Every finding on record at Vancrest of New Carlisle

Based on record review, interview, and facility policy review, the facility failed to ensure residents had the right to visitors per their preference. This affected one resident (#17) of three residents reviewed for resident rights. The facility census was 73.Findings Include: Review of Resident #17's record revealed Resident #17 admitted to the facility on [DATE] with diagnoses including cerebral infarction due to embolism of unspecified cerebral artery, chronic obstructive pulmonary disease, morbid obesity due to excess calories, type two diabetes mellitus without complications, schizoaffective disorder and polyneuropathy. Resident #17 was her own responsible party. Review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact.Interview on 05/14/26 at 10:55 A.M. with Activities Manager #11 confirmed there had been an incident about a month ago with Resident #17 and her friend while attending a facility activity (bible study). After the event, multiple residents complained about how Resident #17's friend acted in the bible study. Activities Manager #11 and the Executive Director spoke to Resident #17's son who did not know who the resident's friend was. Resident #17's son approved the facility to contact the resident's friend and inform her that she was no longer to visit Resident #17, and the resident's son requested facility staff not to inform Resident #17 of the conversation. Activity Manager #11 confirmed she contacted Resident #17's friend and informed her of the facility decision. Interview on 05/14/26 at 11:49 A.M. with Resident #17 revealed she would like her friend to still be able to visit, stating she could still visit and they just wouldn't go to the bible study anymore. Interview on 05/14/26 at 2:18 P.M. with the Director of Nursing (DON) verified Resident #17 did not have a power of attorney (POA) to make decisions on her behalf. The DON reported Resident #17's son was her advocate and emergency contact.Review of the facility policy titled, Visitation, dated October 2022, stated the facility will provide reasonable access to a resident by any entity or individual that provide health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time.This violation represents non-compliance investigated under Complaint Number 2990541.

Based on review of medical records, staff interviews, and review of facility policies, the facility failed to complete comprehensive wound assessments upon identification of skin breakdown which resulted in actual harm when Resident #36 developed an unstageable pressure ulcer [a pressure ulcer where the ulcer is not stageable due to coverage of the wound bed by slough and or eschar] to the coccyx and a Stage III pressure ulcer (a pressure ulcer where there is full thickness tissue loss, subcutaneous fat may be visible, but bone tendon or muscle is not exposed) to the left heel. Additionally, the facility failed to ensure physician wound treatment orders were followed which resulted in actual harm when the facility did not use the ordered treatment for Resident #02 to dress an existing wound to the foot causing a new Deep Tissue Injury (DTI) [purple or maroon area of discolored intact skin due to damage of underlying soft tissue] to the left dorsal foot. The facility census was 77. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 09/09/25 with medical diagnoses of paraplegia, chronic obstructive pulmonary disease, atherosclerotic heart disease, and anxiety. Review of the admission nursing evaluation completed 09/09/25 revealed Resident #36's skin was intact. Review of Resident #36's admission Minimum Data Set (MDS) assessment, dated 09/15/25, indicated Resident #36 had moderate cognitive impairment and required substantial/maximum staff assistance for bathing, bed mobility, and was dependent upon staff for transfers and toilet hygiene. The MDS indicated Resident #36 did not have any skin breakdown. Review of the Braden skin assessment [a clinical tool that assesses a patient's risk of developing pressure injuries], dated 09/12/25, indicated Resident #36 was at high risk for skin breakdown. Review of the shower/skin observation report sheet, dated 09/12/25, revealed Resident #36 had a sore to bottom and a report sheet dated 09/14/25 indicated Resident #36 had skin issues to midline spine, left heel, and buttocks/coccyx area. Further review revealed a shower/skin observation report sheet dated 09/19/25 indicated Resident #36 had skin issues to midline spine and buttocks/coccyx area and a report sheet dated 09/23/25 indicated Resident #36 had skin issues to midline spine, left heel and buttocks/coccyx area. Review of the medical record for Resident #36 revealed no documentation to support the facility completed wound/skin assessments for skin issues noted on the shower/skin observation report sheets dated 09/12/25, 09/14/25, 09/19/25, or 09/23/25. Additionally, review of the medical record for Resident #36 revealed no documentation to support the facility completed weekly skin assessments until 10/21/25. Review of the wound physician note, dated 09/17/25, documented Resident #36 was observed to have an unstageable pressure ulcer (due to necrosis) to coccyx which measured 10 centimeters (cm) by 4 cm by 0.1cm, 100% slough noted, no signs/symptoms of infection and a treatment was ordered. Review of the wound physician note, dated 09/24/25, documented Resident #36 had an unstageable pressure ulcer to coccyx with poor healing potential, 100% slough, moderate serous exudate which measured 7 cm by 2 cm by 0.1cm and the wound was debrided. The note also indicated Resident #36 had a Stage III pressure ulcer to left heel which measured 3 cm by 2 cm by 0.1 cm. Review of the wound physician notes for Resident #36 revealed a note, dated 10/17/25, which indicated the ulcer to the left heel had healed and Resident #36 continued with a Stage IV pressure ulcer [Full thickness tissue loss with exposed bone tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.] to coccyx which measured 5.5 cm by 1.8 cm by 0.4 cm. Review of the wound physician note, dated 12/17/25, documented Resident #36 continued with a Stage IV pressure ulcer to coccyx which measured 2 cm by 1 cm by 0.7 cm. Review of the medical record for Resident #36 revealed a physician order dated 09/13/25 to cleanse lower lumbar with normal saline or soap and water, pat dry, apply medi-honey, and cover with bordered gauze daily and as needed. Review of a physician order dated 09/16/25 indicated weekly skin assessment to be completed, if a new area was noted, complete the skin risk, notify the physician to obtain treatment orders and notify the resident representative, and document findings in the nursing progress note. Further review revealed physician orders dated 09/18/25 to paint left heel with betadine every shift and to cleanse lower lumbar with normal saline or soap and water, pat dry, apply calcium alginate and cover with bordered gauze daily and as needed. Review of the physician orders dated 09/25/25 revealed an order to cleanse left heel with wound cleanser or normal saline, pat dry, apply calcium alginate as primary dressing, cover with bordered gauze as secondary dressing daily and as needed and an order to cleanse lower lumbar (coccyx region) with normal saline or soap and water, pat dry, apply calcium alginate as primary dressing and cover with bordered gauze as secondary dressing daily and as needed. Review of a physician order dated 09/30/25 documented to cleanse midline spine with normal saline, pat dry, apply medi-honey, and cover with bordered gauze every shift and as needed. Review of the Treatment Administration Records (TAR) for September 2025 indicated weekly skin assessments were signed off as completed on 09/16/25, 09/23/25, and 09/30/25; however, the medical record did not contain documentation to support the weekly skin assessments were completed. Review of the TARs for September, October, November, and December 2025 revealed documentation to support treatments were completed as ordered for lower lumbar, left heel, and midline spine. Interview on 12/18/25 at 9:40 A.M. with Director of Nursing (DON) confirmed Resident #36 did not have any skin breakdown noted upon admission. The DON confirmed the shower/skin observation report sheet dated 09/12/25, indicated Resident #36 had a sore to bottom but the facility had no documentation to support a comprehensive wound evaluation was completed upon identification of skin issue. The DON confirmed Resident #36's wound to lower lumbar/coccyx was initially assessed by the wound physician on 09/17/25 and was determined to be an unstageable pressure ulcer. The DON also confirmed the shower/skin observation report sheet dated 09/14/25 indicated Resident #36 had skin issues to midline spine, left heel, and coccyx. The DON confirmed Resident #36's medical record did not have documentation to support the facility completed comprehensive wound assessments to coccyx, left heel or midline spine. The DON also confirmed the wound to Resident #36's left heel was initially assessed by the wound physician on 09/24/25 and determined to be a Stage III pressure ulcer. The DON stated the medical record for Resident #36 had no documentation to support a comprehensive wound evaluation was ever completed for the skin issue to the midline spine or that the facility completed weekly wound user defined assessments (UDA) in the electronic health record to monitor the progress of Resident #36's wounds. The DON also confirmed Resident #36's medical record had no documentation to support weekly skin assessments were completed until 10/21/25. 2. Review of the medical record for Resident #02 revealed an admission date of 04/10/25. The resident was admitted with diagnoses including non-pressure chronic ulcer of left heel, Chronic Obstructive Pulmonary Disease (COPD), Peripheral Vascular Disease (PVD) and atherosclerosis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. She required set up assistance for eating, maximum assistance for bed mobility, transfers and was dependent for toileting. Review of the physician orders for the left heel were to cleanse wound with saline, apply Santyl Collagenase (for debridement) ointment, cover with saline soaked gauze, cover with an abdominal pad, kerlix and secure with light ace wrap compression with a start date of 07/30/25. Record review of the 08/04/25 pressure wound report documented a suspected deep tissue injury to the right dorsal foot, not the left dorsal foot where the wound was located. The wound measured 0.5 centimeters (cm) by (x) 1.0 cm. Printed under the other section documented the pressure wound was related to tight bandage. The initial treatment was to monitor. Record review of the 08/12/25 right dorsal foot pressure wound, not the left dorsal foot pressure wound where the wound was located, documented the deep tissue injury measurement was 1.5 cm x 1.0 cm. Printed in the other section documented exacerbated related to stretch gauze. Review of the physician orders for the left dorsal foot wound was to cleanse wound with sterile saline, to wet puracol (collagen) with sterile saline and apply to wound. Apply Murpirocin (antibiotic) ointment and cover wound. Wrap with Kling as needed with a start date of 08/12/25. A second order was for no stretch gauze, bulky kerlix only with treatments. Do not use small stretch gauze with a start date of 08/12/25. Record review of the 08/19/25 Podiatry appointment assessment documented to continue daily dressing to the top of the left foot. Do not have any sort of wrap directly touching the wound as this is what caused the wound in the first place. Interview on 12/22/25 at 11:20 A.M. with the DON verified the documentation of the Deep Tissue Injury was inaccurate. The wound was on the left foot and not the right foot. She also shared the wound was caused by staff using conforming gauze instead of the ordered ACE wrap (elastic bandage). The DON acknowledged the treatment for the 08/04/25 discovery of the deep tissue injury was to monitor the wound. She explained this would have been done during the daily dressing changes. The DON verified there was no documentation of the wound during dressing changes or otherwise until the next pressure wound assessment on 08/12/25 when it had increased in size. Review of the facility policy, Nursing Care Policy and procedures Pressure Ulcer Risk Assessment and Management revised 01/20/25 revealed it is the policy to assess all residents on admission and regularly thereafter to determine the presence of skin conditions and or areas of skin compromise and to identify potential risk factors for their development. All skin conditions and pressure sores will be treated according to physician orders. Review of the facility policy, Managing Skin Integrity undated revealed nursing in collaboration with the interdisciplinary team, will assess and manage skin integrity for all residents throughout the stay. Risk for pressure ulcer development will be evaluated upon admission and on a routine basis for all residents using the Braden Scale. Risk assessments will be done more often when the resident condition warrants more frequent assessment. Skin inspections will be completed on admission and regularly for all residents. The purpose was documented to maintain the integrity of residents' skin, a significant factor in health. To minimize the risks and prevent the occurrence of skin breakdown. To provide for early detection and intervention of all breakdown evident upon admission to the facility and to promote prompt evaluation and intervention of any changes in skin integrity during the stay. Upon identification of a wound a full wound assessment, including its location, and description of the tissue involved will be completed. Interventions and progress towards outcome focused goals need regular documentation according to established procedures.

