How many inspection deficiencies does AVENUE AT LYNDHURST have?

AVENUE AT LYNDHURST has 59 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at AVENUE AT LYNDHURST?

AVENUE AT LYNDHURST has a two-star staffing rating from CMS with 0.72 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is AVENUE AT LYNDHURST located?

AVENUE AT LYNDHURST is located in LYNDHURST, OH. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does AVENUE AT LYNDHURST have?

AVENUE AT LYNDHURST has 80 certified beds.

Who owns AVENUE AT LYNDHURST?

AVENUE AT LYNDHURST is a for profit - limited liability company facility and is part of the PROGRESSIVE QUALITY CARE chain.

What questions should families ask when visiting AVENUE AT LYNDHURST?

Families visiting AVENUE AT LYNDHURST should ask about staff retention and training programs. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does AVENUE AT LYNDHURST compare to other nursing homes?

AVENUE AT LYNDHURST has a 1-star overall rating, which is below average compared to other nursing homes in OH. Families should carefully review inspection findings and consider alternatives.

AVENUE AT LYNDHURST

Name: AVENUE AT LYNDHURST
Address: 5442 RAE ROAD, LYNDHURST, OH, 44124, US
Telephone: (440) 684-8448
Rating: 1.0

5442 RAE ROAD, LYNDHURST, OH 44124 · (440) 684-8448

For profit - Limited Liability company 80 Beds PROGRESSIVE QUALITY CARE Data: November 2025

Trust Grade

10/100

#833 of 913 in OH

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Last Inspection: January 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Avenue at Lyndhurst has received a Trust Grade of F, indicating significant concerns and a poor overall quality of care. It ranks #833 out of 913 nursing homes in Ohio, placing it in the bottom half of facilities statewide, and #81 out of 92 in Cuyahoga County, suggesting limited local options for better care. Unfortunately, the facility is worsening, with issues increasing from 14 in 2024 to 40 in 2025. Staffing is a concern, with a rating of 2 out of 5 stars and a high turnover rate of 69%, which is above the Ohio average of 49%. While the facility has no fines, indicating compliance with regulations, recent inspections revealed serious deficiencies, including a failure to provide timely pain management for a resident and issues with food safety in the kitchen, posing risks to resident health.

Trust Score: F
In Ohio: #833/913
Safety Record: Moderate
Inspections: Getting Worse
Staff Stability: 69% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: No fines on record. Clean compliance history, better than most Ohio facilities.
Skilled Nurses: Each resident gets 43 minutes of Registered Nurse (RN) attention daily — more than average for Ohio. RNs are trained to catch health problems early.
Violations: 59 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★★☆

4.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 14 issues

2025: 40 issues

The Good

4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

1-Star Overall Rating

Below Ohio average (3.2)

Significant quality concerns identified by CMS

Staff Turnover: 69%

23pts above Ohio avg (46%)

Frequent staff changes - ask about care continuity

Chain: PROGRESSIVE QUALITY CARE

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (69%)

21 points above Ohio average of 48%

The Ugly 59 deficiencies on record

1 actual harm

Aug 2025 10 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0573 (Tag F0573)

