed and admitted [DATE] and a discharge date of [DATE]. Diagnoses included diverticulitis of large intestine with perforation and abscess without bleeding, unspecified abdominal pain, need for assistance with personal care, and chronic obstructive pulmonary disease (COPD). Review of Resident #90's hospital discharge summary dated 08/16/24 revealed the resident was discharged from the hospital after having perforated diverticulitis, an exploratory laparotomy (a surgical incision into the abdominal cavity for diagnosis or in preparation for surgery) was completed as well as a sigmoid colectomy (a surgical procedure to remove the sigmoid colon, the lower part of the large intestine that connects to the rectum) and an end sigmoid colostomy (a surgical procedure that creates an opening in the abdominal wall for stool to drain through). The procedures were completed on 07/23/24 and a wound vacuum (a treatment used to help wounds heal) was removed on 08/14/24. The resident had a wound in his abdomen that required wet to dry dressing changes twice daily. He was discharged with an order for pain medication, Oxycodone immediate release (IR) 5 milligram (mg) tablet with instructions to take a half tablet or a whole tablet by mouth every six hours as needed for up to five days. The prescription was sent to the facility. Review of the admission assessment dated [DATE] revealed Resident #90 was alert and generally oriented to person, place, and time. His memory was intact and his thinking was clean and organized. Review of Resident #90's physician's orders revealed an order dated 08/16/24 for Oxycodone five mg with instructions to take one tablet by mouth every six hours as needed for pain for up to five days and an order to cleanse the residents midline abdomen with normal saline, pat dry, pack the wound bed, apply normal saline moistened gauze, and cover with an abdominal (ABD) pad twice a day and as needed. Review of Resident #90's Medication Administration Record (MAR) revealed he did not receive any pain medications while at the facility (08/16/24 and 08/17/24). The record documented on dayshift (7:00 A.M. to 7:00 P.M.) his pain was rated a four and nightshift (7:00 P.M. to 7:00 A.M.) pain was a 0. Review of Resident #90's Physical Therapy (PT) evaluation and plan of treatment dated 08/16/24 revealed the resident's pain level was determined based upon behaviors exhibited by the patient and behaviors were exhibited; The note revealed the resident reported abdominal discomfort and the nurse was aware. Review of Resident #90's progress notes revealed a Nurse Practitioner note dated 08/16/24 at 1:56 P.M. indicating the resident was being admitted due to a perforated sigmoid colon, he was colostomy status, and had an abdominal wound. The note revealed to continue wound care, colostomy care, and to give Oxycodone for pain. The note indicated the resident was being seen and examined in his room, he was alert and oriented times two to three, and he was very frail and cachectic looking. The resident had just arrived from the hospital with his wife, he reported pain and discomfort in the belly, denied nausea and vomiting, and stated he could tolerate regular food. Continued review of notes revealed the next progress note on 08/17/24 at 9:05 A.M. indicated the resident was sent to the hospital via ambulance per patient and family request. Review of Resident #90's emergency room and admission paperwork dated 08/17/24 at 9:40 A.M. and discharge on 08/21/24 revealed the resident was readmitted with abdominal pain. The emergency room report revealed Resident #90 had abdominal pain and a wound dressing and kept calling 911. He presented to the emergency department for evaluation of abdominal pain and requesting a new nursing/rehabilitation facility. He was recently admitted (to the hospital) for perforated viscus and was discharged (to the nursing home) with instructions to do wet-to-dry dressings twice a day. According to the resident, the rehabilitation facility did not change his dressing since he had been there. He was also endorsing abdominal pain all over his abdomen. The report revealed the resident received Hydromorphone 0.5 mg intravenous on 08/17/24 at 10:29 A.M. and the follow up pain assessment at 10:51 A.M. was a three out of ten (a pain scale from zero to 10 with a zero being no pain and a 10 being the worst pain). Review of the staffing schedule for 08/16/24 revealed Licensed Practical Nurse (LPN) #110, Certified Nursing Assistant (CNA) #112, and Registered Nurse (RN) #113 were all assigned to the 300 hall where Resident #90's room was located between the hours of 7:00 P.M. until 7:00 A.M. Interview on 12/18/24 at 11:56 A.M. with RN #113 (the nurse assigned to Resident #90 on 08/16/24 from the hours of 2:00 P.M. until 7:00 P.M.) reported she could not recall the resident or being told of his pain. Interview on 12/18/24 at 2:00 P.M. with Clinical Quality Specialist Registered Nurse (CQSRN) #107 reported Resident #90 was admitted to the facility around 2:00 P.M. on 08/16/24. She stated he came with a prescription for Oxycodone 5 mg. She stated they faxed the prescription and got an authorization for the medication a little after 7:00 P.M. that night. She stated that only one nurse had accesses to their Omnicell (a machine where the medication is kept onsite) so she was unable to pull the medication for the resident (as two nurses accesses were needed to access the medication). She revealed she spoke with LPN #110 who stated she gave the resident Tylenol at some point that night, but confirmed it was not documented. CQSRN #107 reported Resident #90 contacted EMS services during the night and eventually in the morning he was transported to the hospital due to complaints of pain. She verified the resident was not