Based on record review, staff interviews and facility policy the facility failed to conduct quarterly care conferences to include residents and/or resident representatives as required. This affected two (#2, #3) of two reviewed for care conferences. The facility also failed to timely update a resident care plan after there was a change in the residents comprehensive assessment and status. This affected one (#9), of 18 reviewed for care planning. The facility census was 77.Findings include:Review of medical record for Resident #2 revealed admission date of 04/10/25. The resident was admitted with diagnoses including non-pressure chronic ulcer of left heel, Chronic Obstructive Pulmonary Disease (COPD), Peripheral Vascular Disease and atherosclerosis. The resident remained at the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. She required set up for eating, maximum assistance bed mobility, transfers and was dependent toileting. Interview on 12/18/25 at 11:12 A.M. with Resident #2 revealed she could not recall having a care conference since her admission to the facility. Interview on 12/18/25 at 11:19 A.M. with Social Services Designee (SSD) #185 verified she had not held a care conference with Resident #2 since her admission to the facility 2. Review of the medical record for Resident #03 revealed an admission date of 06/16/25 with medical diagnoses of anemia, right femur fracture, cerebral infarctions, dementia, and hypertension. Review of the medical record for Resident #03 revealed a quarterly MDS assessment, dated 09/18/25, which indicated Resident #10 had moderate cognitive impairment and required partial/moderate staff assistance for toilet hygiene, transfers, and bathing, and supervision for bed mobility. Review of the medical record for Resident #03 revealed a care conference note, dated 10/01/25, which stated Social Services, Unit Manager, Activity Director and Dietary staff were present. Review of the care conference note did not have any documentation to support Resident #03 or her representative were present at the care conference. Interview with Resident #03 on 12/15/2025 at 1:52 P.M. revealed the resident was not aware of any care conferences. Interview on 12/17/25 at 2:19 P.M. with Social Service #185 confirmed Resident #03's care conference was held on 10/01/25 and that Resident #03 or her representatives were not present for the conference. Social Service #185 stated she called Resident #03 representative on the phone to review what was discussed at the care conference. Social Service #185 confirmed Resident #03's medical record did not have documentation to support Resident #03's representative was called and notified of care conference. 3.Review of the medical record for the Resident # 09 revealed an admission date of 08/31/24. Diagnoses included chronic respiratory failure with hypoxia, pan lobular emphysema, chronic obstructive pulmonary disease , asthma and bi-polar disorder. Resident #09 elected the hospice benefit on 11/05/25 with a diagnosis of end stage chronic obstructive pulmonary disease. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #09 was cognitively intact with a Brief Interview of Mental Status Score (BIMS) of 14, indicating the resident was cognitively intact. The resident required cueing and one person for set up for activities of daily living and required a Hoyer lift to get out of bed. Review of the care plan on 12/22/25 dated 07/22/25 revealed no indication the care plan was revised and her updated. It did not include Resident #09 receiving hospice services. Interview with the Minimum Data Systems (MDS) Coordinator on 11/18/25 at 2:34 P.M. confirmed the Hospice service was not part of Resident #09 care plan. Interview with the Director of Nursing (DON) on 12/22/25 at 11:10 A.M. after surveyor intervention Resident #09 Care Plan was updated to include Hospice Services. Review of the facility policy titled, Care plan, comprehensive person-centered policy, revised March 2022 stated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs were developed and implemented for each resident. The policy stated the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident. The policy stated participation of the resident and his/her resident representative in development of the resident's care plan was determined to be practicable and explanation was to be documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative process. The policy stated the comprehensive, person-centered care plan would include measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on medical record review, staff interview, and pharmacy reconciliation review the facility failed to ensure a medication reduction order was followed in a timely manner. This affected one Resident (#33) of five reviewed for medication reconciliation. The census was 77.Findings include: Review of medical record for Resident #33 revealed admission date of 08/09/22. The resident was admitted with diagnoses including Type Two Diabetes Mellitus, atherosclerotic heart disease, delusional disorders, anxiety and depression. The resident remained at the facility.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 13 indicating intact cognition. She required set up for eating, moderate assistance with bed mobility and transfers.Record review of the July Monthly Medication review revealed documentation Resident #33 was due for a trial dose reduction of medication per the Centers for Medicaid and Medicare Services (CMS) regulation which included Sertraline (depression) 175 milligrams (mg) daily. The physician agreed and an order was written to decrease the Sertraline to 150 mg daily and it was signed on 07/29/25.Review of the physician orders revealed an order for Sertraline 150 mg daily was started on 08/15/25.Interview on 12/18/25 at 2:33 P.M. with the Director of Nursing verified the 07/29/25 physician order to decrease Sertraline to 150 mg was not started until 08/15/25.

