Every finding on record at Willow Ridge of Mennonite Home Communities of Ohio

Based on observation, review of dishwasher temperature records, staff interview, and facility policy review, the facility failed to ensure dishwasher temperature monitoring was completed as required and failed to ensure open food items were properly dated to prevent spoilage. This had the potential to affected all 16 residents residing in the facility. The facility census was 16.Findings include:1. Review of the dishwasher temperature records in the [NAME] House on 07/20/26 at 9:52 A.M. revealed no rinse cycle temperatures were recorded on 07/17/26 for breakfast and lunch, and no temperatures were recorded for dinner on 07/17/26. Additionally, no dishwasher temperatures were documented for breakfast, lunch, or supper on 07/18/26 and 07/19/26.Interview on 07/20/26 at 9:52 A.M. with Certified Nurse Aide (CNA) #100 verified the dishwasher temperatures were not completed on the above listed dates in [NAME] House.Review of a facility policy titled, Dishwasher Machine Temperature Log, dated 2019, revealed staff will record dishwasher machine temperatures for the wash and rinse cycles at each meal.2. Observation in the [NAME] House on 07/20/26 at 10:30 A.M. revealed a zip lock bag containing bacon with a freezer date of 05/02/26 and no open date. Several additional items in the refrigerator were found without open dates, including a 32 ounce (oz.) container (approximately 3/4 full) of flavored coffee creamer, a 16 oz. container (approximately 1/4 full) of Half and Half, a 46 oz. (approximately 1/4 full) of tomato juice, a 6.5 oz. (approximately 1/2 full) spray can of whipped cream, and a 16 oz. (approximately 1/2 full) container of heavy whipping cream. Interview on 07/20/26 at 10:48 A.M. with CNA #114 verified there were no open dates on the above mentioned food items in the refrigerator. Review of an undated facility policy titled, Dietary, revealed food placed in a refrigerator from freezer to thaw much be used in seven days minus any previous days under refrigeration.

Based on review of Resident Council minutes, resident and staff interview, and policy review, the facility failed to provide timely follow up to concerns brought forth by residents. This had the potential to affect all 11 (#1, #2, #3, #4, #6, #7, #9, #11, #12, #14, and #17) residents who attended Resident Council meetings. The facility census was 16. Findings include:Review of resident gathering meeting minutes dated 08/26/25 revealed Resident #1 wanted to know the cost of toenails to be trimmed.Review of resident gathering meeting minutes dated 09/22/25 revealed Resident #1 wanted to swim at the assisted living facility, and Resident #2 would like cards or dominos and the card game, UNO.Review of resident gathering meeting minutes dated 10/20/25 revealed Resident #2 would rather play UNO instead of Connect Four.Review of resident gathering meeting minutes dated 11/17/25 revealed Resident #2 was still not happy with the menu and felt like the menu repeated every two weeks.Review of resident gathering meeting minutes dated 12/29/25 revealed Resident #1 felt the meat was overcooked, inquired when toenails were going to be cut again and how much it costs, and inquired about pool exercises at the assisted living. Further review revealed Resident #2 was not happy with the food in general and did not like the menu.Review of resident gathering meeting minutes dated 02/23/26 revealed Resident #1 wondered if he could do the pool exercises and Resident #3 felt the meals were hit or miss.Review of resident gathering meeting minutes dated 03/23/26 revealed Resident #2 still did not like the menu indicating there was no variety and green beans three times a week.Review of resident gathering meeting minutes dated 04/20/26 revealed Resident #14 missed the podiatrist and wondered if she could get someone to trim her toenails.Review of resident gathering meeting minutes dated 05/18/26 revealed Resident #2 was not happy with the salmon and fish patties, and felt green beans were on the menu too often.Interview on 07/22/26 at 7:53 A.M. with Activities Director (AD) #116 revealed when there was a concern brought up in resident gathering meetings, she would send the meeting minutes to the department heads via electronic mail (email). AD #116 verified there were the same concerns at multiple resident gathering meetings via email.Interview on 07/22/26 at 10:33 A.M. with Resident #2 revealed she did not feel like her issues with the menu were addressed timely.Review of the undated policy titled, Resident Council Meetings, revealed the facility shall act upon concerns and recommendations of the council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the council.

Based on observation, resident and staff interview, and facility policy review, the facility failed to maintain a comfortable and homelike environment. This had the potential affected five (#1, #5, #9, #12, and #17) out of eight residents that eat in the dining area at the [NAME] House of the facility. The census was 16.Findings include:Observation and interview on 07/20/26 at 7:45 A.M. revealed Resident #17 was observed sitting at the dining table wearing a sweater with a blanket on her lap. During interview, Resident #17 felt, cold to the bone. Interview on 07/20/26 at 8:02 A.M. with Registered Nurse (RN) #118 verified thermometer settings and digital infrared thermometer reading for dining area and beauty shop to be 67 degrees Fahrenheit (F).Review of facility policy titled, Homelike Environment, dated February 2021, revealed comfortable and safe temperatures were between 71 and 81 degrees F.

