Every finding on record at Tranquility of Richmond Heights

Based on record review, interview, and facility policy review, the facility failed to document concerns regarding Resident #37's care in the facility. This affected one (Resident #37) out of three residents reviewed with concerns. The facility census was 54.Findings include: A review of Resident #37's clinical record revealed an admission date 06/18/25 with diagnoses including fractured pelvis and left arm, anemia, anxiety, dementia, depression, neuromuscular dysfunction of the bladder and schizophrenia. Resident #37's physician order dated 06/30/24 revealed an appointment was scheduled with the orthopedic physician for after-care of bone fractures. Resident #37's progress note dated 06/30/25 indicated Resident #37 was transported to an appointment at 12:24 P.M. and returned to the facility following an orthopedic appointment at 3:27 P.M. A review of Resident #37's discharge information from the hospital dated 06/18/25 indicated a follow-up appointment was scheduled on 06/30/25 at 12:30 P.M. with the orthopedic physician's office for X-rays. An interview with Resident #37's niece on 07/10/25 at 9:45 A.M. revealed she was Resident #37's guardian and was not notified that Resident #37 had an appointment scheduled for a follow-up visit with the orthopedic physician on 06/30/25. Resident #37's niece stated she found out that Resident #37 had been transported to an appointment and was not in the facility when another family member went to visit Resident #37. Resident #37's niece stated she voiced her concerns to the Administrator but had no follow-up to her concerns. An interview with the Administrator on 07/10/25 at 11:06 A.M. revealed Resident #37's niece constantly complained about her aunt's care in the facility. The Administrator stated Resident #37's niece had talked to the Director of Nursing (DON) #67 and had screamed at DON #67 and stated she was furious the facility had not notified her of Resident #37's appointment on 06/30/25. The Administrator stated Resident #37's niece was Resident #37's guardian and would have been notified of the follow-up appointment with the orthopedic physician scheduled on 06/30/25 upon the discharge from the hospital. The discharge paperwork was given to Resident #37's niece when discharged from the hospital and the information was entered into the electronic system (MyChart) for patients to review their care while in the hospital. The Administrator stated the DON tried to explain the notification of family/responsible party policy and Resident #37's niece just kept yelling at the DON, and Administrator had to end the conversat A review of Resident #37's clinical record revealed no documentation that Resident #37's niece was upset the facility had failed to notify her of the appointment scheduled with the orthopedic physician. A review of the Concern Log dated 05/2025 to 07/2025 revealed no concerns were documented regarding Resident #37's niece's concern with notification of appointments or any other concerns during Resident #37's stay in the facility. An interview with the Administrator and DON #67 on 07/14/25 at 2:47 P.M. verified the above information and had failed to document Resident #37's niece's concerns in Resident #37's medical record. A review of the facility policy titled Charting and Documentation (undated) indicated the policy was that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The Policy Interpretation and Implementation included:Documentation in the medical record may be electronic, manual or a combination.The following information is to be documented in the resident medical record:Objective observations;Medications administered;Treatments or services performed;Changes in the resident's condition;Events, incidents or accidents involving the resident; andProgress toward or changes in the care plan goals and objectives.Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LPN/LVN, physicians, therapists, etc.) in accordance with state law and facility policy. Certified nursing assistants may only make entries in the resident's medical chart as permitted by facility policy.Information documented in the resident's clinical record is confidential and may only be released in accordance with state law, the Health Insurance Portability and Accountability Act (HIPAA) and facility policy. Refer all requests for information to the director of nursing services, nurse supervisor/charge nurse or to the business office. This deficiency represents non-compliance investigated under Master Complaint Number 2568840.

Based on record review, review of the police report, interview and facility policy review, the facility failed to appropriately discharge Resident #55. This affected one (Resident #55) out of three residents discharged from the facility. The facility census was 54 residents.Findings include: A review of Resident #55's clinical record revealed an admission date of 06/23/25 with diagnoses including cellulitis of the left lower limb, cerebral palsy, high blood pressure, major depression and genetic intellectual disability. Resident #55 was discharged from the facility on 07/07/25. A review of Resident #55's Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #55 was moderately cognitively impaired and needed assistance with bathing, dressing and personal care. Resident #55's plan of care initiated on 06/23/25 indicated a self-care deficit related to intellectual disability. Interventions on the care plan included encourage Resident #55 to participate in planning day-to-day care, evaluate Resident #55's ability to perform activities of daily living (ADL), maintain a consistent schedule with a daily routine, minimize environmental stimuli, provide assistance with ADL as needed. Resident #55's plan of care initiated on 07/02/25 indicated Resident #55 had impaired cognitive impairment with functional/dementia or impaired thought processes related to difficulty making decisions and impaired decision making. Interventions on the plan of care included for staff to communicate with Resident #55, family, caregivers regarding Resident #55's capabilities and needs, discuss concerns about confusion, disease process, nursing home placement with Resident #55, family and caregivers, engage Resident #55 in simple structured activities that avoid overdemanding tasks according t A review of Resident #55's form titled Notice of Medicare Non-Coverage dated 07/07/25 indicated Resident #55 was notified his last day for payment of skilled services was 07/05/25 and the instructions for the right to appeal the decision were included on the form. The form was signed by Resident #55 on 07/03/25. A review of Resident #55's physician orders dated 06/23/25 to 07/07/25 revealed no order to discharge Resident #55 from the facility. A review of the police report dated 07/07/25 revealed the police received a call at 6:24 P.M. that a male needed transported from an independent living facility to the hospital for a health evaluation. The police report revealed Resident #55 left the independent nursing facility at 6:41 P.M. and was transported to the hospital. An interview on 07/10/25 at 8:49 A.M. with Social Services Designee (SSD) #62 revealed she had attempted to obtain the Power of Attorney (POA) paperwork to prove Resident #55's POA was legally appointed as his POA. SSD #62 contacted the POA listed on Resident #55's hospital discharge papers and requested the paperwork to prove he was Resident #55's POA. SSD #62 stated she never received the paperwork. SSD #62 revealed on 07/07/25 Certified Nurse Practitioner (CNP) #65 talked to the Assistant Director of Nursing (ADON) from the independent living facility and was informed Resident #55 was denied admission to the independent living facility. SSD #62 stated she and admission Coordinator (AC) #63 traveled to the independent nursing facility on 07/07/25 at 11:00 A.M. and met with the Independent Living Marketing Director and spoke to the Independent Living Administrator ([NAME]) #66 via speaker phone. The [NAME] #66 informed them that the independent living facility was unable to meet Resident #55's needs and woul A voice message was left on Resident #55's POA's phone on 07/07/25 at 9:30 A.M. and a return phone call on 07/10/25 at 12:00 P.M. revealed he was aware the facility has discharged Resident #55 to the independent nursing facility. Resident #55's POA stated he disagreed with the decision to discharge Resident #55 to the independent nursing facility and was working on finding Resident #55 alternate placement in a long term care facility. An interview with Independent Living Employee ([NAME]) #60 on 07/10/25 at 9:34 A.M. revealed Resident #55 had resided in the independent living facility prior to his hospitalization in June 2025 for wound care. When Resident #55 was sent to the hospital Resident #55's POA was notified he would need a higher level of care and could not return to the independent facility. The POA informed the independent living facility he was investigating placement for Resident #55 in a long-term care facility. [NAME] #60 stated the independent living facility Director of Nursing (DON) #61 received a call from the Administrator of the skilled nursing facility where Resident #55 was provided skilled wound care informing them, he would be returning to the independent living facility. DON #61 informed the Administrator #64 from the skilled nursing facility that they were unable to meet Resident #55's needs because he needed a higher level of care. [NAME] #60 stated SSD #62 and AC #63 from the skilled nursing facility met with the M An interview with Administrator #64 on 07/10/25 at 10:51 A.M. revealed Resident #55 was admitted to the skilled nursing facility for wound care following hospitalization. Administrator #64 stated that when Resident #55 was discharged from therapy services she discharged Resident #55 back to the independent facility where he had resided prior to his admission to the hospital. Administrator #64 stated she was aware the independent living facility had denied Resident #55's re-admission to the independent facility and felt it was the responsibility of the independent living facility to arrange for alternate placement of Resident #55 in another nursing facility. An interview with CNP #65 on 07/14/25 at 10:18 A.M. revealed she was informed the independent nursing facility had denied Resident #55's admission on [DATE] and had informed Administrator #64. CNP #65 stated she did not write a discharge order from the physician and the physician did not enter a discharge order for Resident #55. CNP #65 stated she felt Resident #55 needed a higher level of care in an assisted living facility or a long-term care nursing facility. The facility policy and procedure titled Discharging the Resident revised 08/2024 indicated the purpose of the policy was to provide guidelines for the discharge process. The discharge preparation included when the resident was transferred home, ensure that resident and/or responsible party receive teaching and discharge instructions. Assess and document the resident's condition at discharge, including skin assessment, if medical conditions allow. This deficiency represents non-compliance investigated under Complaint Number OH00167466 (1383016).