Based on medical record review, observations, staff interview, and review of facility policies, the facility failed to follow infection control procedures during indwelling catheter care. This affected one (#08) resident out of two residents reviewed for infection control procedures. The facility census was 77.Findings include: Review of the medical record for Resident #08 revealed an admission date of 11/03/22 with medical diagnoses of metabolic encephalopathy, quadriplegia, lumbar spinal stenosis, and neuromuscular dysfunction of bladder. Review of the medical record for Resident #08 revealed an annual Minimum Data Set (MDS) assessment, dated 10/08/25, which indicated Resident #08 was cognitively intact and was dependent upon staff for all activities of daily living. The MDS indicated Resident #08 had an indwelling catheter. Review of the medical record for Resident #08 revealed a physician order dated 08/28/25 for Enhanced Barrier Precautions (EBP) for foley catheter every shift and an order dated 10/13/25 for foley catheter care every shift. Observation on 12/18/25 at 1:54 P.M. revealed Certified Nursing Assistant (CNA) #197 prepared a basin of soap and water, a basin of warm water, and gathered wash clothes and towels for catheter care for Resident #08. CNA #197 was observed to explain the procedure to Resident #08. The observation revealed an EBP sign posted on Resident #08's door but no personal protective equipment (PPE) cart located inside or outside of Resident #08's room. CNA #197 was observed to use hand sanitizer to bilateral hands and donned gloves. CNA #197 proceeded to position Resident #08 on his right side while in bed to remove soiled brief. Resident #08 was observed to have had a bowel movement and CNA #197 proceeded to complete incontinence cares. After incontinence cares were completed, CNA #197 was observed to remove her gloves and apply new gloves. CNA #197 applied a new brief and positioned Resident #08 on his back to complete indwelling catheter care. CNA #197 was observed to complete indwelling catheter care without any concerns. CNA #197 was observed to apply skin barrier cream to Resident #08's groin after indwelling catheter care was completed due to slight redness to groin. CNA #197 completed applying the barrier cream and then was observed to pull Resident #08's blankets up to cover his body and assisted Resident #08 to reposition in bed while wearing gloves with barrier cream on the gloves. Interview on 12/18/25 at 2:13 P.M. with CNA #197 confirmed Resident #08 had an EBP sign posted on his door, and she had not donned a gown while providing incontinence or indwelling catheter care. CNA #197 confirmed Resident #08 did not have a PPE cart located inside or outside of his room. CNA #197 confirmed she had not performed hand hygiene after removing gloves after incontinence cares and prior to applying new gloves for indwelling catheter care. CNA #197 also confirmed she assisted Resident #08 with repositioning in bed and pulled up his covers while wearing her gloves that she wore during indwelling catheter care and for application of skin barrier cream. Review of the facility policy titled, Enhanced Barrier Precautions, stated EBP are utilized to prevent the spread of multi-drug resistant organisms (MDRO). The policy stated EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. The policy stated examples of high-contact resident care activities requiring the use of gown and gloves for EBP included providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) and wound care. The policy also stated PPE was to available outside of the resident rooms. Review of the facility policy titled, Handwashing, stated proper handwashing technique was used for prevention of transmission of infectious diseases. The policy stated all personnel working in the facility are required to wash their hands before and after each resident contact, before and after performing any procedure, after sneezing, coughing or blowing nose, after using the toilet, before handling food, and when hands become obviously soiled.

Based on observations, staff interviews and manufacturer's instructions, the facility failed to ensure Lantus (long lasting insulin) was dated upon opening to ensure it was used in a timely manner. This affected one Resident (#50) of five reviewed for medication. The facility census was 77. Findings include: Review of medical record for Resident #50 revealed admission date of 06/22/23. The resident was admitted with diagnoses including Diabetes Mellitus, stroke and vascular dementia. The resident remained at the facility.Observation and interview on 12/22/25 at 9:51 A.M. with Licensed Practical Nurse (LPN) #145 revealed the Lantus (long lasting insulin) pen for Resident #50 was undated. LPN #145 verified the line for the date was blank and acknowledged the pen should have been dated upon opening to ensure the medication was used in a timely manner.Review of the Lantus manufacture's instruction on page eight documented the Lantus could be used for four weeks after first dose and after that time the pen should be discarded even if there was insulin left in it.