Based on medical record review, staff interview, and facility policy review, the facility failed offer influenza and pneumococcal vaccines as required. This affected one (#15) of five residents reviewed for immunizations. The census was 16.Findings include:Record review for Resident #15 revealed the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease.Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #15 had moderately impaired cognition and was assessed to be dependent on bathing and dressing.Review of Resident #15's care plan dated 07/06/26 revealed the resident had chronic and progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making, and thought process related to brain deterioration.Review of immunizations for Resident #15 revealed influenza and pneumococcal vaccines was not offered at time of admission.Interview on 07/23/26 at 9:01 A.M. with the Director of Nursing (DON) confirmed Resident #15 was not offered influenza or pneumococcal vaccines upon admission.Review of facility policy titled, General Immunization/Vaccination, dated 04/22, revealed immunizations will follow current Centers for Medicare & Medicaid Services (CMS) guidance and scheduling based on the specific vaccinations. Residents and staff will be offered immunizations against infectious diseases as per current federal, state, and local guidance.

Based on medical record review and staff interview, the facility failed to hold timely care conferences following admission to the facility. This affected one (#14) of two residents reviewed for care planning. The census was 16.Findings include:Record review for Resident #14 revealed the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left side; major depressive disorder; and chronic kidney disease, stage three.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had intact cognition and was assessed to be dependent on toileting, bathing, and dressing.Review of the care plan dated 05/06/26 revealed Resident #14 had a history of a cerebral vascular accident (CVA).Review of Resident #14's nursing progress notes revealed care meetings were held on 12/16/25 and 03/10/26 with the first meeting taking place nearly eight months after admission.Interview on 07/22/26 at 2:52 P.M. with the Director of Nursing (DON) revealed Resident #14 did not have a care conference meeting with the resident until nearly eight months after admission.

Based on observation, medical record review, resident and staff interview, review of activity calendars, and policy review, the facility failed to provide activities at varied times to meet resident preferences. This affected one (#2) of three residents reviewed for activities. The facility census was 16.Findings include:Review of Resident #2's medical record revealed an admission date of 04/15/24. Diagnoses included chronic kidney disease, depression, hypertension, heart failure, and chronic obstructive pulmonary disease.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was assessed with intact cognition. Resident #2 indicated, for preferences for routine and activities, it was very important to listen to music she liked, keep up with the news, do things with groups of people, do her favorite activities, go outside with the weather was good, and participate in religious services or practices. Review of Resident #2's care plan dated 04/16/24 revealed she enjoyed tatting, knitting, crocheting, working on jigsaw puzzles, playing BINGO, attending art class, music, and some spiritual programming. The care plan further revealed Resident #2 would be able to set up project materials, such as crocheting and knitting or jigsaw puzzles, or accept invitations to group programs on a daily basis through next re-evaluation. Interventions included to assist the resident in turning on the RFD Channel on Saturday nights as needed or help find music stations with country or polka/dancing, as desired; ensure the resident had her cellular telephone, as desired; help set up a group or independent activity such as jigsaw puzzle, yarn for crocheting, knitting, or tatting, art supplies, reading or listening to music as needed; and invite and escort the resident to programming as needed in the common area or at the [NAME] House such as music programs, Bingo, Bible study, or events the resident would have interest in.Review of an activity progress note dated 04/13/26 at 3:18 P.M. revealed Resident #2 was working on a jigsaw puzzle and received assistance with mailing in an absentee ballot. Review of an activity progress note dated 06/18/26 at 10:56 A.M. revealed Resident #2 received 15 minutes of one-on-one time with staff. Resident #2 was tatting and the activities assistant sat in the room and watched/talked with the resident during this time. Review of an activity progress note dated 07/13/26 at 11:53 A.M. revealed Resident #2 had a doughnut and lemonade with other residents at the swing and talked about the weekend. Resident #2 loved being outside and was asked to come up with ideas for future activities. Review of an activity progress note dated 07/20/26 at 11:11 A.M. revealed Resident #2 spend 30 minutes of one-on-one time with an activities assistant outside on the swing. The resident and staff talked about families and current events, and were joined by another resident and that resident's daughter.Interview on 07/22/26 at 10:33 A.M. with Resident #2 stated it would be nice to have activities after supper prior to going to bed. Resident #2 stated the staff start helping residents to bed right after supper and she was not ready to go to bed at that time.Observation on 07/20/26 at 11:36 A.M. revealed two female residents sitting in recliners in the common area sleeping. At 1:49 P.M. the two residents in recliners in the common area remained sleeping and another resident was observed sitting in a wheelchair looking at her fingers. No activities were observed. Observation on 07/20/26 at 3:27 P.M. revealed the two female residents continued sleeping in the recliners in the common area. The television was observed to be on; however, no residents were watching the movie playing.Observation on 07/21/26 at 1:40 P.M. revealed no residents were in the common area. All residents in House A were either in bed, in their rooms, or in recliners with no activities taking place.Observation on 07/22/26 at 1:52 P.M. revealed two residents sitting in recliners in the common area with the television on that they were not watching. At 2:57 P.M., three residents were observed sitting in recliners in the common area sleeping. The television remained on but no one was watching. At 4:25 P.M., the same three residents continue sitting in recliners in the common area sleeping while the television remained on.Review of the activity calendar for June and July 2026 revealed there were no evening activities scheduled with the exception of a 7:00 P.M. movie and snack pass on Saturdays and group puzzle time at 6:00 P.M. on three of four Sundays. In June 2026, there were no scheduled activities past 11:00 A.M. on Mondays and on Tuesdays there were no schedule activities past 1:00 P.M. In July 2026, there were no scheduled activities past 1:00 P.M. on Tuesdays.Interview on 07/22/26 at 7:53 A.M. with Activities Director (AD) #116 revealed the activity staff come to the facility twice a week for eight hours, and the Shahbaz would have to do the activities in the afternoon and evenings. AD #116 verified the June and July activity calendars had multiple days with no activities in the evening and multiple days with few activities in the afternoon for residents, included Resident #2, to participate in. Review of an undated policy titled, Activities, revealed it was the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the resident interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community.