Based on record review, observation, interview, review of the Centers for Disease Control and Prevention (CDC) guidance on enhanced barrier precautions in nursing homes, and facility policy review, the facility failed to implement enhanced barrier precautions which required the use of gowns and gloves during care for residents with wounds or indwelling medical devices, which affected nine residents (#5, #12, #20, #23, #30, #34, #36, #45, and #46) out of 10 reviewed for transmission-based precautions (TBP) and enhanced barrier precautions. In addition, the facility failed to develop and implement a water management program and Legionella risk assessment, which had the potential to affect all residents residing in the facility. The facility census was 48. Findings include: 1. Review of the medical record for Resident #5 revealed an admitted [DATE] with diagnoses including neuromuscular dysfunction of bladder, dementia, and anxiety disorder. Review of the care plan, dated 04/11/25, revealed Resident #5 had an indwelling foley catheter. Interventions included changing foley catheter as needed (initiated 04/11/25) and providing catheter care every shift and as needed (initiated 04/11/25), Review of the physician's orders for Resident #5 identified an order dated 04/24/25 for enhanced barrier precautions related to the presence of a Foley (indwelling urinary) catheter. 2. Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses including prostate cancer, neuromuscular dysfunction of bladder, hematuria, and reduced mobility. Review of the physician's orders for Resident #12 identified an order dated 01/08/25 for catheter care every shift, an order dated 02/15/25 to change the resident's suprapubic (surgically-created opening in the abdomen through which a catheter is placed for urinary elimination) catheter on the 15th of every month and as needed. Resident #12's physician's orders did not include an order for enhanced barrier precautions. Review of the catheter care plan, dated 01/09/25, revealed Resident #12 had an indwelling foley catheter. Interventions included providing catheter care each shift and as needed and changing catheter monthly. Review of the wound care progress note, dated 05/19/25, revealed Resident #12 had a stage four pressure ulcer to the left heel which had been present since admission and measured 2.0 centimeters (cm) in length, 3.0 cm in width, and 0.2 cm in depth with moderate serous exudate. Treatments included apply alginate calcium dressing once daily for nine days, collagen sheet once daily and as needed for 16 days, abdominal (ABD) pad once daily for nine days, and gauze roll once daily for nine days. 3. Review of the medical record for Resident #20 revealed an admitted [DATE] with diagnoses including end stage renal disease, anxiety disorder, and dependence on renal dialysis. Review of the physician's orders for Resident #20 identified an order dated 11/05/24 to check Resident #20's right chest dialysis catheter for signs and symptoms of bleeding and apply pressure if bleeding was noted after dialysis treatment, and an order dated 11/06/24 for dialysis treatments three times weekly on Monday, Wednesday, and Friday. Resident #20's physician's orders did not include an order for enhanced barrier precautions. Review of the care plan, dated 02/03/25, revealed Resident #20 required enhanced barrier precautions due to the dialysis catheter. Interventions included maintain enhanced barrier precautions, notify the physician of changes, and observe for changes in mental and physical health. 4. Review of the medical record for Resident #23 revealed an admitted [DATE] with diagnoses including chronic venous hypertension with ulcer of right lower extremity, osteomyelitis, cellulitis of the right finger, and need for assistance with personal care. Review of the physician's orders for Resident #23 identified an orders dated 04/24/25 to observe the peripherally inserted central catheter (PICC) line (an intravenous line used to administer fluids and/or medication directly into an individual's bloodstream) site and document every shift, change intravenous (IV) dressing every seven days and as needed, and maintain enhanced barrier precautions related to the presence of Resident #23's left arm PICC line. Review of the care plan, dated 04/29/25, revealed Resident #23 required enhanced barrier precautions for intravenous therapy and wound care with interventions including activities staff to visit resident and decide on activities of choice for the resident during isolation period, enhanced barrier precautions to be maintained by staff during acute infection period, and staff to monitor resident for signs and symptoms of depression. Further review of the care plan revealed Resident #23 required IV antibiotics due to a right finger infection with interventions including administer IV medications as prescribed and monitor results, change dressing to IV site as ordered and per facility policy, maintain occlusive dressing to IV site, and check the IV site for redness and swelling every shift and as needed for signs of infiltration and infection. Review of the wound care progress note, dated 05/19/25, indicated Resident #23 had a stage three pressure ulcer to the left buttock which had been present for more than 70 days and measured 4.0 centimeters (cm) in length, 1.5 cm in width, and 0.1 cm in depth with light sero-sanguineous exudate (drainage). Treatments included apply house barrier cream twice daily for 23 days, alginate calcium dressing twice daily for 16 days, and superabsorbent gelling fiber with silicone border twice daily and as needed for nine days. 5. Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses including dysphagia, neuromuscular dysfunction of bladder, chronic kidney disease, gastrostomy status, and presence of urogenital implants. Review of the catheter care plan, dated 10/22/24, revealed Resident #30 had an indwelling Foley catheter. Interventions included providing catheter care each shift and as needed and to change the catheter monthly. Review of the physician's orders for Resident #30 revealed orders dated 12/12/24 to change Resident #30's Foley catheter as needed and for Foley catheter care to be completed every shift and as needed. An additional order dated 05/21/25 called for Resident #30 to receive bolus tube feedings via Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube used for administration of enteral feeds) with Isosource 1.5 at 400 milliliters (ml) three times daily after each meal. Resident #30's physician's orders did not include an order for enhanced barrier precautions. Review of the tube feeding care plan, dated 05/14/25, revealed Resident #30 required a feeding tube related to dysphagia and poor intake. Interventions included administer enteral feedings and fluids via PEG tube, administer treatment to PEG tube site as ordered, and observe PEG tube site for signs and symptoms of infection such as redness, warmth, edema, and drainage. 6. Review of the medical record for Resident #34 revealed an admitted [DATE] with diagnoses including venous insufficiency, muscle weakness, major depressive disorder, and anxiety disorder. Review of the physician's orders for Resident #34 revealed there were no orders for enhanced barrier precautions. Review of the care plan, dated 04/21/25, revealed Resident #34 required enhanced barrier precautions and/or contact isolation related to vascular wounds. Interventions included maintaining isolation precautions and/or enhanced barrier precautions, notify the physician of any changes, and observe for changes in mental and physical health. Review of the wound care progress note dated 05/19/25 revealed Resident #34 had a venous ulcer of the left leg which had been present for more than 197 days and measured 7.0 cm in length, 1.0 cm in width, and 0.1 cm in depth with light serous exudate. Treatments included apply Santyl (a debriding ointment used to remove dead or damaged tissue from wounds) once daily and as needed for 30 days, Xeroform (a non-adherent dressing that helps maintain moisture, aids in debridement, and helps prevent infection) dressing once daily and as needed for 30 days, abdominal (ABD) pad once daily and as needed for nine days, kerlix (gauze) roll once daily for 30 days, and skin prep once daily for 16 days. 7. Review of the medical record for Resident #36 revealed an admitted [DATE] with diagnoses including end stage renal disease, hydronephrosis, muscle weakness, and need for assistance with personal care. Review of the physician's orders for Resident #36 identified an order dated 10/15/22 to check for thrill of arteriovenous (AV) fistula every shift, an order dated 10/01/23 to monitor Resident #36's AV fistula site for warmth, redness, tenderness, and edema every shift, and an order dated 01/04/24 for dialysis three times weekly on Monday, Wednesday, and Friday. Additional orders included an order dated 02/06/24 for apply calmoseptine to the buttocks, coccyx, and scrotal areas twice daily and as needed and an order dated 02/13/25 to apply betadine and a small piece of Aquacel to the left fourth toe with bandaid twice daily. Resident #36's physician's orders did not include an order for enhanced barrier precautions. Review of the care plan, dated 02/03/25, revealed Resident #36 required enhanced barrier precautions due to the dialysis catheter. Interventions included maintaining enhanced barrier precautions, notify the physician of any changes, and observe for changes in physical and mental health. 8. Review of the medical record for Resident #45 revealed a re-admitted [DATE] with diagnoses including Parkinson's disease, neuromuscular dysfunction of bladder, retention of urine, and presence of urogenital implants. Review of the care plan, dated 10/21/24, revealed Resident #45 had an indwelling suprapubic catheter. Interventions included providing catheter care each shift and as needed, change catheter monthly, and change catheter as needed per physician order. Review of the physician's orders for Resident #45 revealed there were no orders for enhanced barrier precautions. 9. Review of the medical record for Resident #46 revealed an admitted [DATE] with diagnoses including end stage renal disease, type two diabetes mellitus, and dependence on renal dialysis. Review of the physician's orders for Resident #46 identified an order dated 12/09/24 for monitoring left upper arm AV shunt for bruit and thrill every shift and an order dated 05/22/25 for dialysis on Tuesday, Thursday, and Saturday. Resident #46's physician's orders did not include an order for enhanced barrier precautions. Review of the care plan, dated 02/03/25, revealed Resident #46 required enhanced barrier precautions due to the dialysis catheter. Interventions included maintain enhanced barrier precautions, notify the physician of any changes, and observe for changes in mental and physical health. On 05/21/25 from 8:56 A.M. to 9:10 A.M., an observation of the facility revealed there was only one resident room (Resident #1) in the entire building with a sign indicating precautions were in place. Resident #1's signage outside the door called for contact isolation precautions and a container with personal protective equipment (PPE) was present outside the door. There were no signs or PPE containers to indicate any other residents were on isolation precautions or that any residents in the facility were on enhanced barrier precautions. On 05/21/25 at 9:11 A.M., an interview with Laundry Staff #502 stated they were unaware of any residents on isolation precautions in the facility. Laundry Staff #502 further stated when handling isolation laundry, only gloves were used and the non-porous aprons that were hanging on the wall were hardly ever used. On 05/21/25 at 10:11 A.M., an observation of wound care on Resident #23 with Licensed Practical Nurse (LPN) #517 revealed there was no sign indicating enhanced barrier precautions were in place, there was no container of PPE available, and LPN #517 did not don a gown prior to providing Resident #23's wound care. On 05/21/25 at 11:09 A.M., an observation of tube feed administration for Resident #30 with Registered Nurse (RN) #582 revealed there was no sign indicating enhanced barrier precautions were in place, there was no container of PPE available, and RN #582 did not don a gown while administering the tube feed. On 05/21/25 at 2:41 P.M., an observation of catheter care on Resident #12 with Certified Nursing Assistant (CNA) #611 revealed there was no sign indicating enhanced barrier precautions were in place, there was no container of PPE available, and CNA #611 did not don a gown prior to providing catheter care. An interview with CNA #611 at the time of observation verified the proper PPE was not worn during catheter care. CNA #611 stated when residents had catheters or feeding tubes, the nurses used to put PPE on the door for staff to don before going into the rooms of those on enhanced barrier precautions and that was not being done now. On 05/21/25 at 2:58 P.M., an interview with Infection Preventionist (IP) #511 confirmed Resident #1 was on isolation precautions for a skin infection. IP #511 also verified there were no residents currently on enhanced barrier precautions in the facility and that enhanced barrier precautions should have been implemented prior to 05/21/25. IP #511 stated staff were going around the building at this time to put signs up for enhanced barrier precautions. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated 07/12/24, revealed nursing home residents with wounds and indwelling medical devices were at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities was indicated, when contact precautions did not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. High-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing or showering, transferring, providing hygiene care, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy or ventilator), and care of wounds requiring a dressing. 44457 10. Interview on 05/21/25 at 2:22 P.M. with Maintenance Director #609 confirmed he was unable to provide a Legionella risk assessment or a water management plan. Maintenance Director #609 confirmed there was a Centers for Disease Control (CDC) toolkit available to them in their maintenance system for use to develop a risk assessment and plan, but he had not done so yet. Maintenance Director #609 indicated he did check water temperatures every Friday on each hall. Interview on 05/212/25 at 3:48 P.M. with the Administrator confirmed she was unable to locate any additional information regarding a Legionella risk assessment or water management plan. Review of facility policy Water Management Program undated revealed it was the policy of the facility to establish water management plans for reducing the risk of legionnaires and other opportunistic pathogens in the water system. A risk assessment would be conducted by the water management team annually to identify where Legionella could grow and spread. Review of CDC Toolkit for Controlling Legionella in Common Sources of Exposure (Legionella Control Toolkit) dated 01/13/21 revealed the purpose of the document was to help evaluate hazardous conditions associated with potable water systems. The toolkit provided education, guidelines, and recommendations for development of a water management plan.