Based on medical record reviews and staff interviews, the facility failed to ensure the medical record contained accurate documentation. This affected three (#36, #08, and #02) residents out of 18 records reviewed. The facility census was 77.Findings include: 1.Review of the medical record for Resident #36 revealed an admission date of 09/09/25 with medical diagnoses of paraplegia, chronic obstructive pulmonary disease, atherosclerotic heart disease, and anxiety. Review of the medical record for Resident #36 revealed an admission Minimum Data Set (MDS) assessment, dated 09/15/25, which indicated Resident #36 had moderate cognitive impairment and required substantial/maximum staff assistance for bathing, bed mobility, and was dependent upon staff for transfers and toilet hygiene. The MDS indicated Resident #36 did not have any skin breakdown. Review of the medical record for Resident #36 revealed skill nursing notes, dated 09/12/25, 09/13/25, 09/14/25, 09/19/25 which stated Resident #36 did not have any skin issues. Review of the medical record revealed the facility did not have documentation to support weekly skin assessments were completed from 09/09/25 until 10/21/25. Review of the medical record for Resident #36 revealed a physician order dated 09/13/25 to cleanse lower lumbar with normal saline or soap and water, pat dry, apply medi-honey, and cover with bordered gauze daily and as needed. Review of the medical record for Resident #36 revealed a shower/skin observation report sheet, dated 09/12/25, which indicated Resident #36 had a sore on bottom and a sheet dated 09/14/25 which Resident #36 had skin issues to midline spine, buttocks, and left heel. Review of a shower sheet dated 09/19/25 indicated Resident #36 had skin issues to midline spine and buttocks. Interview on 12/17/25 at 1:44 P.M. with Director of Nursing (DON) stated that when a resident admitted to the facility under skilled services the nurses would complete a daily skilled note which included observation of skin. DON stated weekly skin observation assessments were not required for skilled residents as the nurses document any skin issues and treatments on the daily skilled note. DON confirmed Resident #36's shower sheets dated 09/12/25, 09/14/25, and 09/19/25 all indicated Resident #36 had skin issues and the skilled nursing documentation on those days did not have documentation to support Resident #36 had any skin breakdown or that skin issues were assessed. DON confirmed Resident #36's medical record did not have any documentation to support an evaluation of wound to coccyx was completed until 09/17/25 or a wound evaluation of Resident #36's left heel was done until 09/24/25. DON confirmed that the medical record for Resident #36 had no documentation to support the facility evaluated skin issue to midline spine. DON confirmed the medical record for Resident #36 did not have any documentation to support the facility completed weekly skin assessments until 10/21/25. Interview on 12/17/25 at 1:53 P.M. with Licensed Practical Nurse (LPN) #170 stated he worked on the skilled halls and confirmed the nursing staff were to complete a daily skilled note for each resident who admit under skilled services. LPN #170 confirmed the skilled note included an area for observation of skin for each resident. LPN #170 stated the staff did not always complete a full body assessment for the residents under the skin observation area of the skilled note. LPN #170 stated he tried to look at each resident's feet, bottom, under breasts and armpits. 2. Review of the medical record for Resident #08 revealed an admission date of 11/03/22 with medical diagnoses of metabolic encephalopathy, moderate protein-calorie malnutrition, quadriplegia, neuromuscular dysfunction of bladder, and dysuria. Review of the medical record for Resident #08 revealed an annual Minimum Data Set (MDS) assessment, dated 10/08/25, revealed Resident #08 was cognitively intact and was dependent upon staff for all activities of daily living. Review of the MDS revealed Resident #08 had impaired range of motion to bilateral upper extremities. Review of the medical record for Resident #08 revealed a physician note dated 07/23/25. Review of the medical record revealed no documentation to support Resident #08 had been seen by the nurse practitioner or physician after 07/23/25. Interview on 12/28/25 at 12:20 PM with Director of Nursing (DON) stated Resident #08 was seen by either the nurse practitioner or physician on 08/01/25, 08/08/25, 08/13/25, 08/29/25, 09/08/25, 09/10/25, 09/15/25, 09/17/25, 10/20/25, 10/27/25, 11/12/25, and 11/14/25. DON confirmed Resident #08's medical record did not contain the nurse practitioner or physician progress notes for the visits on the above dates. #3 Review of medical record for Resident #02 revealed admission date of 04/10/25. The resident was admitted with diagnoses including non-pressure chronic ulcer of left heel and mid foot, Chronic Obstructive Pulmonary Disease (COPD), Peripheral Vascular Disease PVD) and atherosclerosis. The resident remained at the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. She required set up for eating, maximum assistance bed mobility, transfers and was dependent toileting. Review of the 04/15/25 wound physician evaluation documented an unstageable pressure ulcer of the left heel. Review of the non-pressure wound skin assessment dated [DATE] revealed a diabetic ulcer with surgical debridement of the right heel. Further review of the weekly non pressure wound assessments revealed the left heel was documented as a non-pressure surgical wound until 09/04/25 when a note was added the paperwork noted the wound indicated it was a stage four pressure ulcer. Record review of the 08/04/25 weekly pressure wound assessment documented a deep tissue injury to the right dorsal foot. Continued review revealed documentation had been made through 09/04/25 of a right dorsal foot deep tissue injury. Observation and interview on 12/18/25 of the dressing change by Licensed Practical Nurse (LPN ) #155 and assisted by LPN #160 revealed on open pressure area to the left heel and left dorsal foot. Observation of the right foot revealed no current wound, redness or area of concern. Interview with LPN #155, LPN #160 and Resident #2 confirmed there had been no wounds to the right foot since admission to the facility. Interview on 12/22/25 at 11:20 A.M. with the Director of nursing verified the wound was not on the right heel, but on the left heel. She stated it was also a documentation error the wound was labeled on 06/30/25 as a diabetic ulcer. She also explained after the Deep Tissue Injury was surgically debrided, the wound was inaccurately coded as a surgical wound.

Based on medical record review, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, version 1.20.1 dated October 2025, the facility failed to ensure Minimum Data Set (MDS) assessments were coded accurately. This affected two (#42 and #33) residents out of six residents reviewed for medications. The facility census was 77. Findings include: 1.Review of the medical record for Resident #42 revealed an admission date of 03/24/25 with medical diagnoses of diabetes mellitus, peripheral vascular disease, chronic kidney disease stage III, and hypertension. Review of the medical record for Resident #42 revealed a quarterly MDS assessment, dated 09/11/25, which indicated Resident #42 had moderate cognitive impairment and required substantial/maximum staff assistance for bed mobility, partial/moderate staff assistance for transfers, and was dependent upon staff for bathing and toilet hygiene. Review of the MDS indicated Resident #42 received an anticoagulant and antiplatelet medication. Review of the medical record for Resident #42 revealed a physician order dated 04/02/25 for clopidogrel bisulfate (antiplatelet medication) 75 milligram (mg) one tablet by mouth daily for prevention. Review of the physician orders revealed no documentation to support Resident #42 was ordered an anticoagulant medication. Quality Assurance nurse #184 confirmed Resident #42 had not received an anticoagulant during the review period for the MDS dated [DATE] and that the MDS was coded in error. #2 Review of medical record for Resident #33 revealed admission date of 08/09/22. The resident was admitted with diagnoses including Type Two Diabetes Mellitus, atherosclerotic heart disease, delusional disorders, anxiety and depression. The resident remained at the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 13 indicating intact cognition. She required set up for eating, moderate assistance with bed mobility and transfers. Review of section N (medications) of the MDS revealed the section for diuretics had been marked no indicating the medication had not been received during the seven day look back period. Review of the physician orders for Resident #33 revealed an order for Lasix (diuretic) 40 milligram (mg) tablet daily with a start date of 04/06/25 and Zaroxolyn (diuretic) 2.5 mg every Monday, Wednesday and Friday with a start date of 05/26/25. Interview on 12/22/25 at 11:01 A.M., Quality Assurance Nurse #84 verified Resident #33 did receive diuretic medication during the seven day look back period of the 09/19/25 quarterly MDS and the MDS had been inaccurately coded. Review of the antipsychotic, antianxiety, antidepressant, hypnotic, anticoagulant (warfarin, heparin, or low-molecular weight heparin), antibiotic, diuretic, antiplatelet, hypoglycemic, and anticonvulsant medications. Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, version 1.20.1 dated October 2025, stated the intent for Section N- Medications, was to record the number of days, during the last seven days, that any type of injection, insulin, and/or select medications were received by the resident.