Could have caused harm · This affected 1 resident

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Based on medical record request review, email review, staff interview and facility policy review, the facility failed to fulfill a request for medical records in a timely manner. This affected one (Resident #100) of three residents reviewed for medical records requests. The facility census was 86. Findings include:Review of the medical record for former Resident #100 revealed an admission date of 10/07/24 and discharge date of 10/29/24. Resident #100 passed away while at the facility. Review of the medical records request dated 03/31/25 revealed a law firm representing Resident #100's personal representative requested a complete copy of all resident records in the possession of the facility for Resident #100. The request included a medical authorization form signed by Resident #100's administrator of estate and a court order for the release of the medical records and medical billing records. Review of the medical records request dated 05/12/25 revealed a second request was made for the medical records of Resident #100 by a law firm representing Resident #100's personal representative. Review of the email chain dated 08/20/25 between Medical Records #374 and the facility's corporate office revealed Medical Records #374 requested an update on sending the medical records as requested for Resident #100's administrator of estate. The corporate office responding indicating a secure link was sent to the law firm for access to the medical records on 08/20/25. Review of the uploads to the secure link revealed Resident #100's medical record from 08/01/24 to 07/31/25 was uploaded on 08/13/25. Interview on 08/25/25 at 8:48 A.M. with Medical Records #374 confirmed the requests on 03/31/25 and 05/12/25 were not fulfilled in a timely manner. Medical Records #374 confirmed the law firm was unable to access the medical records until 08/20/25 via a secure link. Interview on 08/25/25 at 8:58 A.M. with the Licensed Nursing Home Administrator (LNHA) revealed the former medical records employee had not fulfilled the medical record requests for Resident #100. LNHA indicated the former medical records employee had been terminated.Review of the facility policy Medical Records Request, dated January 2023, revealed record requests must be approved by the Corporate Clinical Director. A written consent from the resident or representative was required. Fees would be applied per page for medical records.This deficiency represents noncompliance investigated under Complaint Numbers 2581623, 1401397 (OH00163878) and 1401396 (OH00163306).