Based on observation and staff interview, the facility failed to maintain the dumpster area in a sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 48. Findings include: Observation on 05/18/25 at 8:25 A.M. with Dietary Manager (DM) #419 revealed the lid to the dumpster was open and the enclosure to the dumpster was left open. There was significant debris surrounding the dumpster inside the enclosure including cups, plastic wrap, gloves, and food wrappers. Interview on 05/18/25 at 8:25 A.M. with DM #419 confirmed findings of the dumpster area and indicated the maintenance director was responsible for maintaining the dumpster area.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure education on immunization risk and benefits were provided and failed to obtain written consent for COVID-19 immunizations. This affected five residents (#1, #30, #37, #45, and #46) of five residents reviewed for immunizations. The facility census was 48. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses including hypertension, dementia, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, major depressive disorder, cerebral infarction, and aphasia following unspecified cerebrovascular disease. Review of the COVID-19 vaccination consent form, which was not dated, for Resident #1 indicated the vaccination was declined. The form indicated the declination was verbal, there was no indication as to whether the decision was made by the resident or by a resident representative, and there was no signature on the form to indicate education had been provided on immunization risks and benefits. 2. Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses including dysphagia, neuromuscular dysfunction of bladder, chronic kidney disease, gastrostomy status, major depressive disorder, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of the COVID-19 vaccination consent form, which was not dated, for Resident #30 indicated the vaccination was declined. The form indicated the declination was verbal, there was no indication as to whether the decision was made by the resident or by a resident representative, and there was no signature on the form to indicate education had been provided on immunization risks and benefits. 3. Review of the medical record for Resident #37 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, dementia with behavioral disturbance, and major depressive disorder. Review of the COVID-19 vaccination consent form, dated 03/06/25, for Resident #37 indicated the vaccination was declined. The form indicated the declination was verbal, there was no indication as to whether the decision was made by the resident or by a resident representative, and there was no signature on the form to indicate education had been provided on immunization risks and benefits. 4. Review of the medical record for Resident #45 revealed a re-admitted [DATE] with diagnoses including Parkinson's disease, neuromuscular dysfunction of bladder, retention of urine, schizophrenia, hyperlipidemia, and hypothyroidism. Review of the immunizations record for Resident #45 indicated the resident was not eligible for the COVID-19 vaccination on 12/29/23. There was no evidence in Resident #45's medical record that the COVID-19 vaccine had been offered or administered. 5. Review of the medical record for Resident #46 revealed an admitted [DATE] with diagnoses including end stage renal disease, type two diabetes mellitus, and dependence on renal dialysis. Review of the COVID-19 vaccination consent form, which was not dated, for Resident #46 indicated the vaccination was declined. The form indicated the declination was verbal, there was no indication as to whether the decision was made by the resident or by a resident representative, and there was no signature on the form to indicate education had been provided on immunization risks and benefits. On 05/21/25 at 2:58 P.M., an interview with Infection Preventionist (IP) #511 stated immunizations were supposed to be offered to residents and consent forms signed. IP #511 refused to confirm that the vaccination consent forms for Residents #1, #30, #37, #45, and #46 were not signed. On 05/21/25 at 3:10 P.M., an interview with Licensed Practical Nurse (LPN) #517 verified the immunization consent forms did not have any indication as to who provided the vaccine consent or declination and the forms were not signed by the residents or their representatives. LPN #517 stated the former Director of Nursing (DON) had instructed her to just write verbal or verbally on the forms and that would be sufficient. Review of the facility policy titled COVID-19 Prevention, Response, and Reporting, dated 07/01/24, revealed the facility would offer resources and counseling to residents on the importance of receiving the COVID-19 vaccine and staying up to date on with all recommended COVID-19 vaccine doses.

Based on record review, staff interview, and review of facility policy, the facility failed to ensure education on immunization risk and benefits were provided and failed to obtain written consent for influenza and pneumococcal immunizations. This affected five residents (#1, #30, #37, #45, and #46) of five residents reviewed for immunizations. The facility census was 48. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted [DATE] with diagnoses including hypertension, dementia, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, major depressive disorder, cerebral infarction, and aphasia following unspecified cerebrovascular disease. Review of the influenza vaccine consent form dated 11/28/24 for Resident #1 indicated the vaccination was declined. The form indicated the declination was verbal, there was no indication as to whether the decision was made by the resident or by a resident representative, and there was no signature on the form to indicate education had been provided on the risks and benefits. There was no consent form in Resident #1's medical record for the pneumococcal vaccination. 2. Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses including dysphagia, neuromuscular dysfunction of bladder, chronic kidney disease, gastrostomy status, major depressive disorder, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of the influenza vaccine consent form dated 11/15/24 for Resident #30 indicated the vaccination was declined. The form indicated the declination was verbal, there was no indication as to whether the decision was made by the resident or by a resident representative, and there was no signature on the form to indicate education had been provided on the risks and benefits. Review of the pneumococcal vaccine consent form dated 11/15/24 for Resident #30 indicated the vaccination was declined. The form indicated the declination was verbal, there was no indication as to whether the decision was made by the resident or by a resident representative, and there was no signature on the form to indicate education had been provided on the risks and benefits. Review of the immunization records revealed Resident #30 received the pneumococcal vaccination on 11/16/24. There was no signed consent form in Resident #30's medical record indicating consent was received to administer the pneumococcal vaccination. 3. Review of the medical record for Resident #37 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, dementia with behavioral disturbance, and major depressive disorder. Review of the influenza vaccine consent form dated 11/27/24 for Resident #37 indicated consent was received to administer the vaccination. The form indicated the consent was verbal, there was no indication as to whether the decision was made by the resident or by a resident representative, and there was no signature on the form to indicate education had been provided on the risks and benefits. Review of the pneumococcal vaccine consent form, which was not dated, for Resident #37 indicated consent was received to administer the vaccination. The form indicated the consent was verbal, there was no indication as to whether the decision was made by the resident or by a resident representative, and there was no signature on the form to indicate education had been provided on the risks and benefits. Review of the immunizations record for Resident #37 indicated the pneumococcal vaccine was administered on 11/24/24 and the influenza vaccine was administered on 12/19/24. 4. Review of the medical record for Resident #45 revealed a re-admitted [DATE] with diagnoses including Parkinson's disease, neuromuscular dysfunction of bladder, retention of urine, schizophrenia, hyperlipidemia, and hypothyroidism. Review of the influenza vaccine consent form dated 11/28/24 for Resident #45 indicated consent was received to administer the vaccination. The form indicated the consent was verbal, there was no indication as to whether the decision was made by the resident or by a resident representative, and there was no signature on the form to indicate education had been provided on the risks and benefits. Review of the pneumococcal vaccine consent form, which was not dated, for Resident #45 indicated consent was received to administer the vaccination. The form indicated the consent was verbal, there was no indication as to whether the decision was made by the resident or by a resident representative, and there was no signature on the form to indicate education had been provided on the risks and benefits. Review of the immunizations record for Resident #45 indicated the pneumococcal vaccine was administered on 11/16/24 and the influenza vaccine was administered on 12/19/24. 5. Review of the medical record for Resident #46 revealed an admitted [DATE] with diagnoses including end stage renal disease, type two diabetes mellitus, and dependence on renal dialysis. There was no consent form in Resident #46's medical record for the influenza vaccination or the pneumococcal vaccination. On 05/21/25 at 2:58 P.M., an interview with Infection Preventionist (IP) #511 stated immunizations were supposed to be offered to residents and consent forms signed. IP #511 refused to confirm that the vaccination consent forms for Residents #1, #30, #37, #45, and #46 were not signed. On 05/21/25 at 3:10 P.M., an interview with Licensed Practical Nurse (LPN) #517 verified the immunization consent forms did not have any indication as to who provided the vaccine consent or declination and the forms were not signed by the residents or their representatives. LPN #517 stated the former Director of Nursing (DON) had instructed her to just write verbal or verbally on the forms and that would be sufficient. LPN #517 also verified Resident #30's pneumococcal vaccine consent form indicated the vaccine was declined on 11/15/24 and Resident #30's medical record indicated he received the pneumococcal vaccination on 11/16/24. Review of the facility policy titled Influenza Vaccine, dated October 2019, revealed all residents without clinical contraindications would be offered the influenza vaccine annually, education on the risks and benefits of the vaccine would be provided to the resident or resident's legal representative, and consent or declination of the vaccine would be documented in the resident's medical record. Review of the facility policy titled Pneumococcal Vaccine, dated October 2019, revealed all residents would be offered the pneumococcal vaccine within 30 days of admission, education on the risks and benefits of the vaccine would be provided to the resident or resident's legal representative, provision of the education would be documented in the resident's medical record, and refusals of the vaccine would be documented in the resident's medical record.