Based on observations, staff and resident interviews, medical record review and review of facility policy, the facility failed to develop a person centered comprehensive assessment for one (#36) out of 18 residents reviewed. The census was 77. Review of the medical record for Resident #36 revealed an admission date of 09/09/25 with medical diagnoses of paraplegia, chronic obstructive pulmonary disease, atherosclerotic heart disease, and anxiety. Review of the medical record for Resident #36 revealed an admission Minimum Data Set (MDS) assessment, dated 09/15/25, which indicated Resident #36 had moderate cognitive impairment and required substantial/maximum staff assistance for bathing, bed mobility, and was dependent upon staff for transfers and toilet hygiene. The MDS indicated Resident #36 did not have any skin breakdown. Review of the medical record for Resident #36 revealed a wound physician note dated, 09/17/25, which indicated Resident #36 had an unstageable pressure ulcer (due to necrosis) to coccyx. Review of the medical record revealed a wound physician note stated 09/24/25 which stated Resident #36 was seen for unstageable pressure ulcer to coccyx and Stage III pressure ulcer to the left heel. Further review of a wound physician note dated 12/17/25 stated Resident #36 continued with Stage IV to coccyx. Review of the medical record for Resident #36 revealed no documentation to support the facility developed a person-centered comprehensive care plan for Resident #36's pressure ulcers to coccyx or left heel. Interview on 12/18/25 at 9:40 A.M. with Director of Nursing (DON) confirmed the facility had not developed person-centered comprehensive care plans for Resident #36's pressure ulcers to coccyx or left heel. Review of the facility policy titled, Care plan, comprehensive person-centered policy, revised March 2022 stated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs were developed and implemented for each resident. The policy stated the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident. The policy stated participation of the resident and his/her resident representative in development of the resident's care plan was determined to be practicable and explanation was to be documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative process. The policy stated the comprehensive, person-centered care plan would include measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, staff interview, narcotic count record review, and facility policy review, the facility failed to ensure an accurate narcotic count. This affected one (#17) of five reviewed for medications. The census was 77.Findings include:Review of medical record for Resident #17 revealed admission date of 02/13/24. The resident was admitted with diagnoses including depression, artherosclerosis of the renal artery and fibromyalgia. The resident remained at the facility.Observation and record review on 12/22/25 at 9:51 A.M. with Licensed Practical Nurse (LPN) #145 of the controlled medication narcotic count for Resident #17 revealed the narcotic sheet for Lyrica (pain) 150 milligrams (mg) capsule indicated there were five capsules remaining. Observation of the medication card revealed there were six capsules remaining. Interview with LPN #145 at the time of the observation verified the discrepancy with the medication count. LPN #145 verified she had counted with the unnamed night nurse and both signed the count as correct at the start of her shift.Interview and observation with the DON on 12/22/25 at 9:57 A.M. with the Director of Nursing (DON) confirmed Resident #17's narcotic sheet for Lyrica 150 mg indicated there were five capsules remaining and the medication card for Resident #17's Lyrica 150 mg capsule contained six capsules.Review of the progress note dated 12/22/25 at 10:18 A.M. by the DON documented concerns with the Lyrica count. The unnamed Certified Nurse Practitioner (CNP) was notified of the discrepancy. Resident #17 was interviewed and denied increased pain or discomfort and the unit nurse would monitor for increased pain throughout the shift. The pharmacy was contacted and the count was corrected per their recommendations.Review of the facility policy. Controlled Substances revised 11/22 revealed the nursing staff count controlled medication inventory at the end of each shift using the records of personnel access and usage, medication administration records, declining inventory record and destruction or waste of the medication. Report any discrepancies to the DON.

Based on medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to develop a resident centered comprehensive care plan. This affected one (#75) resident out of five residents reviewed for comprehensive care plans. Findings include: Review of the medical record for Resident #75 revealed an admitted [DATE] with medical diagnoses of specified disorders of the brain, dementia, aneurysm of the ascending aorta without rupture, hydrocephalus, and diaphragmatic hernia. The medical record indicated Resident #75 discharged on [DATE]. Review of the medical record for Resident #75 revealed an admission Minimum Data Set (MDS) assessment dated [DATE], which indicated Resident #75 had severe cognitive impairment and required supervision to touching assistance with eating and ambulation up to 50 feet, moderate staff assistance with toilet hygiene, bed mobility, and transfers, and maximum staff assistance with bathing. Review of the medical record for Resident #75 revealed a hospital discharge summary dated 04/03/24, which indicated Resident #75 was treated for obstructive hydrocephalus status post ventriculoperitoneal (VP) shunt (a cerebral shunt that drains excess cerebrospinal fluid when there is an obstruction in the formal flow) placement. Review of the medical record for Resident #75 revealed no documentation to support the facility developed a comprehensive person-centered care plan which indicated Resident #75 had a VP shunt. Interview on 06/03/24 at 2:43 P.M. with Registered Nurse (RN) #203 confirmed the medical record for Resident #75 did not contain documentation to support a diagnosis for VP shunt or a comprehensive care plan which indicated Resident #75 had a VP shunt. RN #203 confirmed the facility utilizes the RAI manual for policy and procedures related to comprehensive care plans. Review of the RAI manual dated October 2023 revealed the facility must develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment. Further review of the RAI manual revealed care plans are to reflect appropriate resident-specific approaches to care based on careful consideration of individual problems and causes. The deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review and staff interview, the facility failed to provide accurate resident medical information when transferred to a hospital. This affected one (#75) resident out of the three residents reviewed for change of condition. The facility census was 73. Findings include: Review of the medical record for Resident #75 revealed an admitted [DATE] with medical diagnoses of specified disorders of the brain, dementia, aneurysm of the ascending aorta without rupture, hydrocephalus, and diaphragmatic hernia. The medical record indicated Resident #75 discharged on [DATE]. Review of the medical record for Resident #75 revealed an admission Minimum Data Set (MDS) assessment dated [DATE], which indicated Resident #75 had severe cognitive impairment and required supervision to touching assistance with eating and ambulation up to 50 feet, moderate staff assistance with toilet hygiene, bed mobility, and transfers, and maximum staff assistance with bathing. Review of the medical record for Resident #75 revealed a hospital discharge summary dated 04/03/24, which indicated Resident #75 was treated for obstructive hydrocephalus status post ventriculoperitoneal (VP) shunt (a cerebral shunt that drains excess cerebrospinal fluid when there is an obstruction in the formal flow) placement. Review of the medical record for Resident #75 revealed it did not contain documentation to support the facility added a diagnosis related to recent VP shunt placement or developed a comprehensive care plan which indicated Resident #75 had a VP shunt. Review of the medical record for Resident #75 revealed a nurse progress note dated 05/09/24 at 1:34 P.M. which stated Resident #75 was sent to the emergency department (ED) for a fall and change in condition. The note indicated the nurse prepared paperwork for the medics. The medical record did not contain documentation to support the facility called the ED to provide them with a report on Resident #75's medical condition or medical diagnoses. Interview on 06/03/24 at 2:13 P.M. with the Director of Nursing (DON) stated when a resident is sent to the ED the nurse is to provide the medics with the resident's face sheet, advanced directives, physician orders, and most recent labs. The DON confirmed the medical record for Resident #75 did not contain documentation to support a recent VP shunt placement. The DON also confirmed the nurse did not call report to the ED on 05/09/24 to update the hospital of Resident #75's medical status or current medical diagnoses. This deficiency represents non-compliance investigated under Complaint Number OH00153799.

