**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, physician interview, and policy review, the facility failed to ensure wound care was completed as required. This affected one (#69) of three residents reviewed for wound care. The facility census was 59. Findings Included: Review of Resident #69's medical record revealed an admission date of 09/18/24. Diagnoses included post operative orthopedic care of the right ankle, rib fracture, sacrum fracture, and cervical fracture due to a motor vehicle accident and congestive heart failure. Review of Resident #69's hospital note dated 09/18/24 revealed the resident was involved in a motor vehicle accident and suffered a fracture and dislocation of the right medial ankle joint. On release to the long-term care facility, the sutures remained intact along with wearing a hinged knee brace locked in extension and a foot/ankle splint. Review of Resident #69's admission Minimum Data Set (MDS) assessment dated [DATE] revealed her cognition was intact. The resident was assessed with one surgical wound. Review of Resident #69's care plan revealed a start date of 09/23/24 which indicated the resident had a surgical wound to her right leg due to surgery on a fracture and a laceration to the right ankle. Review of Resident #69's physician order dated 10/01/24 revealed staff were to cleanse the sutures with normal saline, pat dry, apply an abdominal pad, cover with Kerlix, and apply the Seattle splint (a brace used to treat orthopedic trauma/surgical repairs). The ordered ended on 10/09/24. Review of Resident #69's treatment administration record (TAR) for October 2024 revealed the resident did not have a dressing change completed to the right ankle wound between 10/10/24 and 10/24/24. Review of Resident #69's weekly observation review dated 10/16/24 revealed the resident assessment included an ORIF (open reduction and internal fixation) of the ankle which included a surgical wound. Review of Resident #69's physician order dated 10/25/24 revealed staff were to change the dressing daily to the right lower extremity, cleanse with normal saline, apply adaptic, an abdominal pad, and Kerlix once daily. The ordered had an end date of 10/31/24. Review of Resident #69's progress note dated 10/31/24 revealed the resident was being admitted to the hospital for surgery and debridement of the right ankle wound. Telephone interview with Orthopedic Surgeon (OS) #500 on 11/25/24 at 3:37 P.M. revealed Resident #69 suffered a severe ankle injury and had a lack of blood flow to the area. OS #500 stated the facility should have sought treatment for Resident #69's ankle wound because the resident had an open surgical wound and no active treatment orders from 10/10/24 through 10/24/24. OS #500 stated Resident #69 had many underlying factors and could not definitively say the lack of wound treatment orders between 10/10/24 and 10/24/24 caused the need for surgical intervention and debridement of the resident's right ankle. Interview with the Director of Nursing (DON) on 11/26/24 at 11:00 A.M. revealed Resident #69 had no wound treatment orders for the right ankle between 10/10/24 and 10/24/24. The DON stated she spoke with the wound care nurse and both were unaware of the reason Resident #69 failed to have wound care provided from 10/10/24 through 10/24/24. Review of the facility policy titled, Pressure Injury Prevention and Treatment Policy, revised 09/18/23, revealed injuries will be documented and orders obtained from providers for treatment. This deficiency represents non-compliance investigated under Complaint Number OH00160062 and Complaint Number OH00159749.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, and policy review, the facility failed to provide oral hygiene per physician orders and care plan. This affected one (#5) of one resident reviewed for activities of daily living. The facility census 59. Findings include Review of the medical record revealed Resident #5 had an admission date of 03/01/18. Diagnoses included diffuse traumatic brain injury, dysphagia, moderate intellectual disabilities, hypertension, cognitive communication deficit, and epilepsy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for oral hygiene. Review of the care plan dated 03/04/24 revealed the resident had potential for oral/dental health problems. The resident was noted as resistant to brushing and flossing teeth at times. Interventions included to brush and floss teeth after each meal and at bedtime. Review of a physician order dated 01/19/24 revealed an order to brush teeth and floss after every meal and at bedtime. Review of a dental progress note dated 06/24/24 revealed the resident had a lot of plaque. Please make sure the resident's teeth were cleaned after every meal and flossed. Review of a dental note dated 09/19/24 revealed the resident's teeth had moderate plaque. Please brush and floss after each meal. Review of the nursing assistant task documentation from 09/02/24 through 10/02/24 revealed the resident's teeth were brushed per physician orders only once in the past 30 days. Review of the nurses notes dated 09/01/24 through 10/02/24 revealed the resident had not refused oral hygiene. Observation on 10/02/24 at 8:42 A.M. revealed Resident #5 had completed his breakfast meal in the dining room. Observation on 10/02/24 at 9:04 A.M. revealed