Every finding on record at Windsor Lane Healthcare Center

Based on medical record review, staff interview, facility documentation, and review of facility policy, the facility failed to ensure allegations of resident neglect were reported to the state agency. This affected two (#2, #3) of three residents reviewed for staff treatment and care. The facility census was 72. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 10/28/25. Diagnoses included, type II diabetes mellitus, epilepsy, dementia, major depression, cerebral infarction, parosmia, and hypertension. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had severe cognitive impairment, exhibited no behaviors, was dependent for all activities of daily living including toileting, was frequently incontinent, and was at risk for pressure ulcer with no current skin breakdown. Review of the resident's progress notes from October 2025 through February 2026 lacked evidence regarding any alleged incidents.2. Review of the medical record for Resident #3 revealed an admission date of 09/01/25. Diagnoses included Alzheimer's disease, dementia, epilepsy, major depressive disorder, anemia, and anxiety disorder. Review of the MDS assessment dated [DATE] revealed Resident #3 had severe cognitive impairment, behaviors directed at others, was dependent on staff for completion of activities of daily living, was incontinent of bladder, was continent of bowel, and was at risk for pressure ulcer development with no skin breakdown. Review of the resident's progress notes from October 2025 through February 2026 lacked evidence regarding any alleged incidents.On 02/27/26 at 9:27 A.M. interview with Human Resources Director (HRD) #200 revealed on 12/03/25 Activity Assistant (AA) #300 provided a written statement regarding Certified Nurse Aide (CNA) #400 and CNA #401. The statement indicated CNA #400 and CNA #401 had denied certain residents residing on the dementia unit opportunities to toilet and treated the residents in a disrespectful manner. HRD #200 stated the allegations were not reported to the state agency and a written investigation was not completed. Furthermore, CNA #400 and #401 were not removed from the facility due to the allegations but were placed on a different unit to provide care to those residents.Review of AA #300 written statement dated 12/03/25 revealed her first couple of weeks working in the unit, AA #300 witnessed the nurses aide CNA #400 raise her voice at a resident multiple occasions. One time CNA #400 raised her voice and told Resident #3 she was not allowed to speak to people a certain way and was told she needed to apologize. Later CNA #400 was heard yelling at Resident #3 that she needed to be quiet. Resident #3 was in her room. AA #300 was down the hall in the main area. On another occasion, about a week prior to providing the written statement, Resident #3 asked to use the restroom. Resident #3 had gone maybe 45 minutes prior to asking and CNA #400 asked Resident #3, Are you going to go this time? in a demeaning tone. Resident #3 continued asking if she could use the restroom and was told, hold on by CNA #400. After five to ten minutes of asking, the lunch cart arrived and CNA #400 told Resident #3 it was lunch time now and that she could not take her to the bathroom. Resident #3 was clearly upset. CNA #400 told the resident it was okay, because she was wearing a brief, in front of many people. On multiple occasions CNA 400 has scolded Resident #3. Most recently being yesterday December 2nd in the afternoon. CNA #400 and #401 recounted what seemed to consider a humorous anecdote about Resident #3 being upset about something pertaining to her dog (the resident has a stuffed dog she considers real) and CNA #401 took the dog and threw it in front of Resident #3, causing distress. The joke was they told Resident #3 the dog grew wings in that moment. AA #300 stated Resident #3 is regularly targeted and subjected to bullying and neglectful treatment. Further review of the written of AA #300's written statement revealed a few weeks ago AA#300 was at the table with a few residents, including Resident #2. Resident #2 announced she needed to use the restroom. CNA #401 was assisting another resident. So CNA #400 told her they would help her soon. Over the next hour, Resident #2 continued asking to use the restroom repeatedly. CNA #400, who was on her phone, kept telling her she had to wait. Resident #2 kept telling AA #300 over and over I'm going to poop my pants, I need to go to the bathroom now.On 12/07/25 CNA #400 wrote a statement regarding the allegation on 12/03/25 stating she has never denied any resident's request on brining them to the bathroom when they ask. If they happen to ask during a mealtime and the other aide on the floor is in a resident's room, she apologizes and lets the resident know she cannot leave the dining room unattended and tells them as soon as the other aide comes back she will take the resident to the bathroom. CNA #400 stated she has never told a resident to just go in your brief. As to the allegation of CNA #400 just sitting at the table, its because you can see everything especially the television area where there is also a door. CNA #400 stated they do have a resident that can not have anything by mouth and on occasion one of the residents likes to share snacks with this said resident.On 02/27/26 at 11:40 A.M. interview with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Human Resources Director #200 verified when Activity Assistant submitted written allegations no investigation was documented and the state agency was not notified of the allegations.Review of facility Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy dated 2016. All incident and allegations of Abuse, Neglect, Exploitation, Mistreatment of a resident, or misappropriation of resident property and all injuries of unknown source must be immediately reported to the administrator or designee. The Administrator of his/her designee will notify the state survey agency of all alleged violations involving of Abuse, Neglect, Exploitation, Mistreatment of a resident, or misappropriation of resident property and all injuries of unknown source as soon as possible, but no later than twenty-four (24) hours from the time of the incident/allegation was made known to the staff member.This deficiency represents non-compliance investigated under Complaint Number 2715158.