Based on medical record review and staff interview, the facility failed to ensure residents were nutritionally assessed and monitored on a routine basis. This affected two residents (#30, and #46) of five residents reviewed for nutrition. The facility census was 48. Findings include: 1. Review of the medical record for Resident #30 revealed an admitted [DATE] and diagnoses including right dominant side hemiplegia and hemiparesis, diabetes mellitus, hypertension, diastolic congestive heart failure, chronic ischemic heart disease, and chronic kidney disease. Review of the physician's order dated 12/12/24 revealed Resident #30 was on a regular diet with regular texture and thin liquids. Review of the physician's order dated 02/13/25 revealed Resident #30 received 150 milliliters (ml) water flush every four hours via percutaneous endoscopic gastrostomy (PEG) tube (used for administration of enteral feeds). Review of the physician's order dated 03/15/25 revealed Resident #30 received 400 ml bolus three times per day of Isosource 1.5 (enteral nutrition formula) via PEG tube. Review of weights revealed Resident #30 had weight fluctuations and there was no evidence of weights recorded for November 2024 or March 2025. Further review of the medical record revealed there had not been a nutritional assessment completed on Resident #30 from admission on 10/21/24 until 05/14/25. Review of the dietary progress note dated 05/14/25 confirmed Resident #30 had not had a nutritional assessment since admission. The progress note indicated Resident #30 was at risk for malnutrition related to chronic disease, tube feedings, and dysphagia. It was noted Resident #30 had weight gain over five months of 12 percent (%) and weight maintenance was preferred. Review of Resident #30's plan of care revealed a nutritional care plan was not initiated until 05/14/25 to reflect Resident #30's nutritional risk related to dysphagia, history of poor meal intake, and enteral feeding with PEG tube. Interview on 05/21/25 at 10:05 A.M. with Registered Dietitian Supervisor (RDS) #700 revealed their company had been contracted at the facility for about two weeks and they had been documenting on residents remotely as of 05/12/25. RDS #700 indicated a permanent consultant was scheduled to start next week for routine on site visits. RDS #700 confirmed she was unable to locate any additional nutritional assessment of Resident #30. RDS #700 confirmed she would consider Resident #30 to be at high risk nutritionally and additional monitoring was needed. Interview on 05/21/25 at 10:38 A.M. with the Administrator revealed there had been a couple month lapse in dietitian services. The Administrator indicated there was a corporate dietitian overseeing nutrition services during the lapse, but was unable to provide additional evidence of nutritional oversight of Resident #30. 2. Review of the medical record for Resident #46 revealed an admitted [DATE] and diagnoses including end stage renal disease, dependence on renal dialysis, diabetes mellitus, acute on chronic combined systolic and diastolic congestive heart failure, hypertension, blindness in both eyes, and peripheral vascular disease. Review of physician's order dated 04/11/25 revealed Resident #46 went to dialysis every Tuesday, Thursday, and Saturday. Review of weight records revealed Resident #46 had significant weight loss at 7.5 percent (%) loss from April 2025 at 130.6 pounds to May 2025 at 120.8 pounds. Further review of the medical record revealed there had not been a nutritional assessment completed on Resident #46 from admission on 12/07/24 until 05/19/25. Review of the Nutrition/Dietary Note dated 05/19/25 revealed Resident #46 triggered for significant weight loss and had body mass index (BMI) indicating underweight. The progress note confirmed Resident #46 had not had a nutritional evaluation since admission. It was noted there had been no communication with dialysis dietitian and facility dietitian was awaiting return communication. It was recommended to add pre- and post-dialysis weights, add four ounces of Novasource renal (nutritional) supplement twice daily, and continue to monitor as needed. Review of Resident #46's plan of care revealed a nutritional care plan was not initiated until 05/19/25 to reflect Resident #46's nutritional risk related to dialysis, low BMI, and significant weight changes. Interview on 05/21/25 at 10:05 A.M. with RDS #700 revealed their company had been contracted at the facility for about two weeks and they had been documenting on residents remotely as of 05/12/25. RDS #700 indicated a permanent consultant was scheduled to start next week for routine on site visits. RDS #700 confirmed she was unable to locate any additional nutritional assessment of Resident #46. RDS #700 confirmed she would consider Resident #46 to be at high risk nutritionally and need additional monitoring. Interview on 05/21/25 at 10:38 A.M. with The Administrator revealed there had been a couple month lapse in dietitian services. The Administrator indicated there was a corporate dietitian overseeing nutrition services during the lapse but was unable to provide additional evidence of nutritional oversight of Resident #46. This deficiency represents noncompliance investigated under Complaint Number OH00161627.

Based on resident record reviews, staff interviews, and review of facility policy, the facility failed to ensure communication and monitoring between the facility and dialysis center was completed and maintained. This affected one resident (#46) of one resident reviewed for dialysis. The facility census was 48. Findings include: Record review for Resident #46 revealed the resident was admitted to the facility on [DATE] and had diagnoses including end stage renal disease (ESRD), acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, blindness in both eyes, and dependence on renal dialysis. Review of Resident #46's care plan dated 12/09/24 revealed the resident received dialysis treatments on Tuesdays, Thursdays, and Saturdays. Listed interventions included to auscultate (listen to) lungs sounds as ordered and monitor for edema, check for new orders upon return from dialysis, maintain communication staff with dialysis staff and physician, monitor dressing to vascular catheter/shunt, monitor left arm fistula for bruit and thrill and signs of infection, and monitor labs and report to the physician. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #46 has a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Resident #46 was noted on the assessment as receiving dialysis treatments. Review of the medical record for Resident #46 revealed there was only dialysis communication documentation recorded for 01/09/25 and 01/16/25. There was no additional evidence of dialysis communication contained in the resident's medical record or the facility's dialysis communication book. Interview on 05/21/2025 at 9:10 A.M. with Registered Nurse (RN) #582 revealed Resident #46 did not want his vital signs taken and consistently would refuse prior to leaving for dialysis treatments. RN #582 refused to take his dialysis communication record with him to the off-site dialysis center. RN #582 further confirmed that when Resident #46 returned from dialysis, he did not provide any communication or documentation from the dialysis center and would refuse to have his vital signs taken. Interview on 05/21/25 at 10:00 A.M. with the Director of Nursing (DON) revealed there was a communication book for the nurses to read and record on residents that go out to dialysis treatments. The DON stated Resident #46 would take the dialysis communication sheets with him to dialysis but would not return them. The DON confirmed the facility did not retain a copy of the sheets sent with the resident, and there was no evidence that the facility had reached out to the dialysis center directly to collaborate or communicate. Review of the policy titled Hemodialysis Catheters - Access and Care of with revised date September 2024 revealed that nurses should document every shift for location of catheter, condition of dressing, if dialysis was done during shift, any part of report from dialysis nurse post-dialysis being given, and observations post-dialysis.

Based on medical record review and staff interview, the facility failed to ensure pharmacy recommendations were timely reviewed and addressed by the physician. This affected three residents (#18, #30, and #34) of five residents reviewed for unnecessary medications. The facility census was 48. Findings include: 1. Review of the medical record for Resident #30 revealed an admitted [DATE] and diagnoses including right dominant side hemiplegia and hemiparesis, Diabetes mellitus, essential hypertension, diastolic congestive heart failure, chronic ischemic heart disease, and chronic kidney disease. Review of the pharmacy Consultation Report dated 10/23/24 revealed the pharmacist recommended to obtain a complete blood count (CBC) and basic metabolic panel (BMP) lab draw on next lab day due to Resident #30 receiving Eliquis (an anticoagulant medication). There was no evidence provided that this pharmacy recommendation was addressed by a physician. A BMP and CBC were not obtained until 11/21/24. Review of an additional pharmacy Consultation Report dated 10/23/24 revealed the pharmacist recommended discontinuing as needed Methocarbamol (a muscle relaxant medication) due to the strong, sedating anticholinergic properties. There was no evidence provided that this pharmacy recommendation was addressed by a physician. Resident #30 remained on the medication until 03/06/25. Review of the pharmacy Consultation Report dated 01/27/25 revealed the pharmacist indicated Resident #30 was on duplicate therapy including Doxazosin Mesylate (an antihypertensive medication and can also be used to treat benign prostatic hyperplasia) for hypertension and Tamsulosin Hydrochloride for benign prostatic hyperplasia. The pharmacist recommended to re-evaluate and consider an alternative antihypertensive to Doxazosin. The pharmacy recommendation was not addressed by a physician until 03/03/25. Interview on 05/21/25 at 2:24 P.M. with the Director of Nursing (DON) confirmed she was unable to locate additional evidence pharmacy recommendations were addressed by a physician. The DON indicated these recommendations occurred prior to her becoming the DON. 32650 2. Resident #18 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Multiple Sclerosis, gastroparesis, anxiety, and morbid obesity. Review of the physician's orders for Resident #18 revealed the resident received the following medications: - Ativan (used to treat anxiety) 1 milligram (mg) orally every six hours as needed - Clonazepam (used to treat anxiety) 1 mg orally twice a day - Buspirone (used to treat anxiety) 20 mg orally twice a day - Bupropion (an antidepressant) 150 mg twice a day - Fluoxetine (an antidepressant) 40 mg orally every day - Seroquel (an antipsychotic used to treat bipolar disorder) 400 mg orally every evening - Eliquis (an anticoagulant) 5 mg orally twice a day Review of the pharmacist recommendations for Resident #18 revealed on 06/25/24 and 09/23/24 revealed the resident was receiving Eliquis twice a day, baby aspirin daily, and Naproxen (an anti-inflammatory) twice a day. The pharmacist recommended consideration of discontinuing the Naproxen as it could lead to potentially fatal bleeding. The physician did not provide a response to the recommendation. Review of the current physician's orders revealed Resident #18 no longer had an order for Naproxen. Review of the pharmacist recommendations for Resident #18 revealed on 03/14/25 the resident had an order for Ativan 1 mg orally every six hours as needed for anxiety. There was no date provided for when the medication should be discontinued. The recommendation for all non-antipsychotic medications ordered as needed should be limited to 14 days unless otherwise noted by the physician. The physician did not respond to the recommendation until 04/28/25 when a discontinuation date of six months was provided. Review of the pharmacist recommendations for Resident #18 revealed on 03/14/25 the resident had an order for aspirin and eliquis (an anticoagulant medication) and had not had a complete blood count (CBC) completed in the past six months. The pharmacist recommended the resident have a CBC drawn every six months to monitor for the possibility of gastrointestinal bleeding. The physician did not respond to the recommendation until 04/28/25. Interview with the Administrator on 05/21/25 at 5:00 P.M. revealed she did not know why the physician did not respond to the pharmacist recommendations in a timely manner as he was present in the facility weekly. 38523 3. Review of the medical record for Resident #34 revealed an admitted [DATE] and diagnoses including chronic and peripheral venous insufficiency, adjustment disorder with mixed anxiety and depressed mood and recurrent major depressive disorder and generalized anxiety disorder. Review of the Pharmacy Consultation Report dated 01/01/25 revealed the pharmacist recommended a gradual dose reduction (GDR) of trazodone 50 milligrams (mg) at hour of sleep (HS) to trazodone 25mg at HS, a medication used to treat depression and is used as a sleep aid. The pharmacy recommendation was not addressed by a physician until 03/03/25. Review of an additional Pharmacy Consultation Report dated 01/01/25 revealed the pharmacist recommended re-evaluating and consider discontinuing Doxazosin Mesylate 2 mg HS for hypertension (HTN) and Tamsulosin Hydrochloride 0.4 mg HS for benign prostatic hyperplasia (BPH) consider alternative antihypertensive therapy if necessary. The pharmacy recommendation was not addressed by the physician until 03/03/25. Interview on 05/21/25 at 2:24 P.M. with the DON confirmed she was unable to locate additional evidence pharmacy recommendations were addressed by a physician. The DON indicated these recommendations were prior to her becoming the DON.