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0628 (Tag F0628)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the Ombudsman was notified of transfers for Residents #10 and #93, and the facility failed to ensure a transfer notice was issued for Resident #98. This affected three (Residents #10, #93, and #98) of three residents reviewed for hospitalization. The facility census was 86. Findings include:1. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including acute kidney failure and multiple sclerosis. Review of the medical record revealed Resident #10 was sent to the hospital on [DATE] and was subsequently admitted to the hospital. Reviews of both the electronic and hard charts revealed no documented evidence that the Ombudsman was notified of the residents transfer to the hospital. Interview on 08/20/15 at 2:00 P.M. with Social Service Designee (SSD) #388 revealed that the Ombudsman was not notified that Resident #10 went to the hospital on [DATE]. 2. Review of the medical record revealed Resident #93 was admitted to the facility on [DATE] with a discharge date of 07/25/25. Diagnoses included diabetes mellitus, general anxiety disorder, and acute respiratory failure. Review of the medical record revealed Resident #93 was sent to the hospital on [DATE], 05/28/25, and 07/01/25 and was subsequently admitted to the hospital. Reviews of both the electronic and hard charts revealed no documented evidence that the Ombudsman was notified of the residents’ transfers to the hospital. Interview on 08/20/15 at 2:00 P.M. with SSD #388 revealed the Ombudsman was not notified of Resident #93’s transfers to the hospital on [DATE], 05/28/25, and 07/01/25. 3. Review of the medical record for Resident #98 revealed an admission date of 02/06/24. Diagnoses included cerebral infarction, pneumonia, hemiplegia and hemiparesis, sepsis, gastrostomy status, and dementia. The resident was discharged from the hospital on [DATE]. Review of the Discharge Return Anticipated Minimum Date Set (MDS) 3.0 dated 08/21/24 revealed Resident #98 had severely impaired cognition and required maximum assistance eating, oral hygiene, dressing, personal hygiene, and bathing/showers. Record review revealed there were no transfer notices for a hospitalization on 06/17/24 or a hospitalization on 08/08/24. The lack of the required transfer notices was verified Corporate Director of Operations #409 on 08/25/25 at 1:42 P.M.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure medications were available for administration. This affected two (Residents #20 and #99) out of ten residents reviewed for medication administration. The facility census was 86. Findings include:1. Review of the medical record for Resident #20 revealed an admission date of 08/01/22. Diagnoses included acute respiratory failure, visual loss of both eyes, dementia, peripheral vascular disease, osteoarthritis, and sarcoidosis of lung. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had intact cognition. The resident required partial assistance with toileting and transferring. Review of the laboratory result for urinary analysis final result dated 07/28/25 at 3:28 P.M. revealed a positive result for nitrites and Proetus Mirabilis, a bacterium. Review of the physician progress note dated 07/30/25 at 5:09 P.M. revealed the urinary tract infection (UTI) laboratory results and medications were reviewed. New orders were given for Cefdinir 300 milligrams (mg) (antibiotic) twice daily for seven days and saline nasal spray three times a day. Review of the physician order dated 07/30/25 at 6:30 P.M. for Cefdinir 300 mg, give one capsule twice daily for UTI. The order was started and discontinued on 07/30/25. An order dated 07/31/25 for Cefdinir 300 mg to give twice daily revealed a start date 07/31/25 and discontinue date of 08/07/25. Review of the Medication Administration Record (MAR) for July 2025 revealed on 07/30/25 at 8:00 P.M., Cefdinir was sign off with a number “9” indicating to see the nurse’s note. On 07/31/24 at 8:00 A.M. and 8:00 P.M. Cefdinir was signed off as administered. Review of the nurse’s progress note on 07/30/25 revealed no note regarding the Cefdinir. Interview on 08/25/25 at 1:43 P.M. with the Regional Director of Clinical Service (RDCS) #502 stated she believed on 07/30/25 the nurse did not have the medication from pharmacy and rescheduled it for the following day. RDCS #502 verified the UTI results on 07/28/25 at 3:28 P.M. the physician reviewed the results on 07/30/28, and there was a delay in starting the Cefdinir until 07/31/25 at 8:00 A.M. 2. Review of the closed medical record for Resident #99 revealed an admission date of 02/13/25. Diagnoses included pneumonia, malignant neoplasm of esophagus, encephalopathy, attention deficit hyperactivity disorder, anxiety disorder, and bipolar disorder. The resident was discharged to another facility on 03/11/25. Review of the modification of admission MDS 3.0 assessment dated [DATE] revealed Resident #99 had intact cognition. Review of the physician orders for Resident #99 revealed a medication order for Alprazolam oral tablet 0.5 mg (Xanax) (antianxiety) give one tablet by mouth at bedtime for anxiety, ordered on 02/13/25 with a start date on 02/14/25. Review of the MAR for Resident #99 for February 2025 revealed Alprazolam oral tablet 0.5 mg give one tablet by mouth at bedtime for anxiety was not given on 02/14/25, 02/15/25, and 02/17/25. It was noted to see nurse’s note on 02/14/25, 02/15/25, and 02/17/25. Review of the nursing progress notes for Resident #99 for 02/14/25 revealed no notes regarding the missed dose of Alprazolam oral tablet 0.5 mg. Review of the nursing progress note dated 02/15/25 at 2:17 A.M. revealed the Alprazolam oral tablet 0.5 mg was pending delivery. There was no indication that any action had been taken regarding obtaining the medication. Review of the nursing progress note dated 02/15/2025 at 8:51 PM revealed Alprazolam oral tablet 0.5 mg: Provider notified about script for this medication by this nurse. Provider asked this nurse to call the pharmacy and gave them his cell phone number for pharmacy to call him. The nurse called the pharmacy as instructed and gave them provider's number. The medication was pending. Review of the nursing progress notes for Resident #99 for 02/17/25 revealed no notes regarding the dose missing for Alprazolam oral tablet 0.5 mg, give one tablet by mouth at bedtime for anxiety. Interviews on 08/22/25 at 1:48 P.M. RDCS #502 verified there was no nursing note regarding Alprazolam on 02/14/15 or 02/17/25. It appeared no action was taken until late 02/15/25. There was a delay in Resident #99 receiving Alprazolam. This deficiency represents noncompliance investigated under Complaint Numbers 1401397 (OH00163878) and 1401401 (OH00162944).