Based on medical record review, staff interview, review of facility documentation, and review of facility policy, the facility failed to ensure allegations of resident neglect were promptly acted upon to prevent further neglect, and thoroughly investigated. This affected two (#2 and #3) of three residents reviewed for staff treatment and care. The facility census was 72. Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 10/28/25. Diagnoses included, type II diabetes mellitus, epilepsy, dementia, major depression, cerebral infarction, parosmia, and hypertension. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had severe cognitive impairment, exhibited no behaviors, was dependent for all activities of daily living including toileting, was frequently incontinent, and was at risk for pressure ulcer with no current skin breakdown. Review of the resident's progress notes from October 2025 through February 2026 lacked evidence regarding any alleged incidents.2. Review of the medical record for Resident #3 revealed an admission date of 09/01/25. Diagnoses included Alzheimer's disease, dementia, epilepsy, major depressive disorder, anemia, and anxiety disorder. Review of the MDS assessment dated [DATE] revealed Resident #3 had severe cognitive impairment, behaviors directed at others, was dependent on staff for completion of activities of daily living, was incontinent of bladder, was continent of bowel, and was at risk for pressure ulcer development with no skin breakdown. Review of the resident's progress notes from October 2025 through February 2026 lacked evidence regarding any alleged incidents.On 02/27/26 at 9:27 A.M. interview with Human Resources Director (HRD) #200 revealed on 12/03/25 Activity Assistant (AA) #300 provided a written statement regarding Certified Nurse Aide (CNA) #400 and CNA #401. The statement indicated CNA #400 and CNA #401 had denied certain residents residing on the dementia unit opportunities to toilet and treated the residents in a disrespectful manner. HRD #200 stated the allegations were not reported to the state agency and a written investigation was not completed. Furthermore, CNA #400 and #401 were not removed from the facility due to the allegations but were placed on a different unit to provide care to those residents.Review of AA #300 written statement dated 12/03/25 revealed her first couple of weeks working in the unit, AA #300 witnessed the nurses aide CNA #400 raise her voice at a resident multiple occasions. One time CNA #400 raised her voice and told Resident #3 she was not allowed to speak to people a certain way and was told she needed to apologize. Later CNA #400 was heard yelling at Resident #3 that she needed to be quiet. Resident #3 was in her room. AA #300 was down the hall in the main area. On another occasion, about a week prior to providing the written statement, Resident #3 asked to use the restroom. Resident #3 had gone maybe 45 minutes prior to asking and CNA #400 asked Resident #3, Are you going to go this time? in a demeaning tone. Resident #3 continued asking if she could use the restroom and was told, hold on by CNA #400. After five to ten minutes of asking, the lunch cart arrived and CNA #400 told Resident #3 it was lunch time now and that she could not take her to the bathroom. Resident #3 was clearly upset. CNA #400 told the resident it was okay, because she was wearing a brief, in front of many people. On multiple occasions CNA 400 has scolded Resident #3. Most recently being yesterday December 2nd in the afternoon. CNA #400 and #401 recounted what seemed to consider a humorous anecdote about Resident #3 being upset about something pertaining to her dog (the resident has a stuffed dog she considers real) and CNA #401 took the dog and threw it in front of Resident #3, causing distress. The joke was they told Resident #3 the dog grew wings in that moment. AA #300 stated Resident #3 is regularly targeted and subjected to bullying and neglectful treatment. Further review of the written of AA #300's written statement revealed a few weeks ago AA#300 was at the table with a few residents, including Resident #2. Resident #2 announced she needed to use the restroom. CNA #401 was assisting another resident. So CNA #400 told her they would help her soon. Over the next hour, Resident #2 continued asking to use the restroom repeatedly. CNA #400, who was on her phone, kept telling her she had to wait. Resident #2 kept telling AA #300 over and over I'm going to poop my pants, I need to go to the bathroom now.On 12/07/25 CNA #400 wrote a statement regarding the allegation on 12/03/25 stating she has never denied any resident's request on brining them to the bathroom when they ask. If they happen to ask during a mealtime and the other aide on the floor is in a resident's room, she apologizes and lets the resident know she cannot leave the dining room unattended and tells them as soon as the other aide comes back she will take the resident to the bathroom. CNA #400 stated she has never told a resident to just go in your brief. As to the allegation of CNA #400 just sitting at the table, its because you can see everything especially the television area where there is also a door. CNA #400 stated they do have a resident that can not have anything by mouth and on occasion one of the residents likes to share snacks with this said resident.Review of CNA #400's timecard noted time entries on 12/02/25 from 7:00 A.M. to 2:45 P.M, 12/03/25 from 7:00 A.M. to 3:00 P.M. , 12/04/25 from 7:00 A.M. to 3:00 P.M., and 12/05/25 7:00 A.M. to 5:30 P.M.Review of a progressive disciplinary action form dated 12/03/25 noted CNA #400 received a final warning. Details revealed the employee had been observed using her cell phone multiple times in resident care areas while on clock, violating facility policy. The discipline also referenced CNA #400 having an unprofessional demeanor toward staff and residents on multiple occasions and reports indicating inappropriate or disrespectful demeanor towards co-workers and/or residents including tone of voice, attitude, or behavior inconsistent with facilities standards for resident care along with failure to complete assigned duties and tasks for residents.Review of CNA #401 timecard noted time entries on 12/01/25 from 7:00 A.M. to 7:15 P.M., 12/02/25 from 7:15 A.M. to 3:15 P.M., 12/04/25 from 10:30 A.M. to 11:30 A.M , 12/06/25 from 7:00 A.M. to 7:15 P.M. Review of a progressive disciplinary action form dated 12/04/25 noted CNA #401 received a verbal warning. Details revealed CNA #401 was on cell phone while in resident care areas.On 02/27/26 at 11:40 A.M. interview with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Human Resources Director #200 verified when Activity Assistant submitted written allegations no investigation was documented and the state agency was not notified of the allegations.Review of facility Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy dated 2016. All incident and allegations of Abuse, Neglect, Exploitation, Mistreatment of a resident, or misappropriation of resident property and all injuries of unknown source must be immediately reported to the administrator or designee. The Administrator of his/her designee will notify the state survey agency of all alleged violations involving of Abuse, Neglect, Exploitation, Mistreatment of a resident, or misappropriation of resident property and all injuries of unknown source as soon as possible, but no later than twenty-four (24) hours from the time of the incident/allegation was made known to the staff member. Once the administrator and state survey agency is notified, an investigation of the allegation violation will be conducted. If a staff member is accused or suspected of Abuse, Neglect, Exploitation, Mistreatment of a resident, or misappropriation of resident property. The facility should immediately remove the staff member from the facility and the schedule pending the outcome of the investigation. Documentation in then nurses notes should include results of the residents assessment, notification of the physician and resident representative, and any treatment provided. The investigation must be completed within five (5) working days. Investigation protocol included; Interview the resident, the accused, and all witnesses. Witnesses generally include anyone who witnessed or heard the incident; came in close contact with the resident and/or the alleged victim the day of the incident. Obtain a statement from the resident, if possible, the accused, and each witness. Review the residents records. Evidence of the investigation should be documented. This deficiency represents non-compliance investigated under Complaint Number 2715158.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on resident interview, staff interview, review of facility self-reported incident (SRI), review of electronic medical record (EMR), and review of facility policy, the facility failed to ensure residents were free from verbal abuse. This affected one resident (#30) of three residents reviewed for abuse. The facility census was 70.' Findings Include: Review of the EMR for Resident #30 revealed an admission date of 08/05/24, with diagnoses including type two diabetes, hypothyroidism, anxiety disorder, atrial fibrillation, and hypertension. Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #30 was cognitively intact. Resident #30 was dependent upon staff for toileting, showering/bathing, dressing, and transfers. Review of the facility SRI revealed that on 09/13/25 Resident #30 reported Certified Nursing Assistant (CNA) #401 was verbally abusive to her while assisting her with toileting. CNA #401 told Resident #30 to, Hurry up and pee because she had other people to take care of. Further review of the SRI revealed after investigation, the facility substantiated the verbal abuse from CNA #401 to Resident #30. CNA #401 was suspended on 09/13/25 and was terminated on 09/16/25 after the investigation was completed. Interview on 12/29/25 at 11:32 A.M. with Resident #30 revealed on 09/13/25, while assisting her with toileting, CNA #401 told Resident #30 to, hurry up and finish on the bedpan, so I can get you cleaned up. I have more people to take care of. Resident #30 stated she felt this comment was verbally abusive and caused her mental anguish. Interview on 12/29/25 at 12:10 P.M. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #108 verified the facility substantiated the verbal abuse allegations made by Resident #30 about CNA #401 on 09/13/25. The DON stated CNA #401 was immediately suspended and subsequently terminated upon completion of the investigation. Review of the undated facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, revealed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Abuse also includes deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology, such as through the use of photographs or recording device to demean or humiliate a resident. The deficient practice was corrected on 10/01/25 when the facility implemented the following corrective actions: On 09/13/25 CNA #401, the alleged perpetrator, was suspended pending the facility investigation results. On 09/15/25 Resident #30 was interviewed regarding this incident. On 09/15/25 all residents in the facility were interviewed to determine if they had experienced abuse of any kind. On 09/15/25 all staff received education from the DON and ADON #108 on abuse policies. On 09/16/25, upon completion of the facility investigation, CNA #401 was terminated from the facility. On 09/17/25 five residents were monitored and interviewed for abuse of any kind with none being identified. On 09/24/25 five residents were monitored and interviewed for abuse of any kind with none being identified. On 10/01/25 this incident was reviewed by the Quality Assurance (QA) Committee. Interviews on 12/29/25 with CNA's #158, #162, #176, and #198, Licensed Practical Nurses (LPNs) #127 and #157, and Registered Nurses (RNs) #131 and #400, revealed staff were able to identify types of abuse and procedures for abuse allegations. They all reported they received training on abuse policies and procedures. On 12/29/25 Resident #30 and two additional residents (#32 and #35) were sampled and reviewed for abuse. No other concerns were identified. On 12/29/25, review of the facility's SRI's revealed there were no further concerns identified regarding abuse. This deficiency represents non-compliance investigated under Complaint Number 2620684.

Based on observation, resident interview, medical record review, staff interview, and review of facility policy, the facility failed to ensure skin treatments were completed per physician order. This affected one (#48) of three residents reviewed for wound treatments. The facility census was 71.Findings include:Review of the medical record for Resident #48 revealed an admission of 02/12/25. Diagnoses included morbid obesity, psoriasis vulgaris, seborrheic dermatitis, and Type I diabetes mellitus.Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/09/25, revealed Resident #48 had intact cognition. Resident #48 required moderate assistance with Activities of Daily Living (ADLs). Review of the care plan dated 03/03/23 revealed Resident #48 was at risk for chronic cellulitis. Interventions included to cleanse areas daily with soap and water and dry thoroughly. Further review of the care plan revealed Resident #48 had actual ADL self-care performance deficits and was at risk for incontinence secondary to impaired mobility, generalized weakness, and fatigue. Interventions included monitoring skin during care. Additionally, Resident #48 was at risk for potential skin breakdown related to morbid obesity, lymphedema, and cellulitis. Resident #48 had a diagnosis of psoriasis vulgaris and seborrheic dermatitis. Interventions included documenting any refusals of treatment and completing treatments as ordered.Review of the physician orders revealed an order 02/29/25 for ketoconazole external cream 2%, apply to body topically every four days for psoriasis, apply small amount during shower. Further review revealed an order dated 03/03/25 for miconazole external powder 2% (anti-fungal), apply to folds and groin topically every day and evening shift for excoriation. Lastly, Resident #48 had an order dated 07/09/25 for triamcinolone acetonide external cream 0.1%, apply topically to affected areas every day and evening shift for plaque psoriasis.Review of the Treatment Administration Record (TAR) from 09/01/25 through 09/08/25 revealed Resident #48's ketoconazole external cream, miconazole external powder, and triamcinolone acetonide external cream were documented as administered as ordered. Interview on 09/08/25 at 2:29 P.M. with Resident #48 revealed she completed her own skin treatments, including ketoconazole external cream, miconazole external powder, and triamcinolone acetonide external cream. Resident #48 stated she had been out of the treatments for three days and had told nursing staff.Interview on 09/08/25 at 3:27 P.M. with Licensed Practical Nurse/Unit Manager (LPN/UM) #528 confirmed Resident #48 applied ketoconazole external cream, miconazole external powder, and triamcinolone acetonide external cream herself, and the treatments were left in the room. LPN/UM #528 verified that Resident #48 did not have an order to self-administer her treatments or keep treatments at bedside. LPN/UM #528 confirmed the treatments were signed off as completed on the TAR; however, LPN/UM #528 stated the treatments had not been available for a long time and were not available in the medication cart. Review of the facility policy titled, Medication Administration-General Guidelines, dated 03/20/18 revealed medications were administered in accordance with written orders of the attending physician.This deficiency represents non-compliance investigated under Complaint Number 1357196.

Based on observation, staff interview, medical record review and review of the facility policy, the facility failed ensure medications were properly stored. This affected one (#48) of three residents reviewed for medication storage. The facility census was 71.Findings include:Review of the medical record for Resident #48 revealed an admission date of 02/12/25. Diagnoses included morbid obesity, chronic respiratory failure with hypoxia, and Type I diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/09/25, revealed Resident #48 had intact cognition. Resident #48 required moderate assistance with Activities of Daily Living (ADLs). Review of the care plan dated 03/03/23 revealed Resident #48 had chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and a history of chronic respiratory failure with hypoxia. Interventions included monitoring for difficulty with breathing and give aerosol medication as ordered.Review of the physician orders revealed Resident #48 had an order dated 02/17/24 for fluticasone propionate nasal suspension 50 micrograms (mcg) per actuation (act), two sprays in both nostrils one time a day for allergies. Further review revealed Resident #48 did not have an order to self-administer medications or for medications to be left at bedside.Review of the Medication Administration Record (MAR) for 09/10/25 revealed Resident #48 received fluticasone propionate during morning medication administration.Interview on 09/08/25 at 2:29 P.M. with Resident #48 revealed nurses often left her medication on the bedside table.Observation on 09/10/25 at 8:58 A.M. of Resident #48's bedside table revealed a bottle of fluticasone propionate nasal suspension 50 mg/act with the prescription box next to the bottle. Further observation revealed the resident's name was on the box. Resident #48 was not in the room at the time of the observation. Interview on 09/10/25 at 8:59 A.M. with Licensed Practical Nurse (LPN) #704 revealed she administered Resident #48's morning medications. LPN #704 confirmed the fluticasone propionate was left on the bedside table, and further confirmed Resident #48 did not have a physician's order to self- administer medication or for medications to be left at bedside.Review of the facility policy titled, Medication Administration-General Guidelines, dated 03/20/18, revealed residents were allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medication. This deficiency represents non-compliance investigated under Master Complaint Number 1357285 (OH00167097) and Complaint Number 1357196 (OH00166824).