Based on staff interview, resident interview, record review, and policy review, the facility failed to ensure two ( #32 and #7) of three residents reviewed for admission, transfers, or discharges, were notified of past due payments resulting in a 30 day discharge notice and failed to ensure the reasons for the transfers or discharge was documented in the medical record. The facility census was 49. Findings Include: 1.Resident #32 was admitted to the facility on [DATE] with diagnoses including infection and inflammatory reaction with removal of internal fixation device of a left hip replacement, post traumatic stress disorder, high blood pressure, diabetes, depression, and generalized anxiety disorder. Review of the physician's orders for Resident #32 revealed an order dated 09/04/24 from Medical Doctor (MD) #400 indicating he certified that there is a medical necessity for this patient/resident to be in this skilled nursing facility. I have informed the resident of diagnoses, treatment and care plan. I have read, reviewed and agree with the resident's plan of care. Orders are verified and approved as by my signature, as physician, on the last page. Review of the comprehensive quarterly [NAME] Data Set (MDS) 3.0 assessment, dated 09/11/24, revealed Resident #32 was cognitively intact, exhibited no adverse behaviors, was dependent on staff for toileting, showering, dressing, and personal hygiene. The resident had almost constant pain which did not interfere with sleep or daily activities. Review of the medical record for Resident #32 revealed no documentation regarding the facility issuing a 30 day discharge notice for lack of payment. There was no documentation the facility had discussed with the resident at any time that she owed the facility money for her care and treatment. Interview with Resident #32 on 10/03/24 at 10:40 A.M. confirmed she had been issued a 30 day notice on 09/18/24. She had resided in the facility for a little over a year and had no desire to transfer to another facility. The resident stated she had never been told she owed the facility for nonpayment of her care until the facility gave her the discharge letter on 09/18/24. Resident #32 said she contacted her insurance company and they told her the facility had not submitted the necessary documentation for review to determine if the care she was receiving was necessary. The resident had not been updated about the pending discharge since receiving the discharge notice other than the Administrator was working on finding a way for the resident to remain in the facility. Resident #32 confirmed she had filed an appeal regarding the discharge notice but had not heard anything about a hearing being scheduled. Interview with the Ombudsman on 10/03/24 at 11:06 A.M. revealed he had been notified that a 30 day discharge notice had been issued for Resident #32 and that a hearing had been set to hear the resident's appeal. Telephone interview with the Administrator and the Director of Operations (DOO) on 10/03/24 at 2:22 P.M. revealed the facility did not realize Resident #32's insurance company was not paying the resident's bills. The Admininstrator believed Resident #32's bills stopped being paid when the company took over ownership in December 2023. The residents using this insurance had been previously granted long term care authorization but after taking over the approvals were discontinued. The Administrator was currently working on approval being granted for the resident to stay. The Administrator revealed that he had just been informed of the hearing date for Resident #32's appeal of the discharge notice. The Administrator confirmed he should have documented in the medical record that the 30 day notice had been issued and the reason for the discharge notice. The DOO reminded the Administrator there must be documentation completed when a 30 day discharge notice was issued. Interview with the Director of Nursing (DON) on 10/03/24 revealed she was sure Resident #32 was aware she owed money to the facility so the receipt of a discharge notice should not be a surprise. The DON said she knew Resident #32 from a previous facility and the resident was an expert manipulator and liar and she would say anything to get what wanted. 2. Resident #7 was admitted to the facility on [DATE] with diagnoses including diabetes, bilateral below the knee amputations, major depression, and generalized anxiety disorder. Review of the physician's orders for Resident #7 revealed an order dated 10/27/23 from Medical Doctor (MD) #400 indicating he certified that there is a medical necessity for this patient/resident to be in this skilled nursing facility. I have informed the resident of diagnoses, treatment and care plan. I have read, reviewed and agree with the resident's plan of care. Orders are verified and approved as by my signature, as physician, on the last page. Review of the annual comprehensive MDS 3.0 assessment revealed Resident #7 was cognitively intact. The resident was independent for all activities of daily living. She was not receiving therapy at the time of the assessment. Review of the medical record revealed no documentation regarding the facility issuing a 30 day discharge notice for lack of payment for Resident #7. There was no documentation the facility had discussed with the resident that she owed the facility money for her care and treatment. Interview with Resident #7 on 10/03/24 at 1:58 P.M. revealed she was issued a 30 day discharge notice on 09/18/24 because the facility needed some sort of a discharge. The resident confirmed she had not been aware she owed the facility money for her care and treatment until she received the discharge notice. The resident said she hoped to transfer to the facility's assisted living unit. Resident #7 said she was not aware she could appeal the discharge notice as they never told her that was an option. The resident said she provided all of her own care except for medications and food. She purchased all of her own supplies because she wanted them handy if the facility ran out of them. The resident said she did not know how she went from being a long term resident to suddenly not being one. Interview with the Ombudsman on 10/03/24 at 11:06 A.M. revealed he had been notified that a 30 day discharge notice had been issued for Resident #7. Review of the facility's Transfer and Discharge (including AMA) policy, last reviewed/revised on 04/04/24, revealed a facility-initiated transfer or discharge which the resident objected to or did not originate through a resident's verbal or written request, and/or was not in alignment with the resident's stated goals for care and preferences. A discharge notice could be issued if the resident had failed, after reasonable and appropriate notice, to pay or have paid under Medicare or Medicaid for his/her stay at the facility. Nonpayment applied if the resident did not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denied the claim and the resident refused to pay for his or her stay. The policy also indicated that supporting documentation would include evidence of the resident's or the resident's representative verbal or written notice of intent to leave the facility, a discharge plan, and documented discussions with resident and/or the resident's representative. This deficiency represents non-compliance investigated under Complaint number OH00158120.