Based on medical record review, staff interview, and policy review, the facility failed to ensure pressure wound measurements were obtained weekly. This affected one (#6) of one residents reviewed for wounds. The facility census was 16.Findings include:Review of the medical record for Resident #6 revealed an admission date of 07/26/24 with diagnoses including noninfective gastroenteritis and colitis, dementia, presence of other orthopedic joint implants, unspecified fracture of the lower end of the left radius, fracture of part of the neck of the left femur, and overactive bladder.Review of Resident #6's current physician orders revealed orders for alternating pressure mattress for staff to check every shift for inflation; cleanse the left buttock with soap and water, pat dry, apply Xeroform gauze, then cover with border foam dressing every other day and as needed until healed; cleanse the right buttock with soap and water, pat dry, apply Xeroform gauze, and cover with border foam dressing every other day until healed; and enter a wound note for the area to the right and left buttock every week.Review of Resident #6's wound note dated 07/06/26 revealed the resident had pressure/shearing to the right and left buttocks. The right buttock wound measured 0.6 centimeters (cm) long by 0.5 cm wide by less than 0.1 cm deep. There was no exudate or no pain. The wound edges were dry and peeling with no signs or symptoms of infection noted. The wound had poor progress due to hospice and disease progression. The left buttock measured 2.6 cm long by 2.2 cm wide by less than 0.1 cm deep. There was no pain or exudate, and the wound bed and edges were dry and peeling. The wound had poor progress due to hospice and disease progression.Review of Resident #6's wound note dated 07/21/26 revealed the resident continued with pressure/shearing to the right and left buttock. The left buttock measured 1.0 cm long by 0.1 cm wide by less than 0.1 cm deep. The right buttock measured 4.2 cm long by 5.5 cm wide by less than 0.1 cm deep. There was no tunneling or pain, and scant tan exudate noted. The wound edges were red and poorly blanched.Interview on 07/22/26 at 1:58 P.M. with the Director of Nursing (DON) revealed pressure wounds are to be measured with a wound description weekly. The DON verified Resident #6's pressure wounds were not measured between 07/06/26 and 07/21/26.Review of the policy titled, Documentation of Wound Treatments, dated 04/2025, revealed wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. The following elements are documented as part of a complete wound assessment: type of wound (pressure injury, surgical, etc.) and anatomical location, stage of the wound, if pressure injury (stage one, two, three, four, deep tissue injury, unstageable pressure injury) or the degree of skin loss if non-pressure (partial or full thickness), measurements: height, width, depth, undermining, tunneling, and description of wound bed characteristics (color of the wound bed, type of tissue in the wound bed), condition of the peri-wound skin, presence, amount, and characteristics of wound drainage/exudate, and presence or absence of odor and pain.