Based on medical record reviews, staffing interview, and policy review, the facility failed to provide residents and/or resident representatives with written notification of a room change. This affected three (Residents #06, #56, and #75) of the three reviewed for room changes. The facility census was 73. Findings include: 1. Review of the medical record for Resident #75 revealed an admitted [DATE] with medical diagnoses of specified disorders of the brain, dementia, aneurysm of the ascending aorta without rupture, hydrocephalus, and diaphragmatic hernia. The medical record indicated Resident #75 discharged on [DATE]. Review of the medical record for Resident #75 revealed an admission Minimum Data Set (MDS) assessment dated [DATE], which indicated Resident #75 had severe cognitive impairment and required supervision to touching assistance with eating and ambulation up to 50 feet, moderate staff assistance with toilet hygiene, bed mobility, and transfers, and maximum staff assistance with bathing. Review of the medical record for Resident #75 revealed a Social Service progress note dated 04/17/24 at 3:15 P.M. which stated Social Services and Resident #75's daughter discussed a possible room change and that Resident #75 would have a roommate. The note also stated Resident #75's daughter was informed that Medicaid would not pay for a private room and the daughter stated she was not sure that Resident #75 would be okay with that. Further review of the medical record revealed a Social Service progress note dated 04/23/24 at 11:30 A.M. which stated attempted to reach Power of Attorney (POA) to discuss move to long term care and a voicemail message was left. Review of the medical record revealed a Social Service note dated 04/30/24 at 10:59 A.M. which stated daughter accepted the long-term care room change. Review of the medical record for Resident #75 revealed Resident #75 moved rooms on 05/02/24. Review of the medical record did not reveal any documentation to support the facility provided a written notice of room change on 05/02/24. 2. Review of the medical record for Resident #56 revealed an admitted [DATE] with medical diagnoses of fibromyalgia, osteoarthritis, irritable bowel syndrome, and depression. Review of the medical record for Resident #56 revealed a quarterly MDS dated [DATE] which indicated Resident #56 was cognitively intact and required moderate staff assistance with eating, maximum staff assistance with bed mobility, and was dependent upon staff for toileting, bathing and transfers. Review of the medical record for Resident #56 revealed a Social Service progress note dated 03/07/24 at 10:55 A.M. which stated Resident #56 and his daughter were informed about the move to long term care today. The note stated they both understood and agreed, and that Resident #56 would be moved. Review of the medical record for Resident #56 revealed Resident #56 moved rooms on 03/07/24. Review of the medical record did not reveal any documentation to support the facility provided a written notice of the room change on 03/07/24. 3. Review of the medical record for Resident #06 revealed an admitted [DATE] with medical diagnoses of Alzheimer's disease, low back pain, heart failure, osteoarthritis, and peripheral vascular disease. Review of the medical record for Resident #06 revealed a quarterly MDS dated [DATE] which indicated Resident #06 had severe cognitive impairment and required maximum staff assistance for eating and was dependent upon staff for toileting, bathing, and transfers. Review of the medical record for Resident #06 revealed a communication note dated 04/08/24 at 2:03 P.M. which stated Resident #06 moved to a different room and the family was aware. Review of the medical record revealed Resident #06 moved rooms on 02/07/24. Review of the medical record for Resident #06 revealed no documentation to support the facility provided a written notice of the room change on 04/08/24. Interview on 06/03/24 at 11:26 A.M. with Social Service (SS) #235 confirmed the medical records for Resident #06, #56, and #75 did not contain documentation to support the facility provided the resident or resident representative with written notification of room change. SS #235 stated she verbally notified the residents or resident representatives of the room changes and documented in the progress notes. Review of the facility policy titled, Room change/Roommate Assignment, revised March 2021 stated changes in room or roommate assignment are made when the facility deems it necessary or when the resident requests the change. The policy stated prior to changing a room or roommate assignment, all parties involved in the change/assignment are given a reasonable advance written notice of such change. The policy stated residents have the right to refuse to move to another room in the facility if the purpose of the mode is to relocate the resident from a skilled nursing unit within the facility to one that is not a skilled nursing unit and that if a resident exercises his/her right to refuse a room change, this will not affect the resident's eligibility or entitlement to Medicare or Medicaid benefits. This deficiency represents non-compliance investigated under Complaint Number OH00153799.

Based on medical record review, staff interview, and facility policy review, the facility failed to to provide non-pharmaceutical interventions prior to administering an as needed medication for one (#212) of five residents reviewed for unnecessary medications. The census was 65. Findings Include: Review of the medical record for Resident #212 revealed an admitted [DATE]. Diagnoses included cerebrovascular accident, dementia without behavioral disturbance, cerebral infarction, transient ischemic attack, type two diabetes mellitus, and anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 02/03/23, revealed Resident #212 had severe cognitive impairment. Review of the care plan dated 02/14/23 revealed Resident #212 had potential risk for altered behavior patterns, disruptive interactions, disruptive verbally, resistive to care, dementia, and anxiety. Interventions included administer prescribed medications, observe for side effects, and monitor for effectiveness. Staff to allow resident to pace where she can be observed. Staff to assess for internal/external contributors. Staff to be careful not to invade resident's personal space. Staff to consult with psych if needed. Staff to document summary of each episode. Staff to keep environment calm/relaxed. Review of the physician order dated 01/26/23 revealed Resident #212 was ordered Haldol tablet 1 mg, give 0.5 tablet by mouth every four hours as needed for agitation, nausea, and vomiting. Review of the physician order dated 01/27/23 revealed Resident #212 was ordered Haldol oral concentrate 2 mg/milliliter (ml), give 0.5 ml by mouth every six hours as needed for agitation, nausea, and vomiting. Review of the physician order dated 01/27/23 revealed Resident #212 was ordered Melatonin three mg, give one tablet by mouth as needed for sleep at bedtime. Review of the physician order dated 01/27/23 revealed Resident #212 was ordered trazadone 50 mg, give a half tablet by mouth every 24 hours as needed for sleep at bedtime, Review of the medication administration record (MAR) dated January 2023 revealed Resident #212 received Haldol 0.5 ml by mouth on 01/30/23. There was no evidence any non-pharmaceutical interventions were tried before administering the as needed medication. Review of the MAR dated February 2023 revealed Resident #212 received Haldol 0.5 ml by mouth on 02/02/23 and 02/13/23. Resident #212 received Haldol 0.5 mg tablet by mouth on 02/06/23. There was no evidence any non-pharmaceutical interventions were tried before administering the as needed medication. Review of the MAR dated 02/06/23 for Resident #212 revealed on 02/06/23 she was given trazadone 50 mg, Melatonin 3 mg, and Haldol 0.5 mg tablet as needed. There was no evidence any non-pharmaceutical interventions were tried before administering the as needed medication. Interview on 02/06/23 at 3:31 P.M. with Assistant Director of Nursing (ADON) confirmed there was no documentation of previous interventions being tried before the medication was administered. Review of the facility policy titled Antipsychotic Medication Use, dated December 2016, revealed residents would only receive antipsychotic medications when necessary to treat specific conditions which they are indicated and effective. 44412