Based on interview, record review, and policy review, the facility failed to ensure Resident #100 received assistance as needed and failed to recognize a change in Resident #100's condition. This affected one (#100) of six residents reviewed for the provision of care and services. The facility census was 49. Findings Include: Resident #100 was admitted to the facility on [DATE] with diagnoses including breast cancer to the left breast, dementia without behavioral disturbance, multiple sclerosis, high blood pressure, left mastectomy, and psychotic disorder with delusions. Review of the quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed Resident #100 was moderately cognitively impaired, needed set up for eating, and supervision for toileting and bathing. Review of the progress notes revealed on [DATE] timed 2:06 P.M. revealed Resident #100 had an appointment scheduled for 10:00 A.M. but was unable to make it due to the resident being incontinent of a large amount of stool. It took a long time to clean the resident up so the resident's daughter contacted the doctor's office and was able to reschedule the appointment to 2:00 P.M. Review of the progress noted dated [DATE] at 7:35 A.M. revealed Licensed Practical Nurse (LPN) #421 called the resident's daughter at home and asked where her mother was as she had not returned to the facility. The daughter told LPN #421 that her mother was not doing well, that she had been admitted to the hospital and she would not be returning to the facility. Interview with Resident #100's daughter on [DATE] at 2:17 P.M. revealed on [DATE] the daughter arrived at the facility to take her mother (Resident #100) for a full body scan. She felt her mother was a bit off. She had been finding meal trays in her mother's room with uneaten food and drinks that had not been consumed. No one from the facility notified the family that Resident #10 had decreased eating and drinking. The daughter asked the nurses if they could test her urine when she returned to the facility as she thought her mother might have a urinary tract infection. On [DATE] Resident #100's sister (the daughter's aunt) arrived at the facility to take Resident #100 to her first radiation treatment. Her mother had been incontinent of stool and staff refused to provide incontinence care because the resident was listed as self-sufficient for toileting. The resident's sister gathered the necessary supplies and proceeded to clean Resident #100 without staff assistance. The appointment for radiation treatment was rescheduled for 2:00 P.M. that day. The resident's sister left with Resident #100 at 1:30 P.M. Resident #10 was not able to have her radiation treatment because when the radiologist assessed Resident #10 she was immediately sent to the emergency room (ER) due to being very lethargic, her inability to stand, and difficulty waking her up. The daughter did not notify the facility her mother had been admitted due to dissatisfaction with the care her mother received at the facility. No one contacted the family about the whereabouts of her mother until LPN #421 called her on [DATE] at 7:35 A.M. The daughter informed LPN #421 her mother would not be returning to the facility. The daughter said her mother was admitted to the hospital where they discovered her mother's cancer had metastasized everywhere. She was discharged from the hospital to the daughter's house and died at the daughter's home on [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 4:30 P.M. revealed she was positive either the daughter or the hospital called the facility to inform them of Resident #100's admission to the hospital on [DATE]. The DON confirmed there was no documentation from when the resident left the faciity on [DATE] at 1:30 P.M. until LPN #421 contacted Resident #100's daughter on [DATE] at 7:35 A.M. to find out where the resident was. The DON said LPN #422, who was assigned to Resident #100 on [DATE], was a new graduate nurse and the DON had since educated her regarding when a family requested assistance it should be provided. The DON agreed Resident #100 had a drastic change in condition in a very short period. Documentation of the meal percentages Resident #100 ate during the week before her discharge and Resident #100's care Kardex (a summary of the care needed for each resident and how many people were needed to provide it) were requested and not provided. The DON said the information could not be obtained from the electronic medical record after 30 days. Telephone interview with Resident #100's sister on [DATE] at 3:05 P.M. revealed she arrived at the facility at 9:15 A.M. on [DATE] to take her sister to her first radiation treatment. When she arrived Resident #100 was still in bed and was not dressed to leave. The sister assisted Resident #100 up and realized the resident had been incontinent of a large amount of stool. She assisted the resident back to bed and went to request help. The sister saw LPN #422 and requested assistance getting her sister cleaned up. LPN #422 said she would notify the aides. LPN #422 returned to the room and told the sister Resident #100 was self-sufficient with toileting so the resident would have to clean herself up. The sister realized they would not be able to make their 10:00 A.M. appointment and called the resident's daughter to update her. The resident's sister then proceeded to clean up her sister by herself. Resident #100's daughter was able to reschedule the radiation treatment for 2:00 P.M. The resident and her sister left for the appointment at 1:30 P.M. Resident #100 had to be transported via a wheelchair because she could barely stand which was a drastic change for the resident as she usually walked everywhere. When they arrived at the radiation treatment appointment Resident #100 did not receive her treatment because the physician sent Resident #100 immediately to the emergency room (ER) for evaluation. Resident #100 was subsequently admitted to the hospital. During interview with the DON on [DATE] at 2:35 P.M. the DON said the facility was aware Resident #100 had been admitted to the hospital. The DON said the hospital notified the facility the resident had been admitted , not the family. This deficiency represents non-compliance investigated under Complaint number OH00157364.

Based on interview, record review, and policy review, the facility failed to ensure appropriate and accurate medical record documentation for one (#100) of six residents reviewed for change in condition. The facility census was 49. Findings Include: Resident #100 was admitted to the facility on [DATE] with diagnoses including breast cancer to the left breast, dementia without behavioral disturbance, multiple sclerosis, high blood pressure, left mastectomy, and psychotic disorder with delusions. Review of the quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 08/06/24 revealed the Resident #100 was moderately cognitively impaired and needed supervision for all care. Review of the progress note dated 08/22/24 timed 2:06 P.M. revealed Resident #100 had an appointment scheduled for 10:00 A.M. but was unable to make the appointment because the resident had been incontinent of a large amount of stool and it took a long time to clean the resident up. The resident's daughter contacted the doctor's office and was able to reschedule the appointment to 2:00 P.M. The resident left the facility at 1:30 P.M. The next documented note was dated 08/23/24 timed 7:35 A.M. indicating Licensed Practical Nurse (LPN) #421 called the resident's daughter at home and asked where her mother was as she had not returned to the facility. The daughter told LPN #421 that her mother was not doing well, that she had been admitted to the hospital and she would not be returning to the facility. Review of August 2024 Medication Administration (MAR) for Resident #100 revealed LPN #421 marked Resident #100's 6:00 A.M. medications as given. The medications included protonix (used to treat gastric reflux) 40 milligrams (mg) orally, buspirone (an antianxiety medication) orally, and oxycodone (a narcotic pain medication) 5 mg orally. Interview with the Director of Nursing (DON) on 10/02/24 at 2:10 P.M. revealed she did not remember who notified the facility about Resident #100 being admitted to the hospital. She said her regional nurse told her not to document when a resident is admitted to hospital. The DON said she did not know why LPN #421 would document the protonix, buspirone, and oxycodone as given when the resident was in the hospital. Interview with the DON on 10/02/24 at 4:30 P.M. revealed she was positive either the daughter or the hospital called the facility to inform them of Resident's 100 admission on 08/22/23. The DON confirmed there was no documentation from when the resident left the faciity on [DATE] at 1:30 P.M. until LPN #421 contacted Resident #100's daughter on 08/23/24 at 7:35 A.M. The DON reiterated the regional nurse said not to document anything about admissions in the medical record. A copy of the facility's documentation policy was requested and the DON said they did not have one; what needed to be documented was covered in specific procedure policies. Interview with the DON on 10/03/24 at 2:35 P.M. revealed the facility was aware Resident #100 had been admitted to the hospital following the radiation appointment on 08/22/24. The DON said the hospital notified the facility the resident had been admitted , not the family. The DON indicated although there was no documentation the facility knew where the resident was. This deficiency represents non-compliance investigated under Complaint number OH00157364.

Based on interview and record review the facility failed to ensure Resident #115, who had cognitive and neurological impairments, a diagnosis of dementia, and was at risk for falls, was not left unattended in the facility van with no air conditioning and the door open for an extended period of time. This affected one resident (#115) of three residents reviewed for transportation to outside appointments. The facility census was 67. Findings include: Resident #115 was admitted to the facility on [DATE] with diagnoses including left breast wound, left breast cancer, dementia, multiple sclerosis, heart disease, chronic kidney disease, depression, anxiety, and psychosis with delusions. Review of the Admission MDS (Minimum Data Set) Version 3.0 Assessment Tool dated 05/17/24, Resident #115 had a BIMS (Brief Interview for Mental Status) of 10/15 indicating moderate cognitive impairment. Review of Resident #115's care plan initiated on 05/11/24 indicated Resident #115 had impaired thought processes related to cognitive and neurological impairments from dementia and Multiple Sclerosis. Resident #115 was at risk for falls and poor decision-making. Resident #115 was to receive facility-provided transportation to medical appointments. routine radiation treatment for breast cancer that required transportation to appointments. The facility provided a van/bus for transportation for Resident #115 to attend appointments. On 06/04/24, Resident #115 was scheduled to be transported from the facility to a medical appointment scheduled at 2:00 P.M. that same date. During interview on 06/05/24 at 11:04 A.M., Employee #301 stated that he refers to the Transportation book that tells him who, what time, and where someone needs to be transported. Employee #301 stated he had two residents scheduled to be transported to the hospital for appointments on 06/04/24. Resident #115 had an appointment scheduled at 2:00 P.M. Resident #151 had an appointment scheduled at the same hospital at 2:30 P.M. Employee #301 stated that he first loaded Resident #115 onto the transport van and applied her seat belt. He then lowered the wheelchair lift to go get Resident #151. He stated he left the bus door open. When he went to get Resident #151, she was not ready and needed to be changed. Employee #301 then stated that he went to find Resident #151's nurse but finally decided he could not wait any longer and had to go take Resident #115 to her appointment. Employee #301 stated he arrived at the hospital and let Resident #115 out and went inside to help her sign in and passed his number to the secretary to call and let him know when she was ready to be picked up. Employee #301 confirmed that he did not arrive at the hospital at the scheduled appointment time. Employee #301 also confirmed that he did not leave the air conditioner on while Resident #115 sat in the transport van for 20 to 30 minutes. During interview on 06/05/24 at 3:05 P.M., Resident #115 indicated she was left on the facility transport van for approximately 20 to 25 minutes, with the doors open but no air conditioning with an outdoor temperature of 85 degrees Fahrenheit. Resident #115 stated when she finally arrived late to her medical appointment, she had a headache and was sweaty. This deficiency represents non-compliance investigated under Master Complaint Number OH00154527.

Based on record review, observations, and interview the facility failed to provide activities as scheduled and to support the residents' mental and psychosocial wellbeing. This affected three (#2, #45, #47) of 13 residents interviewed and had the potential to affect nine (#1, #2, #12, #17, #24, #26, #30, #34, and #36) of 48 residents observed for participation in activities. Findings include: Review of the activity calendar for April 2024 revealed on 04/18/24 the facility would provide room visits at 10:00 A.M., exercise at 11:30 A.M., brain teasers at 11:45 A.M., and a scenic ride with ice cream stop at 2:00 P.M. Observations on 04/18/24 at 8:50 A.M. revealed Activity Aide #210 was doing leg exercises with residents in the common area. Observations on 04/18/24 at 11:11 A.M. revealed Residents #1, #2, #12, #17, #24, #26, #30, #34, and #36 were sitting in the common area watching television and sleeping. Staff were seated at the nurse's desk; no organized activities were observed. Observations on 04/18/24 at 1:10 P.M. revealed Residents #1, #2, #12, #17, #24, #26, #30, #34, and #36 were seated in the common area after lunch. No organized activities were observed. Observations on 04/18/24 at 1:37 P.M. revealed Residents #1, #2, #12, #17, #24, #26, #30, #34, and #36 were seated in the common area watching television and sleeping, no organized activities were observed. Observations on 04/18/24 at 2:27 P.M. revealed Residents #1, #2, #12, #17, #24, #26, #30, #34, and #36 were seated in the common area either watching television or sleeping, no staff were present. No organized activities were observed. Interview on 04/18/24 at 2:27 P.M. with Registered Nurse (RN) #207 verified the observation of the nine residents gathered in the common area with the television on and residents sleeping with no staff present and no organized activities in progress. RN #207 shrugged her shoulders and rolled her eyes in response. Observations and interview on 04/18/24 at 3:14 P.M. revealed five residents in the activity room watching television and eating popcorn. Residents #1, #2, #12, #17, #24, #26, #30, #34, and #36 were seated in the common area where no staff or activities were being provided. Interview during the observations with the Activity Director revealed the scenic ride with ice cream stop was canceled because the bus had a broken window. The Activity Director did not have an activity planned for the nine residents sitting in the common area watching television or sleeping. Interview on 04/23/24 from 9:21 A.M. to 9:27 A.M. with Residents #2, #45, and #47 revealed there were not enough activities offered throughout the day; they watched a lot of television. Review of facility policy Activities, dated 01/01/24, revealed the facility would provide activities including religious programs, exercise programs, social activities, education programs, and indoor/outdoor activities. This deficiency represents non-compliance investigated under Complaint Number OH00152849.