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and facility policy review, the facility failed to ensure proper infection control with Resident #69 during incontinence care. This affected one (Resident #69) of one resident reviewed for incontinence care and had the potential to affect six additional (Residents #1, #22, #42, #55, #59, and #77) whom required incontinence care on the Certified Nursing Assistant's (CNA) #365's assignment. The facility census was 86. Findings include:Review of the medical record for Resident #69 revealed an admission date of 09/19/23. Diagnoses included type II diabetes, Alzheimer's disease, encephalopathy, morbid obesity, overactive bladder and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #69 had impaired cognition. The resident was dependent on staff for eating, toileting, showering and dressing. Resident #69 was incontinent of bowel and bladder. Observation on 08/20/25 at 9:20 A.M. of incontinence care with Resident #69, with CNA #365, revealed she gathered the incontinence supplies, washed her hands and donned gloves. CNA #365 removed Resident #69's brief and began providing care. CNA# 365 finished cleaning Resident #69 applied a clean brief and continued to reposition and adjust the bed by touching the remote with the same soiled gloves. CNA #365 removed her gloves and washed her hands and left the room. Interview on 08/20/25 at 9:29 A.M. with CNA #369 stated since the gloves were not visibly dirty, she did not have to change them while repositioning Resident #69 or adjusting her bed. Review of the facility policy titled Incontinence Care, revised March 2022, revealed the procedure stated to clean and dry the resident, replace and drape the resident as requested, dispose of gloves, perform hand hygiene, and ensure call light is in place. This deficiency represents noncompliance identified under Complaint Number 1401393 (OH00162964) and 1401394 (OH00163002).