Based on record review, interviews, observations, and policy review, the facility failed to provide a resident with the appropiate chair to enable the resident to safely get out of bed. This affected one (#28) of one resident reviewed for assistive devices. The facility census was 65. Findings include: Review of the medical record for Resident #28 revealed an admitted [DATE]. Diagnoses included cerebrovascular disease, legal blindness, benign prostatic hyperplasia, hypertensive heart disease without heart failure, polyneuropathy, and history of transient ischemic attack. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/09/23, revealed Resident #28 had moderate cognitive impairment. This resident was assessed to require two-person total dependence with transfers. Review of the care plan dated 01/23/23 revealed Resident #28 had activities of daily living self-care performance deficit related to weakness, low back pain, legally blind. Interventions included staff to help with bed mobility assist one to two person and assist/turn enabler times two for bed mobility. Staff to assist with two-person transfer with Hoyer lift for all transfers. Observations on 02/13/23 from 6:30 P.M. through 9:00 P.M. of Resident #28 revealed he was lying in bed. Observations on 02/14/23 from 8:05 A.M. through 4:38 P.M. of Resident #28 revealed he was lying in bed and was never gotten up out of bed throughout the day. Interview on 02/14/23 at 8:49 A.M. with Resident #28's power of attorney (POA) reported the facility does not get Resident #28 out of bed. The POA reported the facility put the Broda chair in his room just for show. The POA stated she had never seen Resident #28 in it. Interview on 02/15/23 at 4:47 P.M. with Rehab Director #141 revealed Resident #28's POA was happy when Resident #28 was up and out of bed. Rehab Director #141 reported the facility had tried his wheelchair, geri-chair, and a Broda chair but the resident did not tolerate sitting up. Interview on 02/15/23 at 4:59 P.M. with the Assistant Director of Nursing (ADON) revealed she did not believe it was safe for Resident #28 to be in the Broda chair per her nursing judgment. Interview on 02/16/23 at 10:08 A.M. with Occupational Therapist #145 revealed with Resident #28's decline, the facility had not completed an assessment on him for an assistive device/wheelchair. Observations on 02/15/23 from 7:45 A.M. through 5:15 P.M. of Resident #28 revealed he was lying in bed and was never gotten up out of bed throughout the day. Observations on 02/16/23 from 8:20 A.M. through 4:10 P.M. of Resident #28 revealed he was transferred in and out of bed for an appointment outside the facility via a stretcher. Review of the facility policy titled Scheduling Therapy Services, dated July 2013, revealed the therapist shall interview the resident and consult with the attending physician as to the type of treatment to be administered.

Based on medical record review and staff interview, the facility failed follow physician orders regarding the use of oxygen and monitoring oxygen saturation levels. This affected one (Resident #57) of four residents reviewed for respiratory care. The census was 65. Findings Include: Review of the medical record revealed Resident #57 was admitted to the facility on [DATE]. Diagnoses included pneumonia, chronic obstructive pulmonary disease, acute respiratory failure, bacteremia, panobular emphysema, dementia, peripheral vascular disease, anxiety disorder, other chronic pain, and personal history of pulmonary embolism. Review of the Minimum Data Set (MDS) assessment, dated 12/09/22, revealed he was cognitively intact. Review of Resident #57 medical records revealed an order for oxygen four liters via nasal cannula to keep his oxygen saturation (O2) levels above 92% every shift, which was started on 12/11/22. Review of the Medication Administration Record (MAR) dated December 2022, revealed there were no entries into this record to support his O2 saturation levels were completed. Review of Resident #57 vital signs, which included O2 saturation levels, were not recorded on 12/12/22, but it was documented on the MAR that his saturation levels were checked and oxygen was not administered due to O2 saturation levels being appropriate. Review of Resident #57 progress notes, dated 12/13/22, revealed Resident #57 contacted emergency management services (EMS) due to him expressing concerns over being short of breath. EMS arrived and took him to the hospital, where he was admitted for pneumonia. Interview with Registered Nurse (RN) #134 and Licensed Practical Nurse (LPN) #120 on 02/16/23 at 10:37 A.M. confirmed the O2 saturation levels were not documented as being obtained on 12/12/22.

Based on medical record review and staff interview, the facility failed to complete a thorough baseline care plan two (#116 and #121) of 16 resident care plans reviewed. The census was 65. Findings Include: 1. Review of the medical record revealed Resident #116 was admitted to the facility on [DATE]. Diagnoses included low back pain, congestive heart failure, type II diabetes, hypertensive heart disease, dementia without behavioral disturbances, mood disturbances, and anxiety, wheezing, peripheral vascular disease, cerebrovascular disease, muscle weakness, difficulty in walking, acute kidney failure, atherosclerotic heart disease, major depressive disorder, anxiety disorder,a nd hyperlipidemia. Review of admitting medical records, it was identified that her family stated she had suicidal ideations prior to being admitted to the facility. Review of Resident #116's physician orders revealed she was prescribed Seroquel for a mood stabilizer. Review of the baseline care plan revealed no documentation to support care areas related to mental health, the use of a psychotropic, or potential for suicidal ideation. Interview with Registered Nurse (RN) #134 on 02/16/23 at 10:07 A.M. and 11:45 A.M. revealed Resident #116 was ordered Seroquel initially for depression, which contributed to her suicidal ideation. She confirmed this was reported by her family, which occurred prior to being admitted to this facility. She confirmed there was no baseline care plan for suicidal ideations or her use of Seroquel because the facility was under the understanding that Resident #116 mental health was under control. 2. Review of the medical record revealed Resident #121 an admission to the facility on [DATE]. Diagnoses included complete intestinal obstruction, pleural effusion, cirrhosis of liver, type II diabetes, multiple myeloma, shortness of breath, idiopathic hypotension, primary insomnia, hypertensive heart disease, and muscle weakness. Review of Resident #121's orders revealed she was placed on neutropenic precautions on 02/02/23, to reduce the likelihood of a visitor to her room giving her an infection as she was on treatment for cancer. Review of Resident #121 baseline care plan revealed they did not have any care areas related to her being on isolation precautions. Interview with RN #134 on 02/16/23 at 10:07 A.M. and 11:45 A.M. confirmed they did not have a baseline care plan, and did not add to her existing care plan for infections and isolation precautions.

Based on record review, interviews, and policy review, the facility failed to ensure the Ombudsmen was notified for hospital discharges. This affected two (#28 and #50) out of three residents reviewed for discharges. The facility census was 65. Findings include: 1. Review of the medical record for Resident #28 revealed an admitted [DATE] with hospitalization s on 08/16/22, 09/17/22, and 12/11/22. Diagnoses included cerebrovascular disease, legal blindness, benign prostatic hyperplasia, hypertensive heart disease without heart failure, polyneuropathy, and history of transient ischemic attack. Review of the Ombudsmen transfer and discharge notification for August, September, and December 2022 revealed Resident #28 was not listed on the discharge list. Interview on 02/16/23 10:53 A.M. with Social Worker #139 confirmed she did not send notices to the Ombudsmen for those residents who planned to return to the facility after hospitalization . 2. Review of the medical record for Resident #50 revealed an admitted [DATE] with a hospitalization on [DATE]. Diagnoses included sepsis, quadriplegia, major depressive disorder, acute and chronic respiratory failure with hypoxia, and anxiety disorder. Review of the Ombudsmen notification for December 2022 revealed Resident #50 was not listed on the discharge list. Interview on 02/16/23 10:53 A.M. with Social Worker #139 confirmed she did not send notices to the Ombudsmen for those residents who planned to return to the facility after hospitalization . Review of the facility policy titled Transfer or Discharge Documentation, dated December 2016, revealed when a resident was transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information would be communicated to the receiving health care facility or provider.