Based on record review, observation, and interview the facility failed to ensure residents had a dignified eating experience. This affected three ( #12, #19, #34) of 20 residents observed for meals. Findings include: Review of the medical record for Resident #12 revealed an admitted [DATE]. Diagnoses included epilepsy, legal blindness, and cerebral infarction due to unspecified occlusion of the cerebral artery. Review of the quarterly Minimum Data Set (MDS) assessment, dated 03/31/24, revealed Resident #12 had impaired cognition and required moderate assistance for eating. Review of the medical record for Resident #19 revealed an admitted [DATE]. Diagnoses included multiple sclerosis, quadriplegia, and muscle weakness. Review of the quarterly MDS assessment, dated 02/03/24, revealed Resident #19 had intact cognition and required setup and clean up for eating. Review of the medical record for Resident #34 revealed an admitted [DATE]. Diagnoses included unspecified dementia and legal blindness. Review of the quarterly MDS assessment, dated 02/28/24, revealed Resident #34 had impaired cognition and required supervision and touch assistance with eating. Observation on 04/18/24 at 12:32 P.M. revealed State tested Nurse Assistant (STNA) #203 seated at the dining room table next to Resident #19. STNA #203 was observed on her cell phone which was lying on the table as she fed Resident #19. Interview immediately after the observation with STNA #203 confirmed she was using her cell phone while feeing Resident #19 and she should have put the phone away. Observations on 04/18/24 at 12:32 P.M. revealed STNA #204 standing as she fed Residents #12 and #34. STNA #204 was also observed using her cell phone which was lying on the table as she fed the residents. Interview immediately after the observation with STNA #204 revealed she should have been seated when feeding the residents and not using her cell phone. Review of the facility policy Promoting/Maintaining Resident Dignity During Meals, dated 01/01/24 revealed staff were to focus on the resident while talking and addressing them individually and should be seated while feeding residents. This deficiency represents non-compliance investigated under Complaint Number OH00152849.

Based on record review, review of the facility reported incident, review of facility policy and interview, the facility did not ensure Resident #52 was free from physical abuse by Resident #46. This affected one resident (#52) out of four residents reviewed for abuse. The facility census was 49. Findings include: Review of the medical record for Resident #52 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included depression, bipolar disorder, anxiety disorder, and vascular dementia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/19/23, revealed Resident #52 was severely impaired mentally and exhibited physical and verbal behavioral symptoms for one to three days. Review of progress notes for Resident #52, dated 10/09/23 through 10/19/23, revealed Resident #52 had documented behaviors of wandering into other resident's rooms, confusion, aggression and cursing directed towards others. Resident #52 was noted to be urinating in front of other resident's room, wandering into other resident rooms and refusing to leave as well as taking other residents clothing. Review of the medical record for Resident #46 revealed an admitted [DATE]. Diagnoses included end stage renal disease, altered mental status, and cognitive deficit. Review of the quarterly MDS 3.0 assessment, dated 12/27/23, revealed Resident #46 was cognitively intact. Review of a progress note, dated 10/19/23, revealed Resident #46 sprayed [NAME] on another resident's (Resident #52) face due to he wandered into my room again while I was in bed and urinated on my floor, refused to leave when I asked him to. Resident #46 was alert and oriented to person, place, and time. Review of the facility reported incident dated 10/19/23 and the related facility investigation revealed Resident #52 went into the room of Resident #46, exposed his genitals, began urinating on the walls and towards Resident #46 who was lying in bed. Resident #46 sat up and told Resident #52 to get the Hell out of his room. Resident #52 refused to leave, so Resident #46 grabbed [NAME] he kept at his bedside and began spraying it towards Resident #52 ultimately spraying him in the face with the [NAME]. Resident #52 then left his room to enter another room and began stating I can't see there is bleach in my eyes. Following all the yelling Resident #46 said two to three staff members then came into his room to see what was going on. Resident #46 stated he pissed in my room. This is the second time he has done this, the first time he was outside my door. Staff explained Resident #46 was not allowed to have the [NAME] in his room. Resident #46 was willing to give up the [NAME] but said he would obtain more because he did not feel safe with Resident #52 wandering around exposing himself and had intrusive behavior. The facility determined abuse had occurred due to Resident #46 spraying Resident #52 with [NAME]. Treatment to Resident #52 consisted of staff showering him, flushing his eyes, and notifying the physician who ordered for him to be sent out to the hospital for a psychiatric evaluation due to being unsafe and dangerous to the community at the facility. Interview on 01/22/24 at 2:05 P.M. with the Administrator revealed the facility substantiated abuse of Resident #52 because Resident #46 admitted to spraying [NAME] in Resident #52's face. Review of facility policy Abuse, Neglect and Exploitation, revised 01/01/24, revealed the facility would provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. The policy also indicated abuse prevention included identifying behaviors and providing interventions for those behaviors which could lead to conflict.

Based on interview, record review, facility investigation review, and facility policy review the facility failed to ensure the care plan was followed to prevent a fall for Resident #15. This affected one resident (#15) of three residents reviewed for accidents. Findings include: Review of Resident #15's medical record revealed an admitted [DATE]. Diagnoses included Multiple Sclerosis (MS), morbid (severe) obesity, need for assistance with personal care, muscle weakness, and abnormalities of gait and mobility. Review of the care plan dated 11/02/22 revealed Resident #15 required assistance with ADL related to decreased mobility, generalized weakness, and MS. Interventions included bathing, bed mobility, and transfer with full sling Hoyer (mechanical) lift with two-person assistance which was revised on 06/06/23. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition. Resident #15 required extensive assistance of two plus staff for bed mobility, transfers, dressing, toileting, and total dependence for bathing with two plus staff assists. Review of the progress noted dated 06/11/23 at 8:35 P.M. authored by Registered Nurse (RN) #171 revealed she was notified by State tested Nurse Aide (STNA) #183 regarding Resident #15 fell out of bed while being provided care with one assist for bathing. RN #171 did an assessment and notifications and treated skin abrasion to the right knee and assisted Resident #15 back to bed via Hoyer lift with two-staff assistance. Review of the investigation report dated 06/11/23 revealed Resident #15 received care by one staff and fell out of bed. RN #171 assessed Resident #15 and he was Hoyer lifted back into bed with two staff assist. RN #171 did notifications. Resident #15 sustained an abrasion to his right knee with treatment provided. Summary of findings included caregiver provided ADL care to Resident #15 with one assist, and the resident fell out of bed. Root cause: Staff was not following care plan; the resident required two-person assist with ADL and bathing. Interventions with on-the-spot education provided to caregiver. Interview on 07/18/23 at 12:15 P.M. with the Director of Nursing (DON) confirmed Resident #15 had a fall during bed bath with only one staff present, and Resident #15 required two staff per the care plan. Telephone interview on 07/20/23 at 9:06 A.M. with STNA #183 revealed he was giving Resident #15 a bed bath when the resident fell out of bed. STNA #183 confirmed Resident #15 required two staff assist for bed bath and he was the only staff giving the bed bath. Interview on 07/20/23 at 10:34 A.M. with RN #171 confirmed Resident #15 was to have two staff assistance for all ADL, and on 06/11/23 had only one staff was providing a bed bath when the resident fell . Review of the facility policy, Falls and Fall Risk, Managing, revised March 2018, revealed based on previous evaluations and current date, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. This deficiency represents non-compliance investigated under Complaint Numbers OH00144500 and OH00144299.