Based on medical record review, staff interview, and policy review, the facility failed to ensure nutrition recommendations were implemented timely. This affected one (#1) of one residents reviewed for nutrition. The facility census was 16.Findings include:Review of the medical record for Resident #1 revealed an admission date of 06/26/25 with diagnoses including a urinary tract infection (UTI), dementia, infection and inflammatory reaction due to an indwelling urethral catheter, and major depressive disorder.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact.Review of Resident #1's documented weights in the medical record revealed the resident weighed 169.0 pounds (lbs.) on 05/01/26, 161.3 lbs. on 06/08/26, 161.0 lbs. on 06/30/26, and 156.3 lbs. on 07/01/26.Review of a nutrition reentry/annual/weight loss note dated 07/07/26 revealed Resident #1 returned from a hospital stay for a UTI. The resident experienced significant weight loss of 7.5 percent (%) in two months, most likely due to decreased intake and hospital stay. The resident was on a regular diet with meal intakes between 25 and 100%. It was documented for the resident to continue a regular diet with a recommendation for Boost Breeze supplement daily for nutritional support.Review of Resident #1's current physician orders revealed no active orders for Boost Breeze daily.Interview on 07/22/26 at 2:51 P.M. with the Director of Nursing (DON) revealed the dietician would send her the recommendations for her to address with the physician. The DON verified Resident #1 had no order for Boost Breeze daily and could not locate the recommendation for the physician.Review of policy titled, Nutritional Management, revised on 04/2025, revealed the physician will be notified of significant changes in weight, intake, or nutritional status, lack of improvement toward goals, and any complications associated with interventions. Nutritional recommendations may be made by the dietician based on the residents' preferences, goals, condition, or other factors and followed up with the physician/practitioner for orders as per facility policy, if indicated. Dietary orders may be written or modified by the qualified dietician or other clinically qualified nutrition professional if the residents attending physician/practitioner delegates the task, dependent upon state law or facility policy.

Based on medical record review, staff interview, and facility policy review, the facility failed offer residents a COVID-19 vaccine as required. This affected one (#15) of five residents reviewed for COVID-19 vaccines. The census was 16.Findings include:Record review for Resident #15 revealed the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease.Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #15 had moderately impaired cognition and was assessed to be dependent on bathing and dressing.Review of Resident #15's care plan dated 07/06/26 revealed the resident had chronic and progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making, and thought process related to brain deterioration.Review of immunizations for Resident #15 revealed no evidence of the facility offering the resident to receive a COVID-19 vaccine.Interview on 07/23/26 at 9:01 A.M. with the Director of Nursing (DON) confirmed Resident #15 was not offered a COVID-19 vaccine upon admission to the facility.Review of facility policy titled, General Immunization/Vaccination, dated 04/22, revealed immunizations will follow current Centers for Medicare & Medicaid Services (CMS) guidance and scheduling based on the specific vaccinations. Residents and staff will be offered immunizations against infectious diseases as per current federal, state, and local guidance.

Based on record review, staff interview, and policy review, the facility failed to ensure a comprehensive care plan was developed and implemented. This affected two (Residents #5 and #18) of two residents reviewed for care planning. The facility census was 20. Findings include: 1. Review of the medical record of Resident #5 revealed an admitted [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had severe cognitive impairment and required set-up assistance for eating and oral hygiene, supervision assistance for ambulation, partial assistance for toileting hygiene, bathing, dressing, bed mobility, and transfers. Review of physician orders revealed an order dated 04/27/24 for an advance directive of Do Not Resuscitate - Comfort Care (DNR-CC), an order dated 04/27/24 for Apixaban (blood thinner) Oral Tablet 2.5 Milligram (mg) (Apixaban), give 1 tablet by mouth two times a day for blood thinner and an order dated 06/14/24 for Seroquel (antipsychotic) Oral Tablet 25 mg (Quetiapine Fumarate), give 25 mg by mouth at bedtime related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #5's care plan revealed the care plan did not address code status, use of a blood thinner, or the use of an anti-psychotic medication. 2. Review of the medical record of Resident #18 revealed an admitted [DATE] with diagnoses of fracture of other parts of pelvis, subsequent encounter for fracture with routine healing and essential (primary) hypertension. Review of the MDS assessment dated [DATE] revealed Resident #18 was cognitively intact. Resident #18 was independent for eating and required partial assistance for bed mobility, and substantial assistance for toileting hygiene, bathing, dressing, transfers, and for wheelchair mobility over 150 feet. Review of physician orders revealed an order dated 05/29/24 for Resident #18's advanced code status was DNR-CC Arrest, an order dated 06/13/24 for Aspirin Oral Tablet Delayed Release 81 mg (Aspirin), give 81 mg by mouth one time a day related to essential hypertension, an order dated 06/13/24 for Metoprolol Tartrate 25 mg two times daily for hypertension, an order dated 06/06/24 for Myrbetriq 25 mg extended release daily for urinary incontinence, and an order for Tramadol 50 mg every six hours as needed for pain. Review of Resident #18's care plan revealed the care plan did not address code status, hypertension, urinary incontinence, or pain. Interview on 07/11/24 at 2:16 P.M. with the Director of Nursing (DON) confirmed Resident #5's care plan was not comprehensive and did not address code status, use of a blood thinner, or use of antipsychotic medication. The interview also confirmed that Resident #18's care plan was not comprehensive and did not address code status, hypertension, urinary incontinence, or pain. Review of the Care Plans policy dated 4/2022 revealed, It is the policy of the facility to develop and implement a person-centered care plan for each resident, consistence with resident rights, that included measurable objectives and timeframe's to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the residents comprehensive assessment.