Based on resident interview, staff interview, medical record review, and review of facility policy, the facility failed to ensure accurate Treatment Administration Records (TARs). This affected one (#48) of three residents reviewed for accurate medical records. The facility census was 71.Findings include:Review of the medical record for Resident #48 revealed an admission of 02/12/25. Diagnoses included morbid obesity, psoriasis vulgaris, seborrheic dermatitis, and Type I diabetes mellitus.Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/09/25, revealed Resident #48 had intact cognition. Resident #48 required moderate assistance with Activities of Daily Living (ADLs). Review of the care plan dated 03/03/23 revealed Resident #48 was at risk for chronic cellulitis. Interventions included to cleanse areas daily with soap and water and dry thoroughly. Further review of the care plan revealed Resident #48 had actual ADL self-care performance deficits and was at risk for incontinence secondary to impaired mobility, generalized weakness, and fatigue. Interventions included monitoring skin during care. Additionally, Resident #48 was at risk for potential skin breakdown related to morbid obesity, lymphedema, and cellulitis. Resident #48 had a diagnosis of psoriasis vulgaris and seborrheic dermatitis. Interventions included documenting any refusals of treatment and completing treatments as ordered.Review of the physician orders revealed an order dated 02/29/25 for ketoconazole external cream 2%, apply to body topically every four days for psoriasis, apply small amount during shower. Further review revealed an order dated 03/03/25 for miconazole external powder 2% (anti-fungal), apply to folds and groin topically every day and evening shift for excoriation. Lastly, Resident #48 had an order dated 07/09/25 for triamcinolone acetonide external cream 0.1%, apply topically to affected areas every day and evening shift for plaque psoriasis.Review of the Treatment Administration Record (TAR) from 09/01/25 through 09/08/25 revealed Resident #48's ketoconazole external cream, miconazole external powder, and triamcinolone acetonide external cream were documented as administered as ordered. Interview on 09/08/25 at 2:29 P.M. with Resident #48 revealed she completed her own skin treatments, including ketoconazole external cream, miconazole external powder, and triamcinolone acetonide external cream. Interview on 09/08/25 at 3:27 P.M. with Licensed Practical Nurse/Unit Manager (LPN/UM) #528 confirmed Resident #48 applied ketoconazole external cream, miconazole external powder, and triamcinolone acetonide external cream herself, and the treatments were left in the room. LPN/UM #528 verified that nursing staff did not know if the resident applied the treatments or not and did not have an order to self-administer her treatments or keep treatments at bedside. LPN/UM #528 confirmed the treatments were signed off by nursing staff as completed on the TAR, including today; however, LPN/UM #528 stated the treatments were not available in the medication cart. Review of the facility policy titled, Medication Administration - General Guidelines, revised 03/20/18, revealed topical medications used in treatments were listed on the TAR. Further review revealed the individual who administered the medication dose recorded the administration directly after the medication was given. This deficiency represents noncompliance investigated under Master Complaint Number 1357285 (OH00167097).