State Tested Nursing Assistant (STNA) #528 assisted the resident to his room and checked the resident for incontinence. Resident #5 had yellow discolored teeth. STNA #528 did not offer to brush Resident #5's or floss teeth after the breakfast meal. Interview on 10/02/24 at 9:08 A.M., STNA #528 revealed the resident required no further care and had not brushed or flossed Resident #5's teeth after breakfast. When asked about brushing the resident's teeth, STNA #528 revealed the resident's teeth were brushed before breakfast and not after. STNA #528 revealed the resident's teeth were brushed twice per day in the morning and at night. Observation on 10/02/24 at 12:45 P.M. revealed Resident #5 had completed his lunch meal in the dining room. STNA #532 and STNA #528 assisted Resident #5 to his room and transferred the resident with the mechanical lift from the wheelchair to the bed to check for incontinence. STNA #528 and STNA #532 then transferred Resident #5 back to his wheelchair and revealed his care was complete. Resident #5's teeth were not brushed or flossed. Interview on 10/02/24 at 12:55 P.M., STNA #532 revealed when asked about brushing and flossing Resident #5's teeth, the resident's teeth would not be brushed until after dinner. Interview on 10/02/24 at 1:08 P.M. with Licensed Practical Nurse (LPN) #542 verified Resident #5 had a physician order to brush and floss teeth after meals and at bedtime. Interview on 10/02/24 at 2:09 P.M. the Director of Nursing (DON) reviewed the oral care documentation for Resident #5 and revealed the resident's teeth were not brushed and flossed per physician orders and care plan. Review of the facility policy Morning Care/AM Care revised 11/08/23, and review of the policy Evening Care/PM Care, revised 06/15/20, revealed staff would assist with or provide oral hygiene.

Based on observation and staff interview, the facility failed to ensure resident care equipment (fall mats) were maintained in a clean and sanitary condition. This affected four (#5, #26, #28 and #32) of four residents reviewed who use a fall matt for safety. The facility census was 59. Findings include: Observation on 10/03/24 between 11:00 A.M. and 11:34 A.M. with Maintenance Director(MD) #534 revealed the falls mats utilized by Residents #5, #26, #28 and #32 were old bed mattress that were held in place by velcro. Observations of these mattresses noted the velcro that held the mattress in place was brown in color and with numerous areas of stains, dirt and other debris on the velcro its self. The outer areas of the mattress had various levels of other dust, dirty and debris as well. An interview with MD #534 verified the condition of the fall mats at the time of observation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview, and review of the facility policy, the facility failed to maintain fall safety interventions to prevent a resident from falling. This affected one (Resident #1) of three residents reviewed for falls. The facility census was 59. Findings include: Review of the medical record for Resident #1 revealed an admission date of 06/24/23. Diagnoses included multiple sclerosis (MS), moderate protein calorie malnutrition, lymphedema, adult failure to thrive, and anxiety. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 06/30/23, revealed Resident #1 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, and ambulation. Review of the fall risk assessment dated [DATE] revealed Resident #1 was at high risk for falls. Review of the plan of care dated 06/26/23 revealed Resident #1 was at risk for falls due to history of fall, multiple sclerosis, and decreased mobility. Interventions included implementing preventative fall interventions/devices, call light in reach, non-skid footwear, wheelchair pedals to be on when transporting resident, and administering medication as ordered. Review of the fall investigation dated 08/12/23 revealed Resident #1 was sitting on side of bed. One state tested nursing aide (STNA) was assisting her with transferring to wheelchair, the floor was wet and slippery. The statement from STNA stated as she was getting Resident #1 up to her chair, she slid and lost balance and she assisted her down to the floor. The care plan stated two-person assists for transfers. A new intervention was making sure the floor was dry prior to getting Resident #1 up. Interview on 09/06/23 at 12:48 P.M. with Resident #1 revealed she had had a couple of falls a few weeks ago. Resident #60 stated she fell when she was being transferred from bed to wheelchair with one staff and her feet got tangled and she fell by bed. Resident #1 stated she has MS and at times her feet don't work like they should. Interview on 09/06/23 at 2:20 P.M. with the Director of Nursing (DON) and Administrator verified Resident #1 was a two-person assist for transfers and one STNA should not have transferred Resident #1 by herself. Interviews on 09/06/23 from 12:50 P.M. through 4:05 P.M. with Licensed Practical Nurse (LPN) #300, #301, STNA #302 and #303 revealed Resident #1 was a two-person assist for transfers. Review of the facility policy titled Fall Management, dated 12/09/19, revealed individualized interventions will be based on assessment and care plan accordingly. This deficiency represents non-compliance investigated under Complaint Number OH00146056.