Based on record review and staff interview, the facility failed to ensure the advance directive code status in the Electronic Medical Record (EMR) matched the signed advanced directive form. This affected two (Resident #5 and #18) of three reviewed for advanced directives. The facility census was 20. Findings include: 1. Review of the medical record of Resident #5 revealed an admitted [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had severe cognitive impairment. Review of a physician order in the EMR dated 04/27/24 revealed Resident #5's advanced code status was Do Not Resuscitate - Comfort Care (DNR-CC). Review of the DNR Order Form dated 04/29/24 revealed Resident #5's advanced code status was Do Not Resuscitate - Comfort Care Arrest (DNR-CCA). Interview on 07/11/24 at 2:16 P.M. with the Director of Nursing (DON) confirmed the advanced directive for Resident #5 was documented in the EMR as DNR-CC but should have been documented as DNR-CCA. 2. Review of the medical record of Resident #18 revealed an admitted [DATE] with diagnoses of fracture of other parts of pelvis, subsequent encounter for fracture with routine healing and essential (primary) hypertension. Review of the MDS dated [DATE] revealed Resident #18 was cognitively intact. Review of a physician order in the EMR dated 05/29/24 revealed Resident #18's advanced code status was DNR-CCA. Review of the DNR Order Form dated 06/11/24 revealed Resident #18'5 advanced code status was DNR-CC. Interview on 07/11/24 at 2:16 P.M. with the DON verified the advanced directive for Resident #18 was documented in the EMR as DNR-CCA but should have been documented as DNR-CC.

Based on record review and staff interviews, the facility failed to properly assess a surgical wound upon admission. This affected one (Resident #172) of one reviewed for wound assessments. The facility census was 20. Findings include: Review of the medical record for Resident #172 revealed an admitted [DATE]. The resident was admitted with diagnoses including aftercare following knee joint prosthesis, Parkinsonism, and hypertension. The resident remained at the facility. Review of the 07/01/24 admission skin assessment revealed documentation of a surgical wound with 31 staples and two sutures. There was no further description and no measurements of the surgical wound in the document. Interview and observation on 07/08/24 at 10:47 A.M. revealed Resident #172 had thigh high compression hose on bilaterally. An Abdominal (ABD) pad was observed over his right knee. Upon questioning, Resident #172 stated he had right knee replacement surgery and was at the facility temporarily for therapy. Interview on 07/10/24 at 1:59 P.M. with Registered Nurse (RN) #414 verified there were no measurements or description of the right knee surgical wound on the admission skin assessment. Review of the undated facility policy, Wound and Skin Care Treatment Program, revealed measurements of a wound would be completed.

Based on record review and staff interviews, the facility failed to ensure a thorough comprehensive care plan was completed for two (Residents #19, #5) of three reviewed for care plans. The facility census was 20. Findings include: 1. Review of the medical record for Resident #9 revealed an admitted [DATE]. The resident was admitted with diagnoses including unspecified dementia, anxiety, depression and senile degeneration of the brain. She was admitted to hospice on 05/16/24. The resident remained at the facility. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had severely impaired cognition. She required moderate assistance with eating, substantial assistance for bed mobility, and was dependent for toileting, hygiene, and transfers. Review of the care plan revealed no goals or interventions in place for hospice care. An interview on 07/11/24 at 2:15 P.M. with the Director of Nursing (DON) verified there was no hospice care plan for Resident #19 and reported the expectation was for the care plan to include hospice care. 48570 2. Review of the medical record of Resident # 5 revealed an admitted [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the MDS assessment dated [DATE] revealed Resident #5 had severe cognitive impairment. Resident #5 required set-up assistance for eating and oral hygiene, supervision assistance for ambulation, and partial assistance for toileting hygiene, bathing, dressing, bed mobility, and transfers. Review of physician orders revealed an order dated 06/14/24 for Seroquel (antipsychotic) Oral Tablet 25 Milligrams (mg) (Quetiapine Fumarate) give 25 mg by mouth at bedtime related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #5's care plan revealed the care plan did not address Resident #5's use of antipsychotic medication. Interview on 07/11/24 at 2:16 P.M. with the DON confirmed Resident #5's care plan did not address use of antipsychotic medication.