Based on observation, medical record review, staff interview, review of a facility investigation including written statements, review of facility camera footage, hospital documentation review, review of a manufacture operating manual, and facility policy review, the facility failed to ensure specialized chairs were utilized in a safe and proper manner to prevent injuries. Actual Harm occurred when Resident #01 was placed in a Broda chair (a supportive positioning chair which allows residents to tilt and recline) equipped with caster type wheels and Resident #01 was left unattended while seated in the chair, which was not assessed for use, with the caster wheels unlocked. Resident #01 proceeded to lean forward and fell from the chair resulting in the resident sustaining serious injuries including a skin tear to the right forearm, a displaced fracture of the distal right femur, and a fracture through the proximal tibia metadiaphysis and fibular neck, subsequently requiring surgical repair. This deficient practice affected one (#01) of three sampled residents reviewed for fall prevention and assistive device use in a facility census of 69. Findings include: Review of the medical record revealed Resident #01 was admitted to the facility on [DATE]. Diagnoses included dementia, cataract, hypertension, congestive heart failure, cerebral infarction, major depressive disorder, atrial fibrillation, anxiety disorder, sick sinus syndrome, cardiac pacemaker, right femur fracture, left tibia fracture, muscular dystrophy, and rheumatoid arthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #01 was assessed with severe cognitive impairment, was dependent on staff for the completion of activities of daily living (ADLs) including transfers, utilized a wheelchair for mobility propelled by staff, was incontinent of bowel and bladder, and had no recorded falls. Review of a fall risk assessment dated [DATE] revealed Resident #01 was at high risk for falling. Review of Resident #01's falls risk care plan dated 05/16/22 revealed Resident #01 was at risk for falls related to fall history, gait or balance, muscular dystrophy, and impaired cognition due to dementia. Interventions included staff education, therapy screening, staff to anticipate the resident's needs, place frequently used items in reach, apply nonskid footwear as the resident allows, provide assistance with ambulation, toileting, and transfers as needed, use an alarm while the resident was in a chair and check placement and function each shift, and use proper turning and transfer technique when assisting the resident. Further review revealed no intervention to include Resident #01 was able to utilize a Broda chair. Review of a nursing progress note dated 11/18/24 at 5:34 P.M. revealed Registered Nurse (RN) #300 was called by a certified nurse aide (CNA) from the memory care unit and was informed Resident #01 had an unwitnessed fall. RN #300 went to the memory care unit and saw the resident on the floor slightly on her side and the resident's head was supported by a CNA. RN #300 checked Resident #01's vital signs and obtained a blood pressure of 132/82 millimeters of mercury (mmHg), a pulse rate of 79 beats per minute, an oxygen saturation level of 97 percent (%), and a temperature of 97.3 degrees Fahrenheit (F). Resident #01 was asked if she had any pain and the resident verbalized pain to her head, hips, and bilateral lower extremities. The resident was moaning in pain. Resident #01 was observed with a skin tear on the right forearm with no other open wounds identified. RN #300 contacted a certified nurse practitioner (CNP) and ordered for Resident #01 to be sent to the emergency room (ER) for evaluation. Emergency medical services (EMS) were called and when EMS arrived the staff safely transferred Resident #01 from the floor to the stretcher. Resident #01's Durable Power of Attorney (DPOA) agreed for the resident to be sent to hospital and report was given to the ER. Review of Resident #01's hospital documentation dated 11/18/24 noted an was x-ray performed in the hospital and revealed a displaced fracture of the distal right femur (upper leg bone) and a fracture through the proximal tibia metadiaphysis and fibular neck (lower leg bones). On 11/19/24, Resident #01 underwent surgical repair which included left tibial surgical internal fixation and right femur intramedulary nail retrograde placement. Review of CNA #200's written statement dated 11/18/24 noted CNA #200 and CNA #201 were walking back after answering a call light when they saw Resident #01's chair tipping. CNA #201 rushed to Resident #01 while CNA #200 called the nurse. Review of CNA #201's written statement dated 11/18/24 revealed CNA #200 and CNA #201 were walking back to the main dining area on the memory care unit when they saw Resident #01's chair tipping. CNA #201 rushed to Resident #01 while CNA #200 called the nurse. On 12/11/24 at 8:17 A.M., interview with CNA #200 revealed on 11/18/24 she assumed care in memory unit at 3:00 P.M. Resident #01 was seated in a Broda chair with her feet elevated halfway up. At an unknown time, CNA #200 and CNA #201 went to a resident room located outside the view of the memory care unit dining room. The CNAs entered Resident #03's room located at the end of the hall. Both CNAs were in the room approximately four (4) minutes and when exiting with CNA #201, observed Resident #01 rocking and proceeded to tip the Broda chair forward. Both CNAs attempted to prevent the resident from falling forward, but were too late and Resident #01 fell to the floor. The Broda chair was tipped on the front two wheels and the footrest. Resident #01 was lying on her side on the floor. CNA #201 stayed with the resident while CNA #200 called the nurse (RN #300) for assistance. Observation and interview on 12/11/24 at 8:55 A.M. with the Director of Nursing (DON), during review of facility camera footage, revealed on 11/18/24 at 3:15 P.M. Resident #01 was seated in the memory care unit dining room. Resident #01 was seated in a Broda chair with the footrest partially lowered. At 3:52 P.M., CNA #200 and CNA #201 left the memory care unit dining room, and at 3:54:53 P.M. Resident #01 was noted to be alone and unattended in memory care dining room in the Broda chair. Resident #01 then leaned back and proceeded to lean forward over her legs. The Broda chair tipped forward and Resident #01 fell to the floor with the chair tipping onto footrest and front wheels. The DON verified the rear wheels were observed to be spinning and unlocked. Both CNAs were observed running into the dining room while the resident was falling forward. On 12/11/24 at 11:32 A.M. an additional interview with CNA #200, during observation of the Broda chair, noted the chair was equipped with four caster wheels with locking mechanisms. CNA #200 sat in the chair with the caster wheels unlocked and proceeded to move her upper body over her legs. The Broda chair was noted to tip forward and CNA #200 placed her foot to the floor to prevent tipping over. CNA #200 stated when Resident #01 was sitting in the Broda chair the wheels were unlocked due to concern of the chair being a restraint. On 12/11/24 at 11:40 A.M. an additional interview with the DON, during review of the Broda chair operating manual, confirmed there was no evidence contained in Resident #01's medical record indicating the Broda chair was assessed for proper use and the chair wheels where locked when Resident #01 was left unattended in the chair on 11/18/24. Review of an undated Broda chair operating manual revealed the resident's primary caregiver was responsible for ensuring that anyone who was unfamiliar with, unwilling, or unable to adhere to the safety and operating instructions, was not permitted to operate or move the chair. After a resident was transferred into the chair, assess the amount of tilt required. It was recommended that when a resident had been moved to their destination, the chair was placed where the resident cannot reach handrails or other objects, fixed or movable. This was to prevent the resident from pulling the chair over or pulling themselves off the seating surface and to prevent the resident from pulling movable objects onto the chair and themselves. It was recommended the chair be used in a supervised area to prevent untrained residents, caregivers, or third parties from unauthorized operation, movement, or unsafe actions such as sitting or leaning on the reclined back, elevated footrest, or the armrests. These actions, if not prevented, put the chair at risk of tipping or damage to the chair. The special casters found on the Broda chair have total lock brakes which prevent the wheels from turning and swiveling. The brakes must always be applied when the chair was not in use, the resident was being transferred (moved) into or out of the chair, and when the chair was not being moved by a caregiver. Review of facility fall management policy, revised 07/31/14, revealed qualified staff assess all residents for fall risk through the nursing assessment form upon admission, quarterly, and with a significant change. The fall risk assessment assists in identifying the appropriate preventative interventions, and that they are recorded on the resident's care plan. If a fall occurs qualified staff immediately investigate the reason and determine the intervention to prevent future falls. Review of the undated fall investigation policy revealed intervention and prevention to include staff training on fall prevention strategies and proper use of assistive devices. This deficiency represents non-compliance investigated under Complaint Number OH00160133.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, resident interview, and facility policy review, the facility failed to ensure a resident was free from physical abuse. This affected two residents (#2 and #3) of three reviewed for abuse. The facility census was 68. Findings include: 1. Review of Resident #2's medical record revealed an admitted [DATE]. Diagnoses included morbid obesity, lymphedema, and chronic pain. Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed intact cognition and the resident had no negative behaviors. Review of Resident #2's care plan revealed she was at risk for mood issues due to a diagnosis of depression and anxiety. Review of Resident #2's progress note dated 11/05/24 revealed an incident happened on 11/02/24 between approximately 12:30 P.M. to 1:30 P.M. The altercation was between two residents (#2 and #3) and unwitnessed by the nurse. When the writer saw the patient, she was wheeling herself inside the building. The nurse asked what happened and the resident verbalized, He called me a fat bitch, referring to the resident involved in the incident. The nurse asked if she did any physical harm to the other resident and she did not admit anything to the writer. The writer advised Resident #2 to stay away from Resident #3 in order to not escalate the situation furthermore. Resident #2 agreed and wheeled self away from the other resident. No further altercation happened within the whole shift. The nurse advised the resident to inform the nurse for any assistance needed. 2. Review of Resident #3's medical record revealed an admitted [DATE]. Diagnoses included morbid obesity, congestive heart failure, and pulmonary edema. Review of Resident #3's MDS assessment dated [DATE] revealed he had an intact cognition and no negative behaviors. Review of Resident #3's care plan revealed the resident was at risk for mood issues related to pain and being in a long term care facility. Review of Resident #3's progress note dated 11/05/24 revealed an altercation occurred between two residents (#2, #3) on 11/02/24 between approximately 12:30 P.M. and 1:30 P.M. The incident was unwitnessed by the nurse. When the nurse arrived to the area of the incident, the nurse asked Resident #3 what happened. Resident #3 explained to the nurse in an angry manner that it started when the materials for a party were placed on the dinner table without them knowing and it interrupted the area that they were using for lunch. Resident #3 informed the nurse that Resident #2 grabbed his left arm and ran her wheelchair into his left lower extremity. At that moment the nurse checked on the resident and no marks, bruises, or wounds were noted. At that time Resident #3 was offered and advised to stay away from the Resident #2 in order not to escalate the situation and he agreed. Resident #3 then wheeled himself inside the building to his room. The nurse offered him to be seen in the emergency room and call authorities, but he verbalized, No it is not needed, but next time I will if this happens again. Resident #3 was checked after an hour while sitting outside and verbalized, I'm feeling better. There was no discomfort at that time. Resident #3 was made aware to call the nurse for any assistance needed. The Certified Nurse Practitioner was made aware. Review of Resident #3's progress note dated 11/05/24 revealed the resident reported to nurse that he had an open area to left lower extremity. The site was assessed and pink drainage was noted. The resident explained that another resident had ran into him with her wheelchair. The site measured 1.5 centimeter (cm) by (x) 1 cm x less than 0.5 cm. The area was cleansed with normal saline, patted dry, and covered with a border dressing. The nurse updated the physician and a new order was received for treatment to cleanse the wound with normal saline, pat dry, and apply a dressing. The resident was made aware. Interview with Resident #2 on 11/22/24 at 8:20 A.M. revealed when she had a party, Resident #3 was bothered and had to make rude comments. She was planning a birthday party on 11/02/24 when Resident #3 became annoyed because the party supplies were on a dining room table which he normally sat at for lunch. He took pictures of the decorations and supplies. After hearing about his taking the photos, Resident #2 confronted Resident #3 outside. After having a verbal confrontation Resident #2 was leaving to return into the building when Resident #3 called her a fat (derogatory word). Resident #2 admitted to grabbing Resident #3's arm and warned him to not call her that again. Resident #3 told her he was going to punch her if she didn't let go of him. At that point staff intervened and requested she return into the facility. Interview with Resident #4 on 11/22/24 at 9:23 A.M. revealed he witnessed the altercation between Residents #2 and #3. He and Resident #2 were in the dining room and activities came in and put boxes on the table where the residents were sitting so they moved into the north dining room. Later he and Resident #3 were outside and Resident #2 came up and asked Resident #3 why he was always (explicit word) with her parties. Resident #3 told her to leave but she came back and ran her wheelchair into Resident #3 and grabbed his arm. The two residents continued to curse at each other. Once the staff came out, Resident #2 let go of Resident #3 and returned inside of the building. Interview with Certified Nurse Aide (CNA) #300 on 11/22/24 at 9:31 A.M. revealed she witnessed the incident between Residents #2 and #3 from inside the facility. She stated she heard a lot of yelling coming from the parking lot and saw the residents in a verbal altercation. Then Resident #2 grabbed Resident #3's arm and would not let go. Another CNA intervened and separated the residents. Management then arrived on the scene. Interview with Resident #3 on 11/22/24 at 10:03 A.M. stated he was outside and he saw saw a couple aides push a cart and one carrying party supplies into the facility for Resident #2. Those items were placed on the dining room table where he sat. Resident #2 was asked by activities to move to another table. The Resident Council rules state that nothing can be decorated during meal times. If there was a party or event the staff must wait until after a meal service to set up. Resident #3 then took a picture on his phone of the hot plates and supplies as it was before 1:00 P.M. After lunch he and Resident #4 went outside. Resident #2 came over to him and she was screaming and cussing. Resident #3 informed her to go back inside the building. Resident #2 then ran her motorized wheelchair into Resident #3's leg which took skin off the bottom of his leg. She grabbed his arm and she attempted to stand up. Resident #3 told her to remove her hands from him and she jerked his arm around. Resident #3 threatened to hit Resident #2 if she did not let go of him. Resident #2 scratched his arm in three places with her fingernails. After staff intervened, Resident #2 returned to the building. He was not going to report this to the police until Resident #2 posted statements regarding him on social media. Resident #3 then called the police and filed charges. Interview with Housekeeper #400 on 11/22/24 at 11:03 A.M. revealed she was in the parking lot taking trash out when she heard Resident #2 scream. Resident #2 then took her electric wheelchair and headed toward Resident #3, ran into his left leg, and grabbed his left arm. The CNA from the memory care unit came out and stopped the altercation. Interview with the Director of Nursing (DON) on 11/22/24 at 11:32 A.M. revealed interventions were put into place and both residents were educated on avoiding each other. The Ombudsman also stepped in and spoke to the resident. The physician ordered anger management classes for Resident #2. Daily monitoring, staff education, and resident assessments were completed. Care plans were updated regarding the potential to demonstrate verbal or physical behaviors. Interview with CNA #310 on 11/22/24 at 11:43 A.M. revealed she was working on the memory care unit, which has large windows, and heard the verbal altercation between Residents #2 and #3. The residents were swearing at each other. Resident #2 began leaving the area when Resident #3 called her a derogatory name. At that point Resident #2 ran her motorized wheelchair into Resident #3's left leg and grabbed his left arm. The CNA stated she attempted to get in between the residents and backed up Resident #2's wheelchair by using the joystick. At that time the DON came out to see what was happening and the CNA then moved away from the incident. Review of an email from the local police department dated 11/21/24 revealed there was no police report at that time because it was not completed. The county prosecutor had the information and was was reviewing the case. Review of the Self-Reported Incident (SRI) dated 11/04/24 revealed the facility substantiated abuse and Resident #3 wanted to press charges against Resident #2. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property: dated 2016 revealed abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Windsor Lane Health Care and Rehabilitation Center will not tolerate Abuse, Neglect, Exploitation of it's residents or the Misappropriation of Resident property The deficient practice was corrected on 11/07/24 when the facility implemented the following corrective actions: 11/02/24 Residents #2 and #3 were separated by the DON 11/02/24 Residents were educated on the abuse policy by the DON 11/05/24 Psychiatric Services provided for Resident #2 11/05/24 All staff educated on the abuse policy 11/07/24 and 11/08/24 All resident care plans were updated regarding the potential to demonstrate verbal or physical behaviors This deficiency represents non-compliance investigated under Complaint Number OH00159726.