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, interviews and facility policy review, the facility failed to provide timely incontinence care for dependent residents. This affected five (Residents #9, #15, #41, #69 and #84) of ten residents observed for incontinence care. The facility census was 86. Findings include:1. Review of the medical record for Resident #84 revealed an admission date of 01/06/24. Diagnoses included chronic kidney disease, encephalopathy, repeated falls and mild cognitive impairment. Review of the plan of care dated 03/01/25 noted Resident #84 was incontinent of bowel and bladder. Interventions included checking and changing on care rounds and as needed. Review of the plan of care dated 03/28/25 noted Resident #84 had a self-care deficit, limited mobility, and impaired cognition. Interventions included toileting assistance of one staff and transferring assistance of two staff with a mechanical lift. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #84 had impaired cognition. Resident #84 required moderate assistance for toileting and mobility. Observation on 08/18/25 at 3:28 P.M. noted Resident #84 activated his call light and yelling “they won’t change me.” Continued observations noted Certified Nurse Assistant (CNA) #304 entered Resident #84’s room at 3:50 P.M. and asked what Resident #84 needed. Resident #84 stated “I need to be changed,” CNA #304 stated she would be back, turned off the call light and left the room. CNA #304 was observed walking across the hall to take another resident to the activities room. Observation at 3:58 P.M., Licensed Practical Nurse (LPN) #301 walked down the hall past Resident #84’s room. LPN #301 was not aware of Resident #84’s need because the call light was turned off. Observation at 3:58 P.M., Resident #84 yelling “hello, hello,” no staff were observed working in the three halls that came together outside Resident #84’s room. Observation at 4:07 P.M. and 4:10 P.M., Resident #84 yelling “hello, hello, anyone help me?” Observation at 4:12 P.M., Resident #84 activated the call light again, again. No staff were observed working in the three halls. The Administrator was walking down the hall and observed Resident #84’s light on. The Administrator asked Resident #84 what he needed, Resident #84 stated “I need to be changed,” the Administrator left the room. Interview on 08/18/25 at 4:15 P.M., the Administrator stated the procedure for call lights was that call lights were not shut off until the need of the resident was met. The Administrator was informed that observations made in the three halls indicated one aide and one nurse were observed in one hall from 3:28 P.M. to 4:15 P.M. The Administrator stated she would find a staff member, Resident #84’s received care at 4:17 P.M. Interview on 08/18/25 at 4:18 P.M., CNA #304 was unable to provide a valid reason why she shut Resident #84’s call light out without providing care and stated she told the nurse about the call being activated. CNA#304 stated she made a mistake by turning off the light without providing care. Review of the facility electronic call light audits for 1275 call light responses noted the facility had a significant number of call lights that were activated for one to two hours. Review of the facility policy titled “Resident Call Light,” dated 2023, noted staff were to answer the call light in a timely manner, do not turn off the call light if staff were unable to meet the resident’s needs, and complete the task the resident has requested. 2. Review of the medical record for Resident #9 noted an admission date of 07/25/25. Diagnoses included bilateral primary osteoarthritis of the hip, pain in the right and left hip, and personality disorder. Review of the plan of care dated 03/28/25 noted Resident #9 had a self-care deficit, limited mobility, and impaired cognition. Interventions included toileting assistance of one staff and transferring assistance of two staff with a mechanical lift. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #9 had intact cognition. Resident #9 required moderate assistance for toileting and mobility. Review of medical record for Resident #15 noted an admission date of 06/25/25. Diagnoses included traumatic amputation of the right foot and chronic kidney disease. Review of care plan dated 07/01/25 noted Resident #15 was at risk for falls related to assistance needed with toileting and transfers. Interventions included keeping the call light within reach. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #15 had impaired cognition. Resident #15 required moderate assistance for toileting and mobility. Review of the medical record for Resident #41 noted an admission date of 05/30/25. Diagnoses included seizures, hemiplegia and hemiparesis. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #41 had impaired cognition. Resident #41 required moderate assistance for toileting and mobility. Review of the care plan dated 07/01/25 noted Resident #41 was at risk for falls related to assistance needed with toileting and transfers. Interventions included keeping call light within reach, encouraging the resident to use call light, and required a mechanical lift for transfers. Observations on 08/20/25 at 3:19 P.M. noted Residents #9, #15, and #41 activated their call lights. CNA #59 was the only staff working on the floor at that time and was in a room with another resident. Further observations noted LPN #346 walk down the hall and enter Residents #9, #15, and #41’s rooms, turned off the call lights and returned to the nurse’s desk. CNA #359 walked out of the other resident’s room and was unaware of the needs of the three residents whose light was turned off. Interview on 08/20/25 at 3:19 P.M., Resident #41 stated she needed to be changed, and the nurse said she would be right back. Interview on 08/20/25 at 3:24 P.M., Resident #15 stated she needed to be in bed, and the nurse said she would be right back. Interview on 08/20/25 at 3:25 P.M., Resident #9 stated she needed to be changed, and the nurse said she would be right back. Resident #9 stated staff always come in, turn the light off and then leave and never return. Interview on 08/20/25 at 3:37 P.M., LPNs #303 and #346 were observed sitting at the nurse’s desk from 3:10 P.M. to 3:37 P.M. Both staff stated CNA #359 was working on the unit. Both staff were asked why they were sitting at the desk with three call light activated. Both staff stated they were doing training. 3. Review of the medical record for Resident #69 revealed an admission date of 09/19/23. Diagnoses included type II diabetes, Alzheimer’s disease, encephalopathy, morbid obesity, overactive bladder and depression. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #69 had impaired cognition. The resident was dependent on staff for eating, toileting, showering and dressing. Resident #69 was incontinent of bowel and bladder. Review of the progress note dated 06/27/25 at 5:02 A.M. written by LPN #398 stated Resident #69’s power of attorney (POA) contacted the facility to inform nursing that Resident #69 had not been checked and changed for a while. The resident was laid down for bed at 9:30 P.M. The CNA reported back to the nurse and stated the last time she checked on the resident was at 1:00 A.M. LPN #389 educated the CNA on the facility policy to check and change resident every two hours. Resident #69’s POA called back ten minutes later to inquire again about care. LPN #398 checked on the CNA, and she was proving care to another resident. The CNA then went into Resident’s #69 room and provided care, and the brief was mildly saturated. The resident was now in bed, resting comfortably and the POA was satisfied. Interview on 08/21/25 at 9:30 A.M. with LPN #389 stated Resident #69’s POA was very strict about times when the resident was changed. LPN #389 verified Resident #69 was not changed every two hours per facility policy. LPN #389 educated the CNA on the facilities policy. Interview on 08/25/25 at 5:00 P.M. with the Director of Nursing (DON) stated she directed LPN #389 to document the incident. Review of the facility policy titled Incontinence Care, revised March 2022, revealed the policy is to ensure a resident who is incontinent of bowel and/or bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. This deficiency represents noncompliance investigated under Master Complaint Number 2589262 and Complaint Numbers 2579574 1401332 (OH00167486), 1401404 (OH00167479), 1401399 (OH00165474), 1401397 (OH00163878), and 1401393 (OH00162964).