properly assessed for pain, documentation was not completed regarding the incident, and he was not given as ordered pain medication after experiencing pain throughout the night due to issues with the onsite emergency medication access. She reported it would be her expectation that the Director of Nursing (DON) would come into the facility and pull the medication for the resident. On 12/18/24 at 2:47 P.M. a telephone interview with LPN #110 reported she was assigned to Resident #90 on the night of 08/16/24 from 7:00 P.M. until 7:00 A.M. She reported she was told the resident had an abdominal wound and had been medicated (for pain) shortly before his arrival to the facility. LPN #110 stated shortly after she arrived at work, the resident began to request pain medication and had rated his pain at a five or six (on a scale of one to 10). She went on to say she told him she was unable to access the medication, and he would need to wait until the shipment of medications came in. The LPN stated the resident's vital signs were stable so she did not feel the situation was urgent. She stated although they had the medication at the facility and an authorization from the pharmacy to pull the medication, only one nurse in the building had access to the supply and two nurses were needed to pull the medication together. The nurse went on to say throughout the night the resident's pain increased, he ripped off his dressing and yelled out requesting medication for pain and to be transported to the emergency department. The nurse stated the resident called EMS several times throughout the night and eventually he was transferred and admitted to the hospital in the morning. She went on to say she contacted the DON after the resident's wife became upset at the facility for not treating the resident's pain and the DON relayed that if the resident's wife had pain medication, she could bring it in. LPN #110 stated before the resident's wife could get to the facility with the pain medication, EMS was already there to transport the resident back to the hospital. She stated the next day the DON and Assistant Director of Nursing (ADON) #102 asked her to come in and make a statement regarding the incident, which she did. When asked why she documented the resident's pain at a zero for her shift she stated she did not know why and she thought she made a detailed progress note regarding the situation. On 12/18/24 at 3:18 P.M. a telephone interview with Certified Nursing Assistant (CNA) #112 revealed she was assigned to Resident #90 on 08/16/24 from 7:00 P.M. until 7:00 A.M. She reported when she arrived for her shift, the resident was agitated because his pain medication was not at the facility. She reported the resident was pushing his call light throughout the night stating he was in pain, he was yelling out and looked pretty sickly. CNA #112 reported she kept telling LPN #110 the resident was in pain and LPN #110 reported to the resident that the medication would not be available until the morning. CNA #112 reported the resident called 911 several times due to pain and wanted to be transported to the hospital. She stated EMS did eventually take the resident to the hospital in the morning. On 12/19/24 at 9:10 A.M. a telephone interview with Assistant Director of Nursing (ADON) #102 revealed she recalled having LPN #110 come back into the facility to make a statement after speaking to Resident #90's wife in relation to the above incident. ADON #102 reported the resident's wife was very upset regarding her husband not receiving any pain medication throughout the night. ADON #102 reported after the statement was collected it would have been up to the DON to complete the investigation into the concerns. Additionally, ADON #102 reported the the facility did have an issue with getting their nurses into the system so they could pull from the emergency medication supply (Omnicell). Interview on 12/19/24 at 9:20 A.M. with the Administrator revealed there were no statements regarding the situation with Resident #90 and she could not recall the incident. Information obtained from Resident #90 as part of the complaint investigation revealed Resident #90 was transported from the hospital to the facility on [DATE] with a large open (abdominal) wound. The resident arrived at the facility at approximately 2:00 P.M. and stated he had last received pain medication around 12:00 P.M. the same day while at the hospital. Upon arrival, the resident was informed the facility did not have a pharmacy on site and the medication would need to come from an outside pharmacy. The resident revealed on 08/16/24 by 11:00 P.M. he was in excruciating pain and he called emergency services to see if they could transfer him out of the facility. The resident's wife was able to contact the on-call doctor and was told to arrange transportation back to the ER immediately. The resident was transported to the Emergency Department (ED) on 08/17/24 at around 10:00 A.M. The resident revealed the first thing the emergency department did was medicate him for pain. The resident stated he was hospitalized for another five days following this admission. Review of the facility policy, Pain Management, revision date 08/01/24 revealed it was the policy of the community to ensure any resident admitted to the facility was assessed for pain and or potential for pain, for the resident to reach and maintain his/her highest practicable level of physical, mental, and psychosocial well being in accordance with the comprehensive assessment and plan of care. A pain evaluation would occur on admission to the facility, at each quarterly review, with significant change in condition, and with any onset of new pain. This deficiency represents non-compliance investigated under Complaint Number OH00160260.