Based on record review and staff interview, the facility failed to ensure the resident's comprehensive care plan was completed and updated. This affected three (Resident #2 #12, and #25) of 17 residents reviewed for care plans. The facility census was 61. Findings include: 1. Review of Resident #12's medical record revealed an admitted [DATE]. Diagnoses included schizophrenia, psychosis, and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact. He required a wheelchair in which he was independent on moving throughout the facility. Review of the Ohio Sex Offender Search revealed Resident #12 was a registered sex offender due to gross sexual imposition and sexual motivation. Review of Resident #12's most recent care plan revealed it was free from documentation regarding care and intervention of the sex offender. Interview on 07/25/24 at 8:05 A.M. with the Director of Nursing (DON) confirmed Resident #12's comprehensive care plan was incomplete and verified there was no care plan in place for the resident being a sex offender. 2. Review of Resident #25's medical record revealed an admitted [DATE]. Diagnoses included congestive heart failure, coronary artery disease, morbid obesity, and respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was cognitively intact. The resident required the use of a wheelchair and was independent with care and mobility. Review of the Ohio Sex Offender Search revealed Resident #25 was a sex offender related to lewd and lascivious acts with a child 14 to [AGE] years old. Review of Resident #25's most recent care plan revealed it was free from documentation regarding care and interventions for a sexual offender. Interview on 07/25/24 at 8:05 A.M. with the Director of Nursing (DON) confirmed Resident #25's comprehensive care plan was incomplete and verified there was no care plan in place for the resident being a sex offender. 44815 3. Review of the medical record for Resident #2 revealed an admitted [DATE] with a diagnosis of dementia. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had impaired cognition and was dependent on staff for personal hygiene. Review of the current care plan revealed no care area for activities of daily life. Interview on 07/25/24 at 8:05 A.M. with the Director of Nursing (DON) confirmed Resident #2's comprehensive care plan was incomplete and verified there was no care plan in place for activities of life . The DON stated she had been having difficulty with the electronic medical record system, and care plans were not staying updated in resident records

Based on observation, record review, resident and staff interview, and policy review, the facility failed to assess and monitor the resident's skin conditions. This affected two (Residents #15 and #50) of two residents reviewed for skin conditions. The facility census was 61. Findings include: 1. Review of Resident #15's medical record revealed an admitted [DATE]. Diagnoses included muscular dystrophies, congestive heart failure, morbid obesity, and cerebral vascular accident. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15's cognition was intact. The resident required substantial assistance to move from lying to sitting on the side of the bed. Review of Resident #15's most recent care plan revealed he was at risk for uncontrolled bleeding due to anticoagulant therapy and the potential for skin breakdown related to morbid obesity. Interventions included a weekly skin assessment and observation during care. Review of Resident #15's Weekly Skin Observation sheets dated 06/21/24, 06/28/24, 07/05/24, 07/13/24, and 07/19/24 revealed the resident's skin was clean, dry and intact. Observation of Resident #15's skin on 07/24/24 at 10:50 A.M. revealed the resident had a large red and scabbed area to the left lower shin. The affected area was approximately 12 inches long and four inches wide. It was dark red and had several rounded scabbed areas to the skin. Interview with Assistant Director of Nursing (ADON) #208 on 07/24/24 at 10:55 A.M. revealed Resident #15's medical record was absent of documentation regarding redness to the left lower extremity which included the Weekly Skin Observations. Interview with Resident #15 on 07/24/24 at 10:57 A.M. revealed the left lower extremity had been red and scabbed for a long time. 44815 2. Review of the medical record for Resident #50 revealed an admitted [DATE]. Diagnoses included chronic respiratory failure, anxiety, and calculus of ureter. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had intact cognition. Review of the consultant wound care note dated 06/19/24 revealed Resident #50 had a new wound to her right buttock identified as moisture-associated skin damage (MASD). Review of a nursing progress note dated 06/26/24 revealed the wound care nurse determined the left buttock was healed and identified a new area to the right buttocks. The wound care nurse began a treatment to the right buttock. Review of the Weekly Skin Observation assessments dated 07/05/24, 07/12/24, and 07/20/24 revealed Resident #50's skin had no wounds and her skin was clean, dry, and intact. Interview on 07/22/24 at 3:07 P.M. with Resident #50 revealed she had wounds on her bottom. Interview on 07/23/24 at 12:33 P.M. with the Director of Nursing (DON) confirmed weekly skin assessments should be completed for all skin concerns. Observation and interview on 07/24/24 at 7:45 A.M. with Wound Care Nurse Practitioner #291, while she performed wound care on Resident #50, confirmed Resident #50 had ongoing MASD on her right buttock. Interview on 07/24/24 at 12:16 P.M. with the DON confirmed no skin assessments were completed for Resident #50 since 06/26/24 to monitor the progress of the right buttock MASD. The DON further confirmed the Weekly Skin Observations indicating Resident #50's skin was clean, dry and intact did not reflect an accurate assessment of her skin. Review of the facility's undated Weekly Skin Assessment Policy revealed licensed nurses would complete skin assessments every seven days from start of admission to discharge. Nurses will observe any open areas, signs of infection, and any abnormalities. Nurses will ensure treatment is in place for any existing areas.

Based on resident and staff interview, observation, review of the medical record, and review of the facility policy, the facility failed to ensure residents wore smoking aprons as ordered by the physician. This affected one (#5) of two residents reviewed for smoking. The facility census was 61. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE] with a diagnosis of chronic respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition. Review of a current physician order for 07/2024 revealed Resident #5 was required to wear a smoking apron while smoking, initiated on 03/23/23. Review of the most recent Smoking Assessment completed on 01/11/24 revealed Resident #5 no longer smoked. The assessment did not clarify whether Resident #5 could smoke independently. Review of a nursing progress note dated 05/01/24 revealed Resident #5 was reminded to wear a smoking apron when out smoking, Resident #5 was educated on the reasons the smoking apron was needed, and Resident #5 refused to wear a smoking apron. Review of the current care plan for Resident #5 revealed no care area for smoking. Review of the facilities list of residents who smoked provided on 07/22/24 revealed Resident #5 smoked. Interview on 07/22/24 at 2:44 P.M. with Resident #5 revealed she was going outside to smoke. Resident #5 stated she had quit smoking in the past while she was a resident at the facility, but had resumed smoking. Observation and interview on 07/24/24 at 7:23 A.M. with Resident #5 revealed she was getting ready to go outside to smoke. Resident #5 was wearing a blanket over her lap. Resident #5 stated the facility did not offer her a smoking apron, and further indicated she thought the order to wear a smoking apron had been canceled. Interview on 07/24/24 at 8:16 A.M. with the Director of Nursing (DON) confirmed Resident #5 had quit smoking, but started again in the last few months. Observation and interview on 07/24/24 at 10:59 A.M. with Transportation Scheduler #236 confirmed Resident #5 was smoking a cigarette and not wearing a smoking apron. Interview on 07/24/24 at 12:18 P.M. with the DON confirmed Resident #5's order to wear a smoking apron remained active; however, the DON stated the order should have been discontinued. Review of the facilities policy titled Smoking Policy, revised 04/24/24, revealed smoking evaluations would be completed for residents upon admission, change of condition, and annually.

Based on observation, record review, and staff and resident interview, the facility failed to ensure residents received high protein nutritional supplementation per dietary's recommendations. This affected one (#16) of three residents reviewed for nutrition. The facility census was 61. Findings include: Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses of type II diabetes mellitus, morbid obesity, and irritable bowel syndrome. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had intact cognition. Review of the current and discontinued orders dated 07/01/24 through 07/24/24 revealed no current or discontinued order for a high-protein nutrition supplement. Review of a nursing progress note dated 07/12/24 revealed Resident #16 received new orders to start a 1,200 kilocalorie (kcal) partial liquid diet. Review of a dietary progress note written by Dietary Manager (DM) #237, dated 07/15/24, revealed DM #237 clarified Resident #16's partial liquid diet order to include a high protein shake with fruit for breakfast, high protein shake with lunch and a yogurt. DM #237 recommended high protein shake, Ensure High Protein, could be substituted for the facility's in-house product, Premier Shake. Interview on 07/22/24 at 8:19 A.M. with Resident #16 revealed she was not receiving the Ensure High Protein shake that was recommended for her. Resident #16 stated she did not like the in-house shake and requested the Ensure High Protein shake from DM #237. Observation on 07/22/24 at 8:28 A.M. revealed Resident #16 received one yogurt on her breakfast tray and no additional food items. The yogurt label indicated it contained 60 kcal and four grams of protein. Interview on 07/23/24 at 4:23 P.M. with DM #237 stated she spoke with Resident #16 who stated she did not like the facility's in-house shake. DM #237 stated Resident #16 did not request an alternative high protein shake. DM #237 stated the kitchen continued to send the in-house high-protein shake to Resident #16. Interview on 07/24/24 at 9:16 A.M. with State tested Nurse Aide (STNA) #250 stated she provided Resident #16 her breakfast tray the morning of 07/24/24 and confirmed the only items on her tray were a yogurt, a napkin and silverware. Observation and interview on 07/24/24 at 12:25 P.M. with STNA #214 revealed Resident #16 received a yogurt and an orange on her lunch tray. STNA #214 confirmed the yogurt label indicated it contained 60 kcals and four grams of protein. Interview and concurrent review of the electronic medical record on 07/24/24 at 12:11 P.M. with the Assistant Director of Nursing (ADON) #208 confirmed Resident #16 did not have an order for a nutrition supplement and confirmed the progress note dated 07/15/24 written by DM #273 indicated Resident #16 should have an order for a high-protein shake with breakfast and lunch meals.

Based on resident interview, record review and staff interview, the facility failed to timely provide a cancer medication to a resident who had a history of cancer. This affected one (#58) of six residents reviewed for medications. The facility census was 61. Findings include: Review of the medical record for Resident #58 revealed a readmitted [DATE] with diagnoses of type II diabetes mellitus and obesity. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 had intact cognition. Review of the hospital paperwork dated 07/07/24, provided to the facility during Resident #58's referral for readmission, revealed Resident #58 had a past medical history of prostate cancer. Review of the fax transmission form dated 07/12/24 revealed a nurse identified as N. Nurse documented Resident #58 had a cancer medication at bedside and requested an order for the medication from the physician. Further review revealed the facility's Nurse Practitioner addressed the request 10 days later on 07/22/24. Review of a progress note dated 07/22/24 at 5:46 P.M. revealed the facility obtained an order for Resident #58 to be administered his home supply of medication. Interview on 07/22/24 at 8:24 A.M. with Resident #58 revealed he had a history of prostate cancer and was prescribed a long term anti-cancer medication prior to his admission. Resident #58 stated the medication was delivered to his house and he brought it to the facility upon readmission 07/11/24. Resident #58 stated the facility took it from him and stated they would speak with the physician to obtain an order for him to receive it at the facility. Resident #58 had not received the medication since they removed it from his room shortly after readmission. Resident #58 then stated his wife planned to call the doctor who prescribed the medication later that day to have him send over a prescription. Subsequent interview on 07/24/24 at 7:51 A.M. with Resident #58 confirmed he was receiving his cancer medication. Resident #58 stated he was unhappy he had to wait to receive his medication since admission on 07/11/24 until 07/23/24. Interview on 07/24/24 at 3:00 P.M. with Assistant Director of Nursing (ADON) #208 confirmed the request for an order for Resident #58's prostate cancer medication dated 07/12/24 was not addressed until 07/22/24 and the order for Resident #58's medication order was initiated on 07/23/24.