Based on medical record review, family and staff interviews, and review of facility policy, the facility failed to provide oral care to residents who were dependent upon staff for oral care. This affected one resident (#29) of one residents reviewed for Activities of Daily Living (ADLs). The facility census was 47. Findings included: Review of the medical record for Resident #29 revealed an admission date of 03/01/18. Diagnoses included hypothyroidism, seizures, retention of urine, personal history of traumatic brain injury (TBI), dysphagia, abnormal posture, hypertension, anxiety, moderate intellectual disability, and cognitive communication deficit. Review of the annual Minimum Data Set (MDS) assessment, dated 04/08/22, revealed Resident #29 was severely cognitively impaired, required extensive assistance with Activities of Daily Living (ADLs), and did not reject care. Review of the plan of care, revised 12/28/20, revealed Resident #29 had an ADL self care performance deficit related to impaired balance, limited mobility, musculoskeletal impairment, TBI, seizures. Resident #29 refused care at times and could be resistive, combative, and refused to allow staff to brush teeth and shave at times. Interventions included if care refused, attempt again later and oral care daily and as needed. Additional review revealed Resident #29 had potential for oral/dental problems due to resistance to brushing and flossing teeth. Interventions included brush teeth after every meal and at bedtime and oral care per routine and as needed. Review of physician orders revealed Resident #29's teeth were to be brushed three times daily and flossed one time daily. Review of dentist progress notes dated 11/18/21 and 02/02/22 revealed Resident #29 had plaque build-up and needed to brush and floss teeth after each meal. Review of a dentist progress note dated 05/09/22 revealed Resident #29 had generalized plaque and needed to brush and floss after every meal and at bedtime. Review of State Tested Nurse Aide (STNA) documentation from 04/01/22 through 05/16/22 revealed Resident #29 was to have his teeth brushed and flossed after each meal, document refusals. Additional review revealed oral care was not documented as provided or refused on 04/01/22, 04/02/22, 04/08/22, 04/17/22, 04/23/22, 04/27/22, 05/03/22, and 05/04/22. Further review revealed not applicable was documented on 04/05/22, 04/06/22, 04/12/22, 04/26/22, 04/28/22, 05/02/22, 05/07/22, 05/08/22, and 05/12/22. Review of nursing progress notes from 04/01/22 through 05/17/22 revealed no documentation Resident #29 refused ADL care, including oral care. Additional review of a note dated 05/09/22 revealed Resident #29 returned from a dental appointment and to encourage teeth brushing and flossing after each meal. Interview on 05/16/22 at 11:42 A.M. of Resident #29's family member revealed the facility did not regularly brush the Resident's teeth. The family member stated she had to take Resident #29 to the dentist every two to three months to have his teeth cleaned because the facility did not adequately keep up with oral care. Interview on 05/17/22 at 9:03 A.M. of Licenses Practical Nurse (LPN) #565 revealed Resident #29 required extensive assistance for all care, including oral hygiene. LPN #565 stated Resident #29 could be resistive to care but staff just needed to re-approach a few minutes later and he would accept care. Interview on 05/17/22 at 9:13 A.M. of State Tested Nurse Aide (STNA) #508 revealed Resident #29 would resist oral care but would generally accept care if re-approached at a later time. Interview on 05/17/22 at 10:38 A.M. of STNA #512 revealed Resident #29 required extensive assistance with all areas of care, including oral care. While Resident #29 was not always cooperative with care, STNA #512 stated joking with the Resident was usually effective and Resident #29 would accept care. STNA #29 stated documentation of care provided to residents, including refusals of care, was documented in the resident's electronic medical records. Interview on 05/17/22 at 11:01 A.M. with the Director of Nursing (DON) revealed nursing staff would update resident physician orders based off any recommendations provided by the physician, including the dentist. The DON verified Resident #29's orders should have been updated to reflect the most recent dentist recommendation, dated 05/09/22, which included brushing and flossing after every meal and at bedtime. The DON stated nursing staff may have spoke with the dentist and received different orders, but she would have to look into whether that happened. The DON verified dental care was not documented as provided or refused by Resident #29 in the STNA documentation for the above identified dates or in nursing progress notes. The DON stated all care provided and refusals should be documented in the resident's electronic medical record (EMR) but she would have to check to see if staff had developed another way of documenting Resident #29's care or refusals of care. The DON also stated she would need to check if any additional orders had been provided by Resident #29's dentist. Follow up interview on 05/17/22 at 1:50 P.M. the DON verified no additional documentation was available related to Resident #29 being provided assistance with oral care or the resident refusing care. In addition, the DON verified there was no documentation of nursing staff contacting the dentist and/or received any other instructions different from the 05/09/22 dentist progress note. The DON stated the oral care physician order was discontinued because oral hygiene was care STNAs should be providing without a physician order. Review of facility policy titled, Morning Care/AM Care, revised 06/15/20, revealed morning care, including oral care, would be offered each day to promote resident comfort, cleanliness, grooming and general wellbeing. Review of facility policy titled, Evening Care/PM Care, revised 06/15/20, revealed evening care, including oral care, would be offered to residents to promote personal hygiene, comfort, relaxation, and safety.