**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, observation, and review of the facility policy, the facility failed to follow the physician's order to treat the resident's pressure wounds and failed to routinely assess the resident's pressure wounds. This affected one (Resident #11) of three residents reviewed for pressure wounds. The facility identified eight residents with pressure ulcers. The facility census was 29. Findings include: Review of the medical record revealed Resident #11 had an admission date of 07/29/24. Diagnoses included chronic systolic heart failure, vertebra osteomyelitis, and Parkinson's disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively impaired. Review of the skin only evaluation dated 07/29/24 revealed Resident #11 had the following skin concerns: left heel, buttocks excoriation, right buttocks medial, back excoriation, right elbow skin tear not painful, right and left lower legs discoloration, and right shin tear. There were no measurements or description of the wounds. Review of the plan of care dated 07/29/24 revealed Resident #11 was at risk for potential for skin breakdown related to bowel incontinence, catheter tubing in use, decreased mobility, previous issues with Moisture Associated Skin Damage (MASD) on right inner buttocks, stage III pressure injury (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed) to the left heel. Deep tissue injury (purple or maroon area of discolored intact skin due to damage or underlying soft tissue) to right buttocks, yeast under right and left arm. Many refusals of care and treatment to be completed. On 08/06/24, a wound consultant assessed Resident #11's wounds and included the following pressure areas: right buttock was a deep tissue injury (DTI) and showed deterioration. Left heel stage III smaller in size. Resident #11 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of the skin only evaluation dated 08/15/24 revealed Resident #11 had wounds which included the following: left heel (DTI), right heel (DTI), right buttock (marked as open lesion), and left buttock (marked as open lesion). There were no measurements or descriptions of the wounds. Resident #11 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of the skin only evaluation dated 08/27/24 revealed Resident #11 had wounds which included the following: back had excoriation, coccyx (open area), left heel (DTI), and right heel (redness). There were no measurements or descriptions of the wounds. Resident #11 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of the skin only evaluation dated 09/03/24 revealed Resident #11 had wounds which included coccyx (open area), left heel (DTI), right heel (redness), and back (excoriation). Review of the Resident #11's wound measurements dated 09/10/24 revealed the right lateral buttocks measured 2.5 centimeter (cm) in length by 2.5 cm in width by 0.1 cm in depth, right inner buttocks measured 3.5 cm by 2.5 cm by 0.1 cm, left lateral buttocks measured 1.0 cm by 1.0 cm by 0.1 cm, and the left inner buttocks measured 1.2 cm by 0.5 cm by 0.1 cm. Review of the physician order dated 09/12/24 revealed Resident #11 had an order to clean with normal saline then apply Remedy Calazime paste 0.4-20.5% to the two open areas on the left buttocks topically daily on day shift. Cover with Optifoam gentle dressing. The order dated 09/12/24 stated to cleanse the two open areas on the right buttocks with normal saline and apply Triad Hydrophillic Wound Dress External Paste. Cover with Optifoam gentle dressing. Interview on 09/12/24 at 3:00 P.M. with the Director of Nursing (DON) verified the facility should have had wound assessments upon admission, and readmission from the hospital for Resident #11 on 07/29/24, 08/15/24, and 08/27/24. The DON verified the facility only completed skin assessments with measurements and description of the wounds for Resident #11 on 09/03/24 and 09/10/24. Observation and interview on 09/16/24 at 2:00 P.M. revealed Licensed Practical Nurse (LPN) #345 and State Tested Nurse Aid (STNA) #277 provided wound care to Resident #11. LPN #345 removed Resident #11's ABD dressing to the right and left buttocks and the treatment was Hydrofero Blue (antibacterial, non-cytotoxic wound care product) dressing under the ABD dressing. LPN #345 confirmed Hydrofero Blue was not ordered for Resident #11's right and left buttocks wound treatment. Review of the facility policy titled Skin: Prevention, Detection and Treatment of Pressure Ulcers dated 08/2024 revealed to prevent pressures sores was to have early detection of potential or actual pressure ulcer sites. Assessments of pressure ulcers included type of ulcer pressure or not, the ulcer stage, ulcer's characteristics, progress toward healing or complications, presence of infection, presence and treatment of pain, and presence and type of dressing and treatment. Review of the facility policy titled Wound Treatment Protocol dated 10/2023 revealed the policy was to establish immediate treatment of non-intact skin, protocols in treating different levels of wounds, and to enhance the healing process of non-intact skin. Continue to describe the wound thoroughly included: wound bed, drainage, peri wound in the skin assessment, and document the specific area being treated in the order set upon admission. This deficiency represents non-compliance investigated under Complaint Number OH00156890.