Based on observation, interview, medical record review and policy review the facility failed to provide Resident #83 requested pain medication prior to pressure ulcer/injury wound care. Actual harm occurred on 04/12/24 at 10:11 A.M. when Registered Nurse #100 was observed to provide Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer/injury wound care to Resident #83, who had a physician order for narcotic pain medication as needed, despite the resident reporting pain and inquiring if she received pain medication prior to the wound care. Resident #83 voiced multiple complaints of pain during the procedure, rated her pain a level eight on a scale of one to 10, and was observed to have facial grimacing (due to the increased pain). This affected one resident (#83) of three residents reviewed for pain management. The facility census was 85. Findings include: Review of Resident #83's medical record revealed an admitted [DATE] with diagnoses including a pressure ulcer of sacral region (Stage IV), end stage renal disease, type 2 diabetes mellitus with other diabetic kidney complications, and acquired absence of right and left legs below the knee. Review of Resident #83's Minimum Data Set 3.0 (MDS) dated [DATE] revealed the resident was mildly cognitively impaired and was admitted with a pressure injury. Review of Resident #83's care plan dated 02/14/24 revealed the resident had potential to have complaints of acute pain related to diabetes, end stage renal disease/dialysis catheter in place, and a wound. Interventions included administer medications per physician orders, encourage resident to request pain medication before pain becomes unbearable, monitor, and record any complaints of pain: location, frequency, intensity, effect on function, alleviating factors, aggravating factors, and monitor and record any non-verbal signs of pain or discomfort and notify physician of pain interventions that are not effective. Review of Resident #83 April 2024 physician's orders revealed an order to cleanse the resident's coccyx with Dakins (wound treatment bleach solution) half strength, apply Anasept gel, apply calcium alginate, and cover with a foam dressing. The dressing was scheduled to be completed twice daily. The resident also had an order for Oxycodone 5 milligrams (mg) tablet every four hours as needed for pain. Review of Resident #83's Wound Management Report dated 04/10/24 revealed the resident had a 7.5 centimeters (cm) length by 9.0 cm (width) by 1.0 cm deep sacrum injury that was present on admission. The wound was classified as a Stage IV pressure injury. Observation on 04/12/24 at 10:11 A.M. revealed Registered Nurse (RN) #100 and RN #200 prepared to complete Resident #83's wound care for the resident's Stage IV pressure injury to the resident's sacrum. RN #100 asked the resident if she was having any pain and the resident replied yes, her bottom is really hurting. The resident then asked if the nurse had given her any pain medication. RN #100 replied I believe I already did and proceeded with care. The resident rolled onto her side, with RN #200's assistance, while RN #100 removed the old pressure dressing, cleansed the wound, and applied a new dressing. During the wound care, the resident stated several times that her bottom was hurting and displayed facial grimacing. The wound was observed to be approximately palm sized in diameter and approximately one cm deep. After the wound care, the resident stated she wished to have her pain medication prior to her dressing changes from now on. Interview on 04/12/24 at 10:35 A.M. with Resident #83 revealed she did not believe she was medicated with pain medication prior to her dressing change and stated that her pain was an eight out of ten during the dressing change. Interview on 04/12/24 at 10:45 A.M. with RN #100 revealed she was unsure if the resident had received her pain medication prior to her dressing change. The RN reviewed the resident's Medication Administration Record (MAR) and confirmed she had not been given the ordered Oxycodone 5 milligrams as needed for pain medication at all on 04/12/24. The RN confirmed she continued with the dressing change, despite the resident requesting pain medication and not verifying if the resident's pain medication had been administered. Interview on 04/12/24 at 4:50 P.M. with the Director of Nursing revealed it would have been her expectation for either RN #100 or RN #200 to have checked to see of Resident #83 had received the as needed pain medication before continuing with the wound care once Resident #83 expressed she was in pain. She continued the staff should have waited until the medication was effective and then completed the wound treatment as ordered. Review of the policy titled Pain Management Protocol revised 10/24/22 revealed it was the policy of this community to ensure any resident who was admitted to the facility was assessed for pain and/or the potential for pain in order for the resident to reach and maintain his/her highest practicable level of physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. This deficiency represents non-compliance investigated under Complaint Number OH00152546 and Complaint Number OH00152320.