Based on interview and record review the facility failed to ensure wound care was provided as ordered by the physician for Residents #4, #11, and #18. This affected three residents (#4, #11, and #18) of three residents reviewed for wound care. The facility census was 33. Findings include: 1. Review of Resident #4's medical record revealed an admitted [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, chronic viral hepatitis c, protein-calorie malnutrition, epilepsy, hypertension, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had impaired cognition. The resident required extensive assistance with bed mobility and toileting and required total dependence for bathing and transfers. Review of the care plan dated 11/13/22 revealed Resident #4 had multiple skin impairments. Interventions included provide wound care as ordered. Review of Resident #4's physician orders for May 2023 revealed wound treatment to left anterior hip to clean with normal saline, pat dry, apply calcium alginate/silver (an effective barrier to bacterial penetration in moderately to heavily exudating wounds) and Medihoney (aides in healing wounds through its anti-inflammatory effects) to wound bed and apply border gauze twice a day and as needed (PRN). Wound treatment to right buttock and sacrum clean with cleanser of choice, pat dry and apply calcium alginate with silver and cover with foam border daily and PRN every night shift. Wound treatment to stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed), left lower medial knee to clean with cleanser of choice, pat dry, apply Dakin's (antiseptic) soaked gauze (1/4 strength) and cover with border gauze island dressing daily every night shift and PRN. Wound treatment to right elbow stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling), clean with wound cleanser of choice, pat dry, apply calcium alginate with silver, cover with gauze island with border daily and PRN every night shift. Wound treatment stage III to left anterior shoulder clean with wound cleanser of choice, pat dry, apply Dakin's-soaked gauze (1/4 strength) to peri wound bed, apply zinc ointment border, cover with gauze island border dressing daily and PRN. Wound treatment left hip clean with normal saline, pat dry, Dakin's-soaked gauze, cover with island border dressing daily and night shift. Wound treatment to left upper buttock clean with cleanser of choice, pat dry, apply Dakin's-soaked (1/4 strength) gauze to wound bed and cover with border gauze island dressing daily and PRN and night shift. Wound treatment left anterior shoulder stage III, cleanse with wound cleanser of choice, pat dry, apply Dakin's-soaked gauze to wound bed and apply zinc ointment to peri wound and cover with border island dressing daily, PRN, and nightly. Wound treatment right distal medial foot, stage III, cleanse using wound cleanser of choice, pat dry, apply Skin-Prep (liquid film-forming dressing that helps reduce friction during removal of tapes and films) to wound bed then cover with border gauze island dressing every night shift and PRN. Wound treatment right anterior shoulder, unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) to clean with cleaner of choice, pat dry, apply oil emulsion (nonadherent gauze mesh impregnated with white petrolatum in an oil emulsion blend) to wound bed and cover with border gauze island dressing every two days and PRN. Wound treatment skin tear, right anterior shoulder, clean with wound cleaner of choice, apply oil emulsion to wound bed cover with border gauze island dressing every two days and PRN. Wound treatment to right hip, stage IV, clean with cleanser of choice, pat dry, apply Dakin's-soaked gauze to wound bed border foam daily on night shift. Wound treatment to right medial knee, stage III cleanse with cleanser of choice, pat dry, apply MediHoney, cover with border gauze island daily and PRN on night shift. Wound treatment to right lower back, unstageable, cleanse with wound cleanser of choice, pat dry, apply Dakin's-soaked gauze to wound bed, apply border gauze island dressing daily and PRN on night shift. Review of Resident #4's Treatment Administration Record (TAR) for May 2023 revealed no documented evidence wound care was provided on 05/04/23, 05/06/23, 05/09/23, 05/10/23, 05/12/23, 05/14/23, 05/15/23, 05/18/23, 05/19/23, 05/21/23, 05/22/23, 05/23/23. Review of Resident #4's TAR for June 2023 revealed no documented evidence wound care was provided on 06/03/23, 06/04/23, 06/06/23, 06/07/23, 06/12/23, 06/13/23, and 06/19/23. Review of Resident #4's TAR for July 2023 revealed no documented evidence wound care was provided on 07/07/23, 07/11/23, 07/12/23, 07/17/23, and 07/20/23. 2. Review of Resident #11's medical record revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), dysphagia, unspecified psychosis, dementia, moderate with other behavioral disturbance, type two diabetes mellitus (DM), and hypertensive heart disease with heart failure. Review of the MDS assessment dated [DATE] revealed Resident #11 had impaired cognition, and required extensive assistance for bed mobility, transfers, and dressing and required two staff assistance with toileting. Resident #11 required total dependence with two plus assistance for bathing and extensive assistance of one for eating and hygiene. Review of the care plan dated 06/11/23 revealed Resident #11 had a stage IV pressure ulcer to the coccyx. Resident#11 had multiple skin impairments. Interventions included provide wound care as ordered. Review of the physician orders for July 2023 revealed an order to apply moisture barrier cream to buttocks after each incontinence episode and every shift for moisture associated skin damage (MASD) every shift. Review of the TAR for May 2023, revealed no documented evidence wound care was provided on 05/30/23 and 05/31/23. Review of TAR for June 2023, revealed no documented evidence wound care was provided on 06/03/23, 06/07/23, 06/08/23 and 06/22/23. Review of TAR for July 2023 revealed no documented evidence wound care was provided on 07/03/23, 07/05/23, 07/08/23, 07/10/23, 07/11/23, and 07/17/23. 3. Review of Resident #18's medical record revealed an admitted [DATE]. Diagnoses included Multiple Sclerosis (MS), major depressive disorder, neuromuscular dysfunction of bladder, obstructive and reflux uropathy cognitive communication deficit, age-related osteoporosis, quadriplegia, and dysphagia oropharyngeal. Review of the care plan dated 09/04/15 revealed Resident #18 had a Deep Tissue Injury (DTI) (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue) to the right buttocks. Interventions included provide wound care as ordered. Review of the MDS assessment dated [DATE] revealed Resident #18 had intact cognition. Resident #18 required extensive assistance of two plus staff for bed mobility, dressing, toileting, hygiene, and total dependence of two plus staff for bathing. Review of the physician orders for July 2023 revealed to an order to apply barrier cream as indicated every shift, may use after each incontinent episode. Review of the TAR for June 2023 revealed no documented evidence wound care was provided on 06/28/23. Review of TAR for July 2023 revealed no documented evidence wound care was provided on 07/08/23. Interview on 07/19/23 at 1:53 P.M. with the Director of Nursing (DON) declined to provide an explanation of the missing documentation on the TARs for Residents #4, #11, and #18's wound care treatments. Interview on 07/19/23 at 2:34 P.M. with the DON reported she had no documentation available to indicate staff provided dressing changes as ordered. The DON further stated, blank spots on TARs; I would assume they didn't do it because they didn't sign it off. This deficiency represents non-compliance investigated under Complaint Numbers OH00144500 and OH00144299.

Based on observation and interview, the facility failed to maintain its garbage disposal area in a clean and sanitary condition. This had the potential to affect all 34 residents. Findings include: Observation of the facility's garbage disposal area with Dietary Director #218 on 05/15/23 at 9:53 A.M. revealed both lids were open on the dumpster. There was some trash and leaves accumulated around the dumpster. Dietary Director #218 verified the above findings at the time of observation.

Based on record review, interview, and facility policy review the facility failed to provide documented evidence an antibiotic stewardship program was in place. This affected six residents (#2, #21, #23, #32, #38, and #141) and had the potential to affect all 34 residents residing in the facility. Findings include: Review of the infection control documentation revealed no documented evidence that an antibiotic stewardship program was in place. Interview on 05/17/23 at 5:22 P.M. with the Director of Nursing (DON) and Administrator revealed antibiotic stewardship was stopped during the COVID-19 pandemic as the task was waivered and had not started back up yet. Review of the facility matrix revealed Residents #2, #21, #23, #32, #38, and #141 were on antibiotics. Review of the facility policy titled Antibiotic Stewardship, dated 12/16, revealed antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program.

Based on observation, interview and record review, the facility failed to implement interventions to prevent Resident #14's newly acquired in-house sacral pressure sore from deteriorating to an unstageable area. The facility also failed to implement pressure-relieving interventions after the discovery of a left heel pressure ulcer. This affected one of three resident reviewed for pressure ulcers. Findings include: Resident #14 was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score (a test for resident's cognitive abilities) dated 06/14/11 indicated the resident was cognitively intact. The pressure ulcer risk assessment completed 06/07/11 indicated the resident was at low risk for developing a pressure sore. There were no physician's orders for any pressure relieving devices. Review of nurses notes dated 07/14/11 revealed the resident notified the nurse she had blood on her adult brief. The nurse wrote she discovered an open area on the coccyx that was 12.0 centimeters (cm) by 8.0 cm by 0.1 cm. which extended from left to right of the outer coccyx area and the surrounding skin was warm and dry. There was no evidence the responsible party was notified of the new open area. A physician's order dated 07/14/11 was written for the wound care; Allevyn (an occlusive padded dressing) to the coccyx on the right and left, change every three days and as needed. There were no intervention put in place for any pressure relief devices in the resident's wheelchair or bed The resident went to see her primary care physician (PCP) on 07/16/11. The PCP wrote an order dated 07/16/11 that stated the resident had a decubitus ulcer, please have the wound care team see to treat. Review of nurses notes dated 07/18/11 revealed the resident developed a pressure sore (a suspected deep tissue injury) to her left heel. An order was obtained to pad and protect the heel and the resident was educated to float her heels. There was no assessment of the area. The resident was not assessed by the wound care nurse for her sacral pressure sore until 07/20/11. The wound had deteriorated to an unstageable pressure ulcer, 100% covered in eschar (thick black necrotic tissue), 7.8 cm long by 6.2 cm wide by unknown depth. The surrounding skin was described as denuded (eroded). The wound nurse then instituted a new daily dressing change. There was a new physician's order for a pressure reduction cushion when up to the wheelchair and an air mattress to the resident's bed. The wound nurse did not evaluate or assess the left heel wound until 07/26/11. There is no documented assessment of the area from 07/18/11 to 07/28/11. Per the wound evaluation flow sheet the area was 8.0 cm long by 13.0 cm wide, no depth was documented. It was assessed to be both unstageable and a suspected deep tissue injury. The wound nurse wrote that the area was covered in 100% eschar. There were no new interventions put in place after the area was assessed. The resident was sent to the hospital emergency roiagnom on [DATE] per the family's insistence and returned on the same day with the [DIAGNOSES REDACTED]. On 08/04/11 a physician's order was obtained to float the resident's heels while in bed and to apply waffle boots while in bed related to the pressure ulcer on the left foot. The director of nursing (DON) was interviewed on 08/09/11 at 5:55 P.M. The DON verified there were no pressure-relieving devices put in place after the initial discovery of the sacral wound on 07/14/11. The DON also verified the physician examined the resident on 07/16/11 and the physician wrote an order for [REDACTED]. The wound care nurse, RN #1, was interviewed on 08/09/11 at 5:55 P.M. along with the DON. RN #1 verified no pressure-relieving devices were implemented until she assessed the resident on 07/20/11. This deficiency substantiates Complaint Number OH 672.