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and facility policy review, the facility failed to ensure residents at risk for falls were safe by implementing interventions written in the plan of care, appropriate call light response, and timely intermittent observations of residents. This affected one (Resident #65) of five residents reviewed for falls. The facility failed to ensure all residents requiring a mechanical lift for transfers were transferred safely. This affected one (Resident #65) of 34 residents who required a mechanical lift for transfers. The facility failed to provide care and services to prevent falls related to level of assistance. This affected two (Residents #18 and #39) of five residents reviewed for falls. The facility failed to ensure Resident #99 had a fall assessment and a pain assessment after a fall with minor injury. This affected one (Resident #99) of five residents reviewed for falls. The facility census was 86. Findings include:1. Review of the medical record for Resident #65 noted an admission date of 08/21/24. Diagnoses included unspecified dementia, encounter for palliative care, and repeated falls. Review of the plan of care dated 04/29/25 noted Resident #65 had continuous video monitoring. Review of the plan of care dated 05/02/24 noted Resident #65 was at risk for cognition decline due to dementia and senile degeneration of the brain. Review of the plan of care dated 05/02/24 noted Resident #65 had impaired visual function. Review of the facility siderail assessment dated [DATE] noted Resident #65 had no visual deficits, was not able to get out of bed, had a history of falls and had no desire to get out of bed. The assessment also indicated a recommendation of bilateral half rails to prevent further falls. No other siderails assessments were completed after 05/13/25. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #65 had impaired cognition. Resident #65 was dependent on staff for mobility. Review of the plan of care initiated on 03/31/25 (updated on 07/07/25 and 07/28/25) noted Resident #65 was at risk for falls due to incontinence of bowel and daily use of psychotropic medications. Interventions included the use of bilateral grab bars, Dycem (non-slip material) to the mattress, a perimeter overlay to the mattress dated 07/07/25, a sitter at night and a mechanical lift for all transfers both dated 07/28/25. Review of the nursing fall risk assessments dated 03/19/25 through 07/30/25 indicated Resident #65 was at risk for falls. Review of the incident log dated 11/24/24 through 08/18/25 noted Resident #65 had a fall on 02/01/25 at 8:01 P.M., 07/06/25 at 10:00 P.M., 07/25/25 at 1:35 A.M., and 07/28/25 at 1:30 A.M. Review of the videos sent in by the family from 07/06/25 through 07/28/25 noted Resident #65 was restless during the late evening and early morning hours. The videos showed Resident #65 fidgeting, removing his blankets and wiggling toward the right side of the bed several times. Review of the video dated 07/06/25 at 10:57 P.M. revealed Resident #65 sitting on the floor. Licensed Practical Nurse (LPN) #400 and Certified Nurse Assistant (CNA) #401 lifted Resident #65 under his arms to place him back in bed. Review of the video dated 07/13/25 from 8:24 P.M. to 11:47 P.M. revealed Resident #65’s call light was activated at 8:40 P.M. Further review revealed Resident #65’s call light was still activated at 11:00 P.M., no staff had checked on Resident #65 since 8:40 P.M. Resident #65 began calling out to the nurse for help from 11:00 P.M. to 11:49 P.M. when LPN #334 entered the room. The staff member observed Resident #65 positioned from the top right of bed to the left bottom of the bed, no repositioning was provided. The call light times were observed by the videos provided, a review of the facility electric call light responses for 07/13/25 noted Resident #65’s call was activated from 5:09 P.M. to 11:47 P.M. This was verified by Corporate Director of Operation (CDO) #505 during the observation of videos. Review of a video dated from 07/27/25 at 9:53 P.M. to 07/28/25 at 6:29 A.M. revealed Resident #65 activated the call light at 9:53 P.M. LPN #334 entered the room at 10:29 P.M. Resident #65 was positioned at the right edge of the bed at that time. LPN #334 straightened Resident #65’s covers and left the room without repositioning the resident. At 12:47 A.M. Resident #65 was observed with his legs hanging over the right side of the bed. At 1:19 A.M. on 07/28/25 Resident #65 was observed on the