Based on review of the medical record, resident and staff interview, and policy review, the facility failed to timely arrange dental services for a resident. This affected one (#56) of three residents reviewed for dental services. The facility census was 61. Findings include Review of the medical record revealed Resident #56 had an admitted [DATE]. Diagnoses included morbid obesity with alveolar hypoventilation, atrial fibrillation, and chronic respiratory failure with hypoxia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had intact cognition. Review of the care plan initiated 04/27/23 revealed Resident #56 had dental problems related to poor oral hygiene. Interventions included to coordinate arrangements for dental care, transportation as needed/as ordered and provide mouth care as per the activities of daily living personal hygiene. Review of a dental note dated 06/28/24 revealed the resident needed extraction of two teeth and would need an oral surgeon to extract the teeth. Review of the medical record from 06/28/24 through 07/23/24 revealed no documentation an appointment was set up with the oral surgeon. Interview on 07/22/24 at 12:07 P.M. with Resident #56 revealed the dentist told her she needed two teeth pulled and needed an appointment with an oral surgeon but the facility had not made the appointment. Interview on 07/22/24 at 2:00 P.M. with the Director of Nursing (DON) verified an appointment had not been made for Resident #56. The DON revealed the facility had attempted to contact three dentists who could not accommodate the resident's size in their offices. The DON revealed the facility would probably need to contact a general surgeon to remove the teeth. Interview on 07/23/24 at 9:05 A.M. with Transportation Staff (TS) #236 stated she had called three oral surgeons who could not extract the resident's teeth. TS #236 verified she had not attempted to call a general surgeon. Review of the undated policy Dental Services revealed the facility would assist resident in obtaining routine and emergency dental care.

Based on review of the facility policy, observation, record review, and staff interview, the facility failed to ensure residents received diets as ordered and failed to provide diets as recommended by the registered dietitian. This affected three (#10, #17, and #26) of six residents reviewed for food. The facility census was 61. Findings include: 1. Review of the medical record for Resident #10 revealed an admitted [DATE] with a diagnosis of kidney failure. Review of the Brief Interview for Mental Status (BIMS) dated 05/31/24 revealed Resident #10 had moderately impaired cognition. Review of a physician order dated 05/30/24 revealed Resident #10 received a no-added salt, no concentrated sweets diet with double protein, regular texture food with nectar thickened liquids. Observations in the kitchen on 07/23/24 beginning at 11:53 A.M. revealed [NAME] #227 plating meals. [NAME] #227 plated one scoop of spaghetti for residents who received standard portions. [NAME] #227 proceeded to plate Resident #10's plate and scooped one scoop of spaghetti onto the plate. [NAME] #227 handed the plate the dietary aide who covered the plate and began to place it in the tray cart. Interview with [NAME] #227 confirmed Resident #10 should receive double protein portions, and further confirmed she did not provide double protein portions to Resident #10. [NAME] #227 asked the dietary aide to put cheese on the tray for additional protein. 2. Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses of type II diabetes mellitus and dementia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had impaired cognition. Review of a physician order dated 08/20/21 revealed Resident #26 received a no-added salt, no concentrated sweets diet with high protein. Continuous observation during meal service on 07/22/24 beginning at 12:03 P.M. revealed STNA #286 removing meal trays from the tray cart and providing the trays to residents. STNA #286 provided two trays to residents before removing Resident #26's tray from the cart. Observation of all three trays revealed each resident received ham and potato casserole as the main dish. Resident #26 received ham and potato casserole as the main dish in the same portion as other residents. Resident #26's tray ticket indicated she should receive a double protein portion. Interview with STNA #286 during the observation confirmed the ticket indicated Resident #26 should receive a double protein portion and the portion on Resident #26's tray was the same size as the portion on the other residents' trays who did not receive double portions. 3. Review of Resident #17's medical record revealed an admitted [DATE]. Diagnoses included chronic respiratory failure, morbid obesity, atrial fibrillation, congestive heart failure, lymphedema, and congestive heart failure. Review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required a therapeutic diet. Review of Resident #17's most recent care plan revealed the registered dietitian (RD) was to evaluate and adjust the diet as appropriate and therapeutic diet orders were to be completed due to being a nutritional risk related to diabetes and morbid obesity. Review of the RD's note dated 12/02/23 revealed the resident had a body mass index of 83 and required 100 to 110 grams of protein per day. Review of Resident #17's physician order dated 06/22/24 revealed she was on a fluid restrictive diet. The diet was to be no added salt and no concentrated sweets. The orders were absent of the required protein. Review of the Dietician Delayed Menu Cycle Nutritional Analysis revealed the residents received 588.7 grams of protein per week. Resident #17 had RD recommendations of 700 to 770 grams of protein per week. Telephone interview with RD #290 on 07/24/24 at 12:52 P.M. verified Resident #17 failed to receive the weekly amount of protein per her diet needs. Review of the facility policy titled Nutrition Service Standards of Practice dated April 2004 revealed the Nutritional Service Coordinator (NSC)/Consult Dietician prepares a list of clinical recommendations at each visit and discusses with the Nutritional Service Director and/or Nursing. The NSC/Dietician Consult prepares a report for the Administrator at least monthly that outlines their activities, findings, and recommendations. The NCS/Dietician Consult reviews the items identified on the report with the Administrator and Nutrition Service Director in an exit interview. The Administrator and Nutrition Service Director acknowledge and/or act on the NSD recommendations as evidenced by a written response to the NSC report or notations to the original report.

Based on observation, resident and staff interviews, and record review, the facility failed to ensure residents received thickened fluids as physician ordered. This affected one (#10) of six residents reviewed for food. The facility census was 61. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE] with a diagnosis of kidney failure. Review of the Brief Interview for Mental Status (BIMS) dated 05/31/24 revealed Resident #10 had moderately impaired cognition. Review of a physician order dated 05/30/24 revealed Resident #10 received a no-added salt, no concentrated sweets diet with double protein, regular texture foods and nectar thickened liquids. Observation on 07/23/24 at 8:39 A.M. revealed Resident #10 eating breakfast in his room. Resident #10 had a carton of milk with his breakfast. The milk appeared to be unthickened. Additionally, a pitcher of water was on Resident #10's tray table and the water appeared unthickened. Resident #10 provided a tray card from his garbage can dated 07/20/24 for a breakfast meal. Review of the tray card revealed Resident #10 should receive nectar thickened liquids. Observation and interview on 07/23/24 at 12:17 P.M. with Speech Therapist (ST) #289 during Resident #10's noon meal revealed Resident #10 eating lunch in his room with his meal tray on his tray table. Resident #10 had a bottle of water that was approximately one-fourth full and a second pitcher of water with approximately 600 milliliters (ml) of water in it on the tray table. ST #289 confirmed both bottles of water were not thickened to nectar thick consistency and therefore were not appropriate for Resident #10. ST #289 confirmed she was familiar with Resident #10 and confirmed Resident #10 was at risk for choking with unthickened liquids. Concurrent interview with Resident #10 confirmed he drank some of the unthickened water.