Based on video observation, review of QSO memos, medical record review, resident family interview, staff interview, and facility policy review, the facility failed to accurately and appropriate express/inform resident representatives of visitation guidelines. This affected one (Resident #209) of three residents reviewed for observations. The census was 65. Findings Include: Observation of video provided by Resident #209 family, recorded date unknown, revealed a three minute and two second video, a nurse supervisor, later identified as Licensed Practical Nurse (LPN) #128, told the family of Resident #209 that they had to follow Center for Medicare and Medicaid (CMS) guidelines when it came to visiting in the facility. The guidelines that she gave were the family had to keep a mask on at all times and not to go in other resident rooms. She did not specify any other visitation guidelines. She told the family that if they did not want to follow these rules, they had to leave. Review of the medical record revealed Resident #209 was admitted to the facility on [DATE]. Diagnoses were periprosthetic fracture around internal prosthetic right knee joint, atherosclerotic heart disease, hypertensive heart disease, anxiety disorder, major depressive disorder, osteoporosis, dementia, hyperlipidemia, Alzheimer's disease, anemia, unspecified hearing loss, muscle weakness, difficulty walking, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment, dated 12/05/22, revealed Resident #209 had a significant cognitive impairment. Review of Resident #209 physician orders, dated 12/15/22, revealed she was on hospice care. Review of Resident #209 progress notes, dated 12/17/22, revealed Registered Nurse (RN) #132 made Resident #209's family aware that per Centers for Medicare & Medicaid Services (CMS) guidelines, a hospice patient may only have four members in the room and that the family can rotate in and out of that room. Later in the shift, LPN #128 came to the facility, which was recorded by Resident #209 family. The progress note confirmed that LPN #128 explained the CMS guidelines again that only four family members could be in the resident's room. Interview with Administrator on 02/15/23 at 2:46 P.M. confirmed they did not have anu policies or guidelines to limit the number of family members in a resident's room while visiting, especially a resident on hospice care. The only time they would limit is if the resident had a roommate and the roommate stated they had a problem with the number of visitors. But even then, they would work with both residents and the family to find a suitable solution. Interview with LPN #128 on 02/16/23 at 1:57 P.M. confirmed that she tried to tell the family they had to follow CMS guidelines when entering the facility for visitation. She would not confirm whether a specific number of staff were permitted in the room with the resident, only that they were to follow CMS guidelines. Review of facility policy titled Visitation, dated September 2022, revealed the facility permits residents to receive visitors subject to the resident's wishes and the protection of the rights of other residents in the facility. Residents are permitted to have visitors of their choosing at the time of their choosing. Family members are designated as such by the resident or representative. Immediate family is not limited to individuals related by blood, adoption, marriage, or common law. Some visitation may be subject to reasonable clinical and safety restrictions that protect the health, safety, security, and/or rights of the facility's. The facility reserves the right to limit the number of visitors in the room at one time to protect the rights of the person sharing the room. A critically ill resident may have visitors of his/her choice at any time, as long as visitation is not medically contraindicated. The rationale for medically-restricted visitation is documented in the resident's medical record. Review of CMS QSO-20-39-NH Revised memo, dated 09/23/22, revealed no specific guidelines or limitations on the number of visitors a resident can have while in the facility. This represents non-compliance related to Complaint Number OH00138660.

Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure dependent residents received timely care. This affected one resident (#20) out of three residents reviewed for incontinence care. The facility census was 60. Findings Include: Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included fusion of spine, quadriplegia, benign prostatic hyperplasia, depression, neuromuscular dysfunction of the bladder, weakness, and hyperlipidemia. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact, had no hallucinations, delusions, or behaviors, required extensive assistance with all activities of daily living except eating which was supervision only. The resident had an indwelling catheter and was always incontinent of bowel. Interview on 12/13/22 at 11:15 A.M., Resident #20 said the staff had not checked every two hours to know if he had an incontinent episode and the resident said he had no feeling and would not know if he needed changed. Observation of Resident #20 with Assistant Director of Nursing (ADON) #100 on 12/14/22 at 9:24 A.M. revealed the resident was lying on his back with his feet on the mattress, the resident was agreeable to have his incontinent brief checked for stool. Resident #20 stated he had not been checked or changed since the night prior and verified he does not always know when he has had a bowel movement. The ADON #100 turned Resident #20 and opened the brief which revealed the resident had brown soft stool in his gluteal fold. The resident asked if he was soiled and the ADON #100 said he was, and the staff would be coming into the room to clean him up. Interview with the State tested Nursing Assistant (STNA) #130 on 12/14/22 at 9:26 A.M., verified she was the STNA providing care on Resident #20's hallway. The STNA #130 verified she had been in Resident #20's room earlier that morning pulled him up in bed and fed him but had not checked the residents brief or provided any incontinence care for Resident #20. The STNA #130 verified her shift started at 6:00 A.M. Review of the facility policy titled Incontinence Care/Peri Care, undated revealed incontinent resident's skin will be kept clean, dry and free of irritation and odor. Identification of skin problems will be made as soon as possible so treatment can be started right away. This violation represents non-compliance investigated under Complaint Number OH00137991 and OH00137757.

Based on medical record review, staff interview, and review of medication information from Medscape, the facility failed to complete ordered laboratory (lab) values to monitor the effectiveness of a [MEDICAL CONDITION] medication ([MEDICATION NAME]) This resulted in the actual harm when Resident #69 was readmitted to the hospital on [DATE] for [MEDICAL CONDITION] secondary to a low [MEDICATION NAME] level. This affected one (#69) out of five residents reviewed. The census was 62. Findings include: Review of Resident #69's closed medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #69 comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #69 was discharged to the hospital on [DATE] and never returned to the facility. Review of physician orders [REDACTED]. Review of progress notes dated 06/28/20 at 8:54 A.M. revealed Resident #69 was sent to the hospital per emergency squad for being very lethargic, warm. and diaphoretic. Resident #69 would not respond to the nurse asking her name, and just stared blankly and did not respond. Review of hospital records dated 06/28/20 through 07/03/20 revealed Resident #69's [MEDICATION NAME] level upon admission to the emergency department (ED) on 06/28/20 was 6.7 micrograms (ug)/milliliter (ml). Normal ranges for [MEDICATION NAME] levels being 10 to 20 ug/ml. Resident #69 was administered [MEDICATION NAME] (intravenous [MEDICATION NAME]) to raise [MEDICATION NAME] levels. Resident #69 was admitted due to [MEDICAL CONDITION] and subtherapeutic [MEDICATION NAME] levels. Review of hospital discharge orders dated 07/03/20 revealed a order to obtain a serum [MEDICATION NAME] level on 07/08/20. [MEDICATION NAME] suspension 4.0 mg/ml was ordered 12 ml at bedtime per [DEVICE] ([DEVICE]) at bedtime for [MEDICAL CONDITION]. Review of a care plan initiated 07/03/20 revealed Resident #69 has a [MEDICAL CONDITION] disorder. An intervention listed was that labs should be monitored and staff should report subtherapeutic or toxic results to physician. Review of progress notes dated 07/08/20 at 2:32 P.M. revealed Resident #69 was seen by a physician at the facility. No new orders were received. Further review if Resident #69's closed medical record revealed no evidence of a [MEDICATION NAME] level being obtained on 07/08/20. Review of a progress note dated 07/10/20 at 9:09 P.M. revealed that Resident #69 was sent by squad to the hospital for being non-responsive, gurgling in the throat and drooling out the side of her mouth, eyes fixed forward, and pinpoint pupils. Review of hospital records dated 07/10/20 revealed Resident #69 was assessed as having breakthrough [MEDICAL CONDITION] due to subtherapeutic [MEDICATION NAME] levels. Resident #69's [MEDICATION NAME] level was 1.7 ug/ml. Resident #69 was administered [MEDICATION NAME] (intravenous [MEDICATION NAME]) to raise [MEDICATION NAME] levels. Resident #69 was admitted on [DATE] with a primary [DIAGNOSES REDACTED]. On 10/01/20 at 1:04 P.M. an interview with Registered Nurse (RN) #80 confirmed the [MEDICATION NAME] level was not obtained for Resident #69 on 07/08/20. Review of medication information from Medscape (https://www.medscape.com) revealed [MEDICATION NAME] is an anticonvulsant medication and is used to treat [MEDICAL CONDITION]. Further review of Medscape revealed therapeutic range of [MEDICATION NAME] was 10 to 20 ug/ml. This deficiency substantiates Complaint Number OH 267.