Based on observations, staff interviews, and policy review, the facility failed to store and serve food in a sanitary manner. This affected two residents (#17 and #24) who were observed in the dining room. This had the potential to affect all 28 residents who receive food from the kitchen. The facility census was 28. Findings include: 1. Observations on 08/01/22 at 12:27 P.M. revealed State Tested Nurse Aide (STNA) #6 picked up one half of a ham salad sandwich in her bare hand and held it up to Resident #24's mouth. STNA #6 placed her bare hand inside an individual-sized bag of cheeses puffs and placed a chip in Resident #24's hand. Observation on 08/01/22 at 12:31 P.M. revealed Dietary Technician #51 delivered a hamburger on a plate to Resident #17 in the dining room. STNA #6 asked Resident #17 if she wanted mustard, took the top bun off the sandwich with her bare hand, squeezed mustard on top of the hamburger patty, replaced the bun, and patted the bun down with her bare hand. STNA #6 did not sanitize her hands before she continued providing feeding assistance to both Resident #24 and Resident #17. During an interview on 08/01/22 at 12:39 P.M., STNA #6 verified she had touched both Residents #24's and #17's food with her bare hands. STNA #6 stated she had thought if she used hand sanitizer, it was ok to touch food with her bare hands. 2. Observation made on 08/01/22 at 9:14 A.M. revealed the walk-in refrigerator located in the hallway contained multiple expired eight ounce (oz) cartons of milk including: one carton chocolate milk dated 07/13/22, one carton 2% white milk dated 07/23/22, one chocolate milk dated 07/25/22, six cartons 2% white milk dated 07/25/22, and 19 cartons 2% white milk dated 07/31/22. Observation made on 08/01/22 at 9:23 A.M. revealed the reach-in refrigerator located in the kitchen contained multiple bins of expired left over foods including one half-pan labeled chicken and rice prepared on 07/16/22 with a discard date of 07/21/22, one gallon-sized re-sealable bag of cooked hamburgers labeled prepared on 07/28/22 with a discard date of 07/31/22, one labeled quarter pan of chili prepared on 07/19/22 with a discard date 07/31/22 and one labeled plastic container with two and half quarts of black olives opened on 07/20/22 with a discard date of 07/30/22. During an interview on 08/01/22 at 9:29 A.M., Dietary Staff #55 verified the reach-in refrigerator contained multiple pans of leftover foods stored beyond their discard date. Dietary Staff #55 stated leftover foods were labeled with the date they were prepared and discarded with in three to seven days depending on the food item. During an interview on 08/01/22 at 9:43 A.M., Line [NAME] #5 verified the walk-in refrigerator located in the hallway contained 28 eight ounce cartons of expired milk. Review of the facility's policy titled Food Service and Nutrition, revised 09/07/21, revealed the facility stored, prepared, distributed, and served food under sanitary conditions and in a manner that protected against contamination and spoilage according to food service requirements of the Ohio Administrative Code.

Based on record review, observation, staff interview, review of facility policy, and review of the online resource, the facility failed to discard outdated resident medications. This affected Resident #3 for eye drops and had the potential to affect six residents (#8, #17, #22 , #25, #28, #85 and #86) for antacid medication. The facility census was 30. Findings include: 1. Review of record for Resident #3 revealed an admission date of 03/10/16 and a diagnosis of end stage heart failure. Review of the physician orders, dated 05/03/18, revealed an order for the resident to receive artificial tear solution instilled two drops in both eyes threes time per day for dry eye. Review of Medication Administration Record (MAR) for August 2019 for Resident #3 revealed resident received artificial tear solution instilled to both eyes per the physician's order. Observation and interview on 08/07/19 at 10:23 A.M. with Licensed Practical Nurse (LPN) #242 revealed an opened bottle of artificial tear solution labeled with Resident #3's name and dated 06/25/19. The LPN confirmed that the bottle of artificial tear solution was used for Resident #3 and had been dated 06/25/19 to indicate when it had been opened. Interview with the Director of Nursing (DON) on 08/07/19 at 4:15 P.M. confirmed the artificial tear solution did not contain manufacturer instructions regarding when the medication should be discarded once opened. Review of the International Pharmacopoeia, Seventh Edition, dated 2017, revealed multidose ophthalmic drop preparations may be used for up to four weeks after the container is initially opened. Review of facility policy titled Storage of Medications, dated 07/25/19, revealed all multidose vials of medications are to be dated and initialed by the nurse opening the vial and indicating the date of opening. 2. Observation on 08/07/19 at 10:07 A.M. of the rehabilitation unit medication cart with LPN #238 revealed the cart contained an opened house stock bottle of Maalox liquid (over the counter indigestion medication) with a manufacturer's expiration date of 07/2019. Interview with LPN #238 on 08/07/19 at 10:07 A.M. confirmed the opened bottle of house stock Maalox in the rehab cart was expired and should have been discarded. Interview with the DON on 08/08/19 at 10:45 A.M. confirmed that Resident's #8, #17, #22, #25, #28, #85, #86 had orders for Maalox as needed for indigestion and that expired medications should be discarded. Review of facility policy undated titled Storage of Medications revealed medications should not be kept past their expiration date and should be destroyed.

Based on observation, staff interview and review of facility policy, the facility failed to ensure the ice maker was free of mold. This had the potential to affect all residents residing in facility with exception of one resident (#1) whom the facility identified as not receiving food from the kitchen. The facility census was 30. Findings include; During initial observation of the kitchen on 08/08/19 at 8:15 A.M., revealed the ice maker in the main kitchen had several black areas inside the ice maker compartment. Interview with General Manager of Culinary #198 on 08/08/19 at 8:22 A.M. verified the black areas inside the main kitchen's ice maker. General Manager of Culinary #198 stated the black areas inside the ice maker were mold. Review of the facility's list of residents who don't receive food from the kitchen revealed Resident #1 did not. Review of the facility policy titled Ice Machine Maintenance and Cleaning Policy, dated 10/02/18, revealed the facility was to establish a maintenance and cleaning schedule to be certain machines are functioning properly and are clean for infection control.

Based on observation and interview, the facility failed to ensure injectable medications were dated as to when opened and were discarded in accordance to their expiration dates. This had the potential to affect all 31 residents. Findings include: During observation of the facility's medication room refrigerator on 07/19/18 at 10:00 A.M., the following was observed: a. A Humalog Insulin Pen belonging to Resident #14 was located on a shelf in the refrigerator. The expiration date of the Insulin Pen was 06/13/18. b. A vial of Kenlog-40 (a steroid) was located on a shelf in the refrigerator. The medication expiration date was 03/18/18. c. Two opened vials of Tuberculin Purified Protein were in the refrigerator and not dated as to when they were first opened and used. d. A vial of Hepatitis B in the refrigerator had an expiration date of 05/09/18. At the time of the observation the Director of Nursing verified the above items and subsequently discarded the medications.