Based on record review and staff interview, the facility failed to ensure the resident care plans were timely updated. This affected three (Residents #5, #10, and #46) of 17 residents reviewed for care plan. The facility census was 61. Findings include: 1. Review of Resident #46's medical record revealed an admitted [DATE]. Diagnoses included morbid obesity and bariatric surgery on 05/23/24. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 had a high cognitive function. Review of the physician order dated 04/25/24 revealed Resident #46 had a order for high protein Slim Fast shakes or Ensure high protein nutrition shakes five times a day and a clear liquid diet. Review of Resident #46's care plan revealed he was at risk for non-compliance with his diet due to morbid obesity, diabetes mellitus, and hypertension. The care plan was absent of bariatric surgery nor requirement of a high protein diet. Interview with the Dietary Manager #237 on 07/23/24 at 4:32 P.M. revealed Resident #46 began to receive the high protein shakes post bariatric surgery in April 2024. Interview with the Assistant Director of Nursing (ADON) #208 on 07/24/24 at 2:03 P.M. verified the facility failed to update Resident #46's care plan regarding the physician's orders for high protein shakes nor the bariatric surgery. 44815 2. Review of the medical record for Resident #5 revealed an admitted [DATE] with a diagnosis of chronic respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition. Review of the Smoking assessment dated [DATE] revealed Resident #5 no longer smoked. The assessment did not clarify whether Resident #5 could smoke independently. Review of the current care plan for Resident #5 revealed no care area for smoking. Review of the list of residents who smoked provided by the facility on 07/22/24 revealed Resident #5 smoked. Interview on 07/22/24 at 2:44 P.M. with Resident #5 revealed she was going outside to smoke. Interview on 07/24/24 at 8:16 A.M. with the Director of Nursing (DON) confirmed Resident #5 had quit smoking, but started again in the last few months. Follow-up interview with the DON on 07/24/24 at 8:40 A.M. confirmed Resident #5's smoking assessment dated [DATE] did not reflect her current smoking status, and Resident #5's care plan did not include smoking. 3. Review of the medical record for Resident #10 revealed an admitted [DATE] with a diagnosis of kidney failure (05/27/24). Review of the Brief Interview for Mental Status (BIMS) dated 05/31/24 revealed Resident #10 had moderately impaired cognition. Review of the current care plan revealed no indication Resident #10 received hemodialysis (HD). Interview on 07/22/24 at 11:30 A.M. with the Director of Nursing (DON) revealed Resident #10 was the only resident in the facility who received HD. Subsequent interview on 07/23/24 at 3:31 P.M. and 3:43 P.M. with the DON revealed Resident #10 began HD on 06/12/24. The DON confirmed Resident #10's care plan did not reflect he received HD.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure the resident's nutritional and hydration needs were assessed and monitored after beginning on dialysis and collaborated with the hemodialysis center. This affected one (#10) of three residents reviewed for nutrition. The facility census was 61. Findings include: Review of the medical record for Resident #10 revealed an admitted [DATE] with a diagnosis of kidney failure (05/27/24). Review of the Brief Interview for Mental Status (BIMS) dated 05/31/24 revealed Resident #10 had moderately impaired cognition. Review of a nutrition progress note dated 05/23/24 revealed Resident #10 was hospitalized to establish dialysis. Review of a nutrition progress note dated 05/29/24 revealed Resident #10 was readmitted to the facility. RD #290 recommended a no concentrated sweets (NCS), no added salt diet (NAS) and thickened liquids to continue. RD #290 did not indicate in his note whether Resident #10 should continue to receive double protein portions. No additional assessment or review of Resident #10's condition was documented. No further nutrition progress notes were documented regarding Resident #10 receiving hemodialysis (HD). Interviews on 07/22/24 at 11:30 A.M. with the Director of Nursing (DON) revealed Resident #10 was the only resident in the facility who received HD. On 07/23/24 at 3:31 P.M., the DON stated she called Resident #10's HD clinic to determine Resident #10 began HD on 06/12/24. Telephone interview on 07/24/24 at 12:46 P.M. with Registered Dietitian (RD) #290 revealed he was the RD for the facility for more than [AGE] years and was in the facility every few weeks. RD #290 confirmed the comprehensive nutrition assessments he completed were documented in the progress notes. RD #290 stated he reviewed each resident's medical record before making his assessment; however, RD #290 stated he only documented the pertinent information in his note. RD #290 confirmed residents who begin HD have altered nutritional needs. RD #290 confirmed he did not reassess Resident #10's estimated nutrition needs because RD #290 felt a NCS, NAS diet would meet Resident #10's needs after beginning HD. RD #290 stated he expected the double protein portions would continue although he did not specify they should in his progress note on 05/29/24. RD #290 revealed he coordinated care with the HD clinic solely by reviewing Resident #10's laboratory tests, and at the point of the interview, RD #290 had not received any laboratory tests from the HD clinic and therefore had not coordinated care with the HD clinic since Resident #10 began HD treatments 06/12/24. Review of the facility policy titled Nutrition Service Standards of Practice dated April 2004 revealed the Nutritional Service Coordinator (NSC)/Consult Dietician prepares a list of clinical recommendations at each visit and discusses with the Nutritional Service Director and/or Nursing. The NSC/Dietician Consult prepares a report for the Administrator at least monthly that outlines their activities, findings, and recommendations. The NSC/Dietician Consult reviews the items identified on the report with the Administrator and Nutrition Service Director in an exit interview. The Administrator and Nutrition Service Director acknowledge and/or act on the NSC recommendations as evidenced by a written response to the NSC report or notations to the original report.

Based on review of personnel records, staff interview, and policy review, the facility failed to ensure employee reference checks were completed and failed to complete employee verification in the Ohio Abuse Registry. This had the potential to affect all 61 residents residing in the facility. Findings include: Review of the personnel record for Activity Aide (AA) #211 revealed a hire date of 10/27/23. Further review of the personnel record revealed no verification the employee was checked in the Ohio Abuse Registry. Review of the personnel record for State tested Nursing Assistant (STNA) #272 revealed a hire date of 10/10/23. Further review of the personnel record revealed no reference checks were completed. Review of the personnel record for STNA #214 revealed a hire date of 09/01/23. Further review of the personnel record revealed no reference checks were completed. Review of the personnel record for Housekeeper (HSK) #225 revealed a hire date of 03/21/24. Further review of the personnel record revealed no verification the employee was checked in the Ohio Abuse Registry. Review of the personnel record for Dietary Staff (DS) #264 revealed a hire date of 10/26/22. Further review of the personnel record revealed no verification the employee was checked in the Ohio Abuse Registry. Review of the personnel record for HSK #206 revealed a hire date of 08/14/23. Further review of the personnel record revealed no verification the employee was checked in the Ohio Abuse Registry and no reference checks were completed. Review of the personnel record for Maintenance Staff (MS) #201 revealed a hire date of 04/17/23. Further review of the personnel record revealed no verification the employee was checked in the Ohio Abuse Registry and no reference checks were completed. Review of the personnel record for Admissions Staff (AS) #248 revealed a hire date of 05/06/24. Further review of the personnel record revealed no verification the employee was checked in the Ohio Abuse Registry. Review of the personnel record for Registered Nurse (RN) #202 revealed a hire date of 01/04/24. Further review of the personnel record revealed no verification the employee was checked in the Ohio Abuse Registry. Interview on 07/25/24 at 7:17 A.M., Human Resource Staff (HRS) #212 verified AA #211, HSK #225, DS #264, HSK #206, DS #264, MS #201, AS #248, and RN #202 were not checked in the Ohio Abuse Registry. HRS #212 verified reference checks were not completed for STNA #272, STNA #214, and MS #201. Review of the policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 2016, revealed no guidelines for completing employee reference checks. The facility would check with all applicable licensing and certification authorities to ensure that employees hold the requisite license and/or certification status to perform their job functions and do not have a disciplinary action in effect against his or her professional license by a state licensure agency as a result of a finding of abuse, neglect, exploitation or misappropriation of resident property.

Based on record review and staff interview, the facility failed to follow their procedure to have an adequate emergency water supply for the facility. This had the potential to affect all residents. Facility census was 61. Findings include: Interview with the Director of Nursing and Director of Maintenance #500 on 07/24/24 at 3:36 P.M. verified the facility did not have an emergency water supply on site. The Director of Maintenance stated the emergency water supply was kept off site. Review of the facility's undated policy titled Emergency Water Supply revealed the facility would provide three days of food and water for staff or other persons which will stay at the facility during an emergency. Furthermore, the facility's policy stated the water would be stored in the old assembly hall supply closet.

Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to monitor skin as care planned, complete skin assessments, and monitor a resident's wound. This resulted in actual harm when a diabetic foot ulcer was discovered at an outside podiatrist appointment, which resulted in amputation of the right great toe, eleven days after discovery. This affected one (Resident #47) of three residents reviewed for non-pressure wounds. The facility census was 68. Findings include: Review of the medical record revealed Resident #47 was admitted on [DATE]. Diagnoses included encounter for orthopedic aftercare following surgical amputation, osteomyelitis, end stage renal disease, and type two diabetes mellitus with diabetic polyneuropathy and neuropathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #47 required extensive assistance with dressing and toilet use. Resident #47 was totally dependent for transferring. Resident #47 was dependent for putting on and taking off footwear including socks and shoes, was unable to walk, and utilized a motorized wheelchair. Resident #47 had no skin ulcers, wounds, or other skin problems identified at the time of the assessment. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed no changes from the MDS assessment described above except Resident #47 required extensive two-person assistance for transfers instead of total dependence. Review of the care plan dated 03/02/22 revealed Resident #47 had diabetes mellitus and was at risk for diabetic related complications. Interventions included to inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness. Additional interventions included to monitor skin during care and weekly and wash feet daily with mild soap and water, dry thoroughly, may use a light dusting powder or lotion and to not apply lotion or powder between the toes. Further review of the care plan revealed no identification of behaviors or the resident refusing care. Further review of the medical record revealed no evidence daily foot care was completed as care planned. Review of the weekly skin assessments dated 04/28/22 to 07/14/22 and 07/28/22 revealed no skin concerns identified to Resident #47's right great toe. No weekly skin assessments were completed on 07/21/22 or after 07/28/22. Review of facility provided document revealed on 05/12/22 and 06/02/22 Resident #47 returned to the facility from podiatry appointments with no new orders related to the right great toe. Review of the nurse's progress note dated 08/11/22 revealed Resident #47 returned from a podiatry appointment with new orders for an antibiotic and treatment to a wound on the right great toe with a follow up appointment scheduled next week. Review of podiatry documentation dated 08/11/22 revealed Resident #47 had a wound to the right hallux (big toe) with an order to cleanse the wound with antibacterial soap and water then pat dry, apply Medi honey to ulcer and cover with 4x4 gauze, kerlix roll, and ace bandage or Band-Aid and change daily. Follow-up appointment scheduled the following week. Further review of the medical record revealed no documentation showing the wound was assessed or measured by facility staff after the wound was discovered at the 08/11/22 podiatry appointment. Review of the physician order dated 08/12/22 to 09/03/22 revealed an order for the right great toe to cleanse with antibacterial soap and water, pat dry, apply Medi honey to ulcer, cover with 4x4 gauze, kerlix roll, and ace bandage and to be changed daily. Review of the Treatment Administration Record (TAR) for August 2022 revealed the order for the right great toe was applied 08/12/22 through 08/18/22. After 08/19/22 the TAR indicated Resident #47 was hospitalized except for 08/22/22 and 08/23/22, which had no documentation. Review of the nurse's progress note dated 08/12/22 revealed Resident #47's dressing was removed, and skin looked like it was necrotic (dead tissue) on the lower side of the toe. New treatment was applied, and the podiatrist was aware. Review of the nurse's progress note dated 08/14/22 revealed treatment was completed to Resident #47's right great toe with foul odor and drainage noted to the wound bed. Review of the nurse's progress note dated 08/15/22 revealed necrotic tissue noted to the wound bed, no drainage or odor noted. Review of the nurse's progress note dated 08/18/22 revealed Resident #47 went to a podiatry appointment and was transferred to the local hospital to have the right great toe amputated. Review of the hospital notes dated 08/18/22 revealed Resident #47 was admitted to the hospital on 08/18/22. Resident #47 was evaluated by podiatry and excisional debridement down to muscle, tendon, and periosteum (sheath outside bone) to the right great toe was completed and a culture was obtained. Resident #47 was admitted for intravenous (IV) antibiotics and magnetic resonance imaging (MRI) with possible amputation. Resident #47 had a culture that grew methicillin-resistant Staphylococcus aureus (MRSA). Further review revealed a full thickness wound with exposed tendon and capsular tissue to the right great toe measuring 3.3 centimeters (cm) by (x) 2.1 cm x 0.2 cm, which was approximately 100% fibrotic in nature. There was exposed periosteum, tendon, and muscle. There was mild to moderate edema and erythema. There was malodor and slight amount of purulent drainage noted. No proximal streaking lymphadenopathy, no pain on palpation secondary to neuropathy, and epicritic and protective sensation absent to the toes and foot. Assessment concluded the resident had an infected diabetic foot ulcer with necrosis of muscle to the right great toe. Review of the podiatry notes dated 08/19/22 revealed Resident #47 was admitted on [DATE] with a worsening diabetic foot ulcer to the right great toe. Resident #47 had presented to the podiatry office one week ago with a large wound to the right great toe secondary to likely pressure against the foot of the bed as Resident #47 was non-ambulatory with neuropathy. Resident #48 did not know he had the wound when he presented to the office one week ago for diabetic foot care and at that time was referred back to the physician for evaluation. When seen on 08/18/22 Resident #47 had significant necrotic tissue to the wound, great toe as well as redness, and swelling to the right great toe. Resident #47 was advised to go to the hospital for admission, IV antibiotics, and MRI and possible amputation of the right great toe. Infectious disease has been consulted and was on vancomycin and cefepime. Review of the hospital record dated 08/22/22 revealed Resident #47's right great toe was amputated. Interview on 11/30/22 at 9:05 A.M. with Resident #47 revealed approximately two months ago his right big toe was amputated. Resident #47 reported he cannot feel his feet and stated the facility was not checking on his feet like they were supposed to. It was reported staff did not have time or said someone else would do it. Resident #47 stated, it is water under the bridge now, and can still do the same things he could before the amputation. Interview on 11/30/22 at 1:36 P.M. with the Director of Nursing (DON) verified Resident #47 did not have weekly skin assessments completed on 07/21/22 or after 07/28/22. The DON verified there was no documentation Resident #47's wound was measured, assessed, and monitored after the wound was discovered at the podiatrist appointment on 08/11/22. The DON verified the resident had to go to the hospital and had his right great toe amputated. Interview on 12/01/22 at 12:43 P.M. with the DON verified there was no documentation of Resident #47's right great toe ulcer prior to the podiatry visits on 08/11/22. The DON acknowledged Resident #47's care plan interventions included to check and wash Resident #47's feet daily and stated the former MDS nurse did not add the intervention as a documented task. Review of the facility policy titled, Prevention of Skin Breakdown, dated April 2015 verified skin sweeps will be done weekly and if there are any skin issues, the doctor will be called, new orders/interventions received, and the resident will be referred to the wound care nurse. Open areas will be measured weekly by wound nurse or treatment nurse and will be documented on appropriate skin grids. Review of the facility policy, Wound Care Standards of Practice-Evaluation, dated September 2003 verified evaluations of wounds will be performed on admission, weekly, and on discovery. The evaluation is a formal process, and the evaluation components include location, measurements, appearance, drainage, odor, presence of undermining/tunneling, healing, state, pain, and edema. Review of the facility policy titled, Wound Care Standards of Practice- Wound Documentation, dated September 2003 verified documentation of wounds will be completed on admission and/or discovery and the clinician initiates the wound documentation process. This deficiency represents non-compliance investigated under Complaint Number OH00134135.

Based on medical record review, observation, policy review and staff interviews, the facility failed to provide supervision and implemented the physician ordered safety interventions to prevent falls. This resulted in actual harm when Resident #3 fell from his wheelchair and suffered a left [MEDICAL CONDITION]. This affected one (#3) of three residents reviewed for falls. The facility identified 11 residents at risk for falls. The facility census was 62. Findings include: Review of the medical record for Resident #3 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessments dated 01/07/21 revealed Resident #3 was severely cognitively impaired. He required extensive assistance of one or two staff with bed mobility, transfers, walking, dressing, toileting and personal hygiene. He was not steady while walking, transferring or changing position but had no impairment of the arms or legs. He used a walker or wheelchair for mobility. Review of the Plan of Care (POC) revealed Resident #3 was at risk for falls related to weakness and impaired mobility/cognition from the [DIAGNOSES REDACTED]. Resident #3 takes medications that will increase his risk for falling. Resident #3 had a fall with a left [MEDICAL CONDITION] on 02/09/21. The goal for Resident #3 was to have reduced risk of fall related injury through the review date. one of the interventions included Resident #3 would use an electronic alarm on his bed and chair to alert staff if he was getting up unassisted. Ensure the device is in place as needed. Review of Resident #3's Fall Risk assessment dated [DATE] and 02/09/21 revealed he was at high risk for falls with a history of falls in the last six months. Review of the physician orders revealed Resident #3 had an order to use a pad alarm to chair and in bed. Check the alarm every shift dated 08/25/20. Review of the nurse progress notes dated 02/09/21 at 7:00 P.M., revealed Resident #3 was in his wheelchair seated at the dining room table with his seatbelt fastened. Resident #3 unfastened the seatbelt, got out of his wheelchair, walked approximately two steps and fell on his left side. Resident #3 was having left hip pain. LPN #115 obtained an order for [REDACTED]., revealed Resident #3 was still in pain and his left hip area was swelling. The mobile X-ray was still pending. LPN #115 obtained a physician order to send him to the emergency room for evaluation and treatment. Review of the progress note dated 02/10/21 at 9:19 A.M., revealed Resident #3 had been admitted to the hospital and will be having surgery this morning. Resident #3 had a left [MEDICAL CONDITION]. Review of the progress note dated 02/12/21 at 5:55 P.M., revealed Resident #3's intramedullary nailing surgery of his left hip went well. On further x-ray Resident #3 was found to also have an odontoid [MEDICAL CONDITION] spine. Review of the facility witnessed fall incident report for Resident #3 dated 02/09/21 at 7:00 P.M., revealed Licensed Practical Nurse (LPN) #115 completed the report. Resident #3 was found lying on his left side when she entered the dining room area. Other residents had witnessed the fall. LPN #115 assessed vital signs and neurological signs which were within normal limits. Resident #3 was assisted by LPN #115 and State tested Nurse Aid (STNA) #65 back into his wheelchair. Resident #3 complained of leg pain. Injury to the left hip was observed at the time of the incident. The type of injury was undetermined. Resident #3 was oriented to person only and had predisposing risk factors including confusion, incontinence, gait imbalance and impaired memory. Resident #3 was wheelchair-bond with a situational factor of ambulating without assistance. Other information obtained from the report was Resident #3 unfastened his seatbelt and got up out of his wheelchair, took approximately two steps and fell , landing on his left side. There was no mention of the physician ordered/care planned intervention for an electronic alarm sounding or being on Resident #3's wheelchair to alert staff of his getting up unassisted. Interview on 02/24/21 at 1:04 P.M., via telephone with LPN #115 verified she was caring for Resident #3 on the night of his fall dated 02/09/21. LPN #115 was completing medication administration when she heard someone calling for assistance because Resident #3 had fallen in the dining room. LPN #115 verified Resident #3 was having left hip pain and she obtained a physician order for [REDACTED].#115 verified Resident #3 suffered a left [MEDICAL CONDITION] as a result of the fall. LPN #115 also verified Resident #3 was not wearing his physician ordered electronic chair alarm at the time of the fall. The alarm was not on his wheelchair. LPN #115 stated after his fall, she and State tested Nurse Aide (STNA) #65 were in his room and she noted the alarm was on his bed. LPN #115 stated she asked STNA #65, if Resident #3 was supposed to be wearing the alarm. STNA #65 informed the LPN #115 that Resident #3 was supposed to have the alarm on at all times. LPN #115 again verified Resident #3 was not wearing the alarm at the time of the fall because it was still in his room and was not on his wheelchair when he had the fall. Interview with Assistant Director of Nursing (ADON) #96 on 02/23/21 at 11:28 A.M., verified the fall investigation for Resident #3 indicated there was no chair alarm on Resident #3 at the time of his fall on 02/09/21. ADON #96 verified he had an order for [REDACTED]. Observation on 02/18/21 at 6:28 P.M., revealed Resident #3 was in his room in bed. The bed was in low position and his call light was in reach next to him. No electronic bed or chair alarm was attached to Resident #3 or observed to be available anywhere with visual inspection as per his physician order and the Plan of Care. Interview on 02/18/21 at 6:35 P.M., with STNA #35 verified Resident #3 fall interventions include an electronic chair alarm or bed alarm if he was in bed. Observation at 6:47 P.M., with STNA #35 revealed Resident #3 had no bed alarm connected to him anywhere , which would alert staff in the event he tried to stand without staff assistance. STNA #35 stated is was just there yesterday, hooked to his shirt and attached to the bedside drawer. She looked around the room for the alarm and could not find it. Interview with Assistant Director of Nursing (ADON) #96 on 02/23/21 at 11:28 A.M., verified Resident #3 had an order for [REDACTED]. Review of the facility policy titled Fall Management Policy revised 07/31/14, revealed the health care center identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls. The qualified staff assesses all patients/residents for fall risk through the Nursing Assessment Form upon admission, quarterly, and with a significant change. Upon determination that the patient/resident is at risk, the qualified staff completes the Fall Risk Assessment. The Fall Risk Assessment assists in identifying the appropriate preventative interventions, and that they are recorded on the patient/resident's care plan. This citation substantiates the Complaint Number OH 175.