Based on review of Self Reported Incidents (SRI), staff interviews, record review, and review of facility policy, the facility failed to complete thorough investigations related to resident-to-resident sexual abuse. This affected three residents (#16, #15, #7) of three reviewed for abuse. The facility census was 20. Findings include: 1. Review of the medical record for Resident #16 revealed an admitted [DATE]. The resident was admitted with diagnoses including dementia, stroke, type two diabetes mellitus, depression, and hypertension. The resident remained at the facility. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had intact cognition and required extensive one person assistance for toileting and supervision for eating, bed mobility and transfers. Review of the care plan revealed Resident #16 had a history of being drawn to various females by doting affection, asking for dates and wanting companionship. Interventions included to educate family members regarding affectionate behavior and plans to divert, discourage, monitor displays and to offer alternative activities. Record review revealed Resident #16 had documented 15-minute checks from 03/10/24 at 9:30 P.M. until 03/18/24 at 3:15 P.M. Review of the progress note date 03/11/24 revealed Resident #16's daughter was called and notified of an incident with another resident which had occurred the previous day, and he remained on 15-minute checks. Review of the progress note dated 03/13/24 at 3:57 P.M. revealed activity staff requested an interview with Resident #16. Resident #16 began to rub activity staff's back and shoulders and staff attempted to redirect him. Resident #16 was documented to have told the activity staff he got lonely and would like to marry someone and leaned in to kiss her. Review of progress notes dated 03/14/24 and 03/15/24 reveled Resident #16 was observed on multiple occasions to hold hands, touch the leg, and put his arm around a female elder. Review of the progress note dated 03/16/24 revealed Resident #16 touched a staff member's breast two times and asked if someone could go to bed with him. 2. Review of the medical record for Resident #15 revealed an admitted [DATE]. The resident was admitted with diagnoses including Alzheimer's Disease, depression, aphasia and anxiety. The resident remained at the facility. Review of the quarterly MDS assessment dated [DATE] revealed Resident #15 had impaired cognition and required extensive two person assistance for bed mobility, one person assistance for transfers and toileting, and supervision for eating. Review of a progress note dated 03/18/24 revealed Licensed Practical Nurse (LPN) #421 recieved a call from House #2 from State tested Nurse Aide (STNA) #238 that Resident #15 had been observed touching the shoulder and thigh of Resident #7 and kissing her on the lips and cheek. Resident #15 had been removed fromt the area. 3. Review of the medical record for Resident #7 revealed an admitted [DATE]. The resident was admitted with diagnoses including Alzheimer's Disease, unspecified psychosis, anxiety, depression and paranoid personality disorder. The resident remained at the facility. Review of the quarterly MDS assessment dated [DATE] revealed Resident #7 had severely impaired cognition and required extensive two-person assistance with bed mobility, transfers, and toileting, and supervision for eating. Review of the SRI dated 03/16/24 revealed Resident #16 had been observed by staff touching the arm of Resident #15. At a later time, Resident #16 was observed by State tested Nurse Aide (STNA) #492 touching the right breast of Resident #15. Resident #16 was removed from the area and a full body assessment of Resident #16 was completed with no concerns. The physician and families were notified. Review of the SRI dated 03/18/24 revealed Resident #16 was observed kissing Resident #7 by STNA #428. Resident #16 was removed and nursing staff were notified. A thorough skin assessment was completed of Resident #7 with no concern. The physician and families were notified and Resident #16 was admitted to a different facility for his behaviors. Interview on 07/10/24 at 10:42 A.M. with the Administrator, Director of Nursing (DON), and Clinical Services #505 while reviewing the SRI revealed a physical assessments of Resident #15 and Resident #7 was performed with no concerns, however no other residents were assessed. No interviews of residents were completed in regards of a concern for abuse. No staff statements were provided and no staff education had been given following the incident. The DON and Administrator stated they were not employed at the time of the incident and were unaware of the progress notes documenting behaviors prior to the sexual abuse, which had been substantiated at the time of either investigation. Review of the 10/22 facility policy, Abuse, Neglect and Expolitation, revealed allegations of abuse would be investigated.

Based on record review, observations, staff interviews, pharmacist interview, and policy review, the facility failed to ensure medications that should not be crushed were not crushed. This affected one (Resident #18) of one resident reviewed for medication administration. The facility census was 20. Findings include: Review of the medical record of Resident #18 revealed an admitted [DATE] with diagnoses of fracture of other parts of pelvis, subsequent encounter for fracture with routine healing and essential (primary) hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #18 was independent for eating and required partial assistance for bed mobility and substantial assistance for toileting hygiene, bathing, dressing, transfers, and for wheelchair mobility over 150 feet. Review of physician orders revealed an order dated 06/13/24 for Aspirin Oral Tablet Delayed Release 81 Milligrams (mg) (Aspirin), give 81 mg by mouth one time a day related to essential hypertension. Observation and interview on 07/10/24 at 7:54 A.M. with Registered Nurse (RN) #414 revealed the Aspirin Delayed Release was crushed and administered to Resident #18. RN #414 confirmed the medication was crushed. Interview on 07/10/24 at 10:28 A.M. with Pharmacist #510 confirmed Aspirin Delayed Release is what is supplied in the package for Resident #18's daily medication. Interview also confirmed the pharmacy was not aware of Resident #18 needing her medications crushed and that Aspirin Delayed Release should not be crushed and that she will be reaching out to the physician for a change in medications. Interview on 07/11/24 at 2:16 P.M. with the Director of Nursing (DON) confirmed the Aspirin Delayed Release for Resident #18 should not have been crushed. Review of the Standards for Medication Administration dated 08/15/12 revealed the policy does not address crushing medications that are not to be crushed.

Based on review of facility policy, documentation, and staff interviews, the facility failed to follow their Legionnaires policy. This had the potential to affect all 20 residents at the facility. Findings include: Review of the undated facility policy, Legionnaires Policy, revealed the policy applied to all water systems which included, but not limited to shower heads and hoses, ice machines and infrequently used equipment, cold water would be heated to 140 degrees Fahrenheit by water heaters in each house and relevant procedures and record keeping related to the program would be kept, maintained and reviewed as necessary. Interview on 07/11/24 at 2:59 P.M. with Maintenance Director #509 revealed the provided policy and water testing by an outside testing facility for Legionella and intermittent room water temperatures were the only documentation available for Legionella. He verified in the seven months he had been employed, he did not test the temperature of the water heaters and there was no documentation the shower heads had been treated or when a resident room was empty, stagnant water prevention was completed. Review of facility documentation revealed there was no documentation to show the facility was following their policy of checking water heaters.

Based on record review and staff interviews, the facility failed to ensure a thorough baseline care plan was created for one (Resident #172) of one reviewed for baseline care plans. The facility census was 20. Findings include: Review of the medical record for Resident #172 revealed an admitted [DATE]. The resident was admitted with diagnoses including aftercare following knee joint prosthesis, Parkinsonism, and hypertension. Review of the 07/01/24 admission skin assessment revealed documentation of a surgical wound with 31 staples and two sutures. Review of Resident #172's baseline care plan revealed no interventions or goals in place for the resident's surgical wound. Interview and observation on 07/08/24 at 10:47 A.M. revealed Resident #172 had thigh high compression hose on bilaterally. An Abdominal (ABD) pad was observed over his right knee. Upon questioning, Resident #172 stated he had right knee replacement surgery and was at the facility temporarily for therapy. Interview on 07/12/24 at 2:15 P.M. with the Director of Nursing verified there was no baseline care plan related to the surgical wound of Resident #172 and reported it was the expectation the base line care plan would have addressed the resident's surgical wound. Review of the 03/22 facility, Baseline Care Policy revealed any services and treatments to be administered on the behalf of the facility would be developed within the first 48 hours.

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to obtain and evaluate appropriate treatment, and removed an old dressing in a manner to prevent pain and tissue damage for one (#14) resident. This resulted in actual harm when Resident #14's ordered dressing was adhering to her open wound and was removed by the nurse without any interventions to loosen the dressing before removal. Resident #14 was noted to squeeze her eyes shut, grimace, tense her upper body, grab hold of the armrest with her hand, and pull her leg away when the dressing was removed. The wound was noted to be opened and actively bleeding following the immediate removal of the adhering dressing. Additionally, the facility failed to conduct a comprehensive wound assessment which including measurements of the wound for one (#14) resident out of one resident reviewed for wounds. The facility census was 18. Findings Include: Review of Resident #14's medical record revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The assessment listed the resident as being at risk for pressure ulcers and having no pressure ulcers. Review of Resident #14's nurse's note dated 12/28/21 revealed the resident was noted to have a raised racquetball sized bruise to the posterior aspect of the left knee. There were no measurements of the area. There were no additional assessments of the area until 01/08/22. Review of Resident #14's nurse's note dated 01/08/22 revealed ABD pad and kerlix were applied to left calf area due to black swollen fluid filled area. There were no measurements of the area. Review of Resident #14's nurse's note dated 01/09/22 revealed ABD pad and kerlix were applied to blackened fluid filled cyst behind left knee. Bloody discharge was noted on previous bandage. There were no measurements of the area. Review of Resident #14's weekly skin sweep dated 01/10/22 listed previously documented racquetball size lump now with blackened fluid filled area and previous ABD pad saturated with dark red/tan discharge. Review of Resident #14's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply warm compress to site to promote absorption every morning and as needed. Review of Resident #14's wound culture final report dated 01/14/22 revealed moderate growth of staphylococcus aureus isolated. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Wrap area loosely with ACE wrap, as the area shrinks, apply ace wrap tighter. Review of Resident #14's current care plan revealed the care plan did not address the resident's wound or wound infection. Skin sweep dated 01/17/22 revealed posterior left calf had reddened area due to fluid filled cyst draining and brownish red discharge on previous dressing. There were no measurements of the area. Review of Resident #14's nurse's note dated 01/20/22 at 2:24 P.M. revealed post hematoma left posterior calf which measured 5 centimeters (cm) by 7 cm by <0.1 cm and was draining bright red blood. The note documented the resident noted to grimace during the dressing change. An ABD pad and ace wrap applied per order. [MEDICATION(S)] placed on wound under the ABD pad to prevent sticking to the wound. The physician was notified. Observation on 01/20/22 at 10:05 A.M. revealed Registered Nurse (RN) #439 completed a wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was to apply an ABD pad over hematoma site and wrap with an ACE wrap. When RN #439 removed the old ABD pad from the wound upper left posterior leg, the pad was sticking to the wound and was not easily removable. RN #439 pulled the ABD pad off the area without any interventions to loosen the dressing. There was a moderate amount of bright red blood on the ABD pad and blood dripping from the wound immediately after removal of the ABD pad. The wound was was observed to be very large in size and open. As the nurse was removing the old ABD pad from the resident's wound the resident squeezed her eyes shut, grimaced, tensed her upper body, grabbed hold of the armrest with her hand, and pulled her leg away. Per surveyor intervention the RN measured the resident's wound and obtained a measurements documented in the 01/20/22 nurse's note. Interview on 01/20/22 10:05 A.M. with RN #439 stated Resident #14 had a large hematoma behind her left knee and then the wound opened up. RN #439 was unaware of when the area became an open wound. RN #439 verified the ABD dressing was sticking to Resident #14's wound on the left leg and it appeared to hurt the resident when she removed it. RN #439 stated she would contact the physician for a different treatment. Interview on 01/20/22 10:55 A.M., the Director of Nursing (DON) stated Resident #14 had a hematoma behind her left knee which started on 01/08/22 and was a fluid filled area. DON stated the hematoma opened up on 01/19/22 and verified there was no documentation of the area becoming an open wound. The DON verified there were no measurements taken of the area until 01/20/22. Review of facility policy titled Treatment Guidelines for Pressure Injury and Wounds, dated 06/05/18, revealed a very important consideration in establishing and implementing a treatment program for any type of wound is an individualized treatment program for each Elder. For infected wounds, cover with [MEDICATION(S)] border foam and change everyday.

Based on observation and staff interview, the facility failed to prevent possible transmission of COVID-19 infection by failing to ensure the thermometer used for screening was properly disinfected between use by different persons. This had the potential to affect all 18 residents in the facility. The facility census was 18. Findings include: Observations on 01/18/22 through 01/22/22 revealed surveyors had to self screen upon entrance into the facility on a sheet of paper. The surveyors used a hand held thermometer to obtain their temperatures upon entrance. The facility staff did not disinfect thermometer between uses nor was there disinfectant available to disinfect the thermometer between uses. Interview on 01/19/22 at 2:40 P.M. with State tested Nurse Aide (STNA) #430 verified she did not disinfect the thermometer after use.

Based on observation, staff interview, and review the Dish Machine Temperature Log, the facility failed to ensure dishes were properly sanitized in the dishwashers in the 101 House. This affected all nine residents (#2, #6, #7, #10, #12, #13, #268, #269, and #270) who resided in the 101 House. The facility census was 18. Findings Include: Observation on 01/18/22 at 1:26 P.M. of State tested Nursing Assistant (STNA) #415 found her running the dishwasher following the lunch meal in the 101 House. The dishwasher was noted to be a low temperature, chemical sanitization machine using chlorine for sanitation. The observed wash temperature was 120 degrees Fahrenheit (F) and rinse temperature of 129 degrees F. STNA #415 completed a test strip for chlorine sanitation levels and found the level were 25 parts per million (ppm). STNA #415 verified the proper level for sanitation was at least 50 ppm and dishwasher was not at the proper level of chlorine for sanitation. Observation on 01/18/22 at 1:38 P.M. of a second cycle of the dishwasher found the chemical sanitation level continued to be 25 ppm. STNA #415 verified it was still not reaching the proper sanitation level. She checked the chemicals and found them to be full and connected properly. STNA #415 stated she would notify the maintenance staff to have the machine serviced. Review of the Dish Machine Temperature Log for lunch on 01/18/22 revealed the chemical sanitation level was documented as 50 ppm. Interview on 01/18/22 at 2:12 P.M. with STNA #415 verified the chemical sanitization level for the lunch meal on 01/18/22 was 25 ppm and the documented 50 ppm was inaccurate. Review of the log titled Dish Machine Temperature Log, dated January 2022, revealed the dish wash machine temperatures should be between 120 degrees F and 140 degrees F and the chlorine sanitizer should be 50 ppm. Resident #2, #268, #269, #10, #6, #7, #12, #13, and #270 resided in the 101 House.