floor next to the right side of the bed. No staff had checked on Resident #65 since 10:29 P.M. on 07/27/25. At 1:20 A.M., another resident entered the room after hearing a loud thud and hollering to find Resident #65 lying on the floor. Resident #26 left the room to call for help. Staff entered the room stating “why does he not have full side bed rails and discussed a way to transfer Resident #65 back into bed by lifting or by using the mechanical lift. Staff used the mechanical lift and positioned Resident #65 to the right side of the bed, covered him and left the room. From 1:37 A.M. to 6:09 A.M., no staff entered the room to check on Resident #65. From 3:19 A.M. to 3:31 A.M. Resident #65 was observed with both legs hanging off the right side of the bed. LPN #334 entered Resident #65’s room at 6:09 A.M. and stated that she could not pull the resident by herself. The nurse picked up Resident #65’s legs and placed them on the edge of right side of the bed, covered him up, took vital signs and left the room. Observation on 08/22/25 at 7:59 A.M. noted Resident #65 lying on his back in the center of the bed. LPN #385 was asked if Resident #65 had Dycem under him as written in the care plan. LPN #385 stated she did not think so as she had never observed it before. Continued observations noted Unit Manager (LPN #405) and Unit Manager Registered Nurse (RN) #307 turned Resident #65 to see if the Dycem was utilized. Both staff verified that no Dycem was placed under the resident to prevent sliding. LPN #405 stated the Dycem should be placed under the mattress to prevent the mattress from sliding. Unit Manager RN #307 stated the Dycem would be placed under Resident #65 after care was provided. Interview and observation on 08/22/25 at 11:39 A.M., CDO #404 and Regional Director of Clinical Services (RDCS) #502 observed the videos provided and verified all findings. Review of the facility policy titled “Resident Call Light,” dated 2023, noted staff were to answer the call light in a timely manner, do not turn off the call light if staff were unable to meet the resident’s needs, and complete the task the resident has requested. 2. Review of the medical record for Resident #65 noted an admission date of 08/21/24. Diagnoses included unspecified dementia, encounter for palliative care, and repeated falls. Review of the plan of care dated 03/31/25 noted Resident #65 was at risk for falls due to incontinence of bowel and daily use of psychotropic medications. Resident #65 required a mechanical lift for all transfers. Interventions included the use of bilateral grab bars, Dycem to the mattress dated 07/07/25, and a mechanical lift for all transfers dated 07/28/25. Review of the quarterly MDS 3.0 assessment dated [DATE], revealed Resident #65 had impaired cognition. Resident #65 was dependent on staff for mobility. Observation on 08/18/25 at 11:25 A.M. noted Hospice Aide (HA) #505 transferring Resident #65 via a mechanical lift without staff assistance. Resident #65 was observed in the lift sling parallel to the bed approximately four feet in the air. Interview immediately after the observation, HA#505 stated there were no staff to assist her. HA#505 stated she looked for staff but was on a tight schedule and needed to get her assignments completed. Interview on 08/18/25 at 11:50 A.M., the Administrator stated the facility policy required at least two staff members when transferring a resident via a mechanical lift. Review of the physician order dated 08/20/25 indicated Resident #65 required a mechanical lift of two staff assistance for transfers. Review of the facility policy titled “Hoyer Lift,” dated 2022, noted the procedure required two staff members present at all times. 3. Review of the medical record for Resident #18 revealed an admission date of 06/24/25 and diagnoses including quadriplegia, convulsions, and aphasia. Review of the plan of care dated 06/24/25 revealed Resident #18 had activities of daily living (ADL) needs. Interventions included dressing and grooming assistance of two staff and toileting assistance of two staff. Review of the MDS 3.0 admission assessment dated [DATE] revealed Resident #18 had severely impaired cognition. Resident #18 required partial/moderate assist to roll left and right and was dependent on staff for toileting hygiene, lower body dressing, and transfers. Resident #18 was unable to complete the toileting transfer task. Resident #39 was always incontinent of bowel and bladder. Review of the fall investigation dated 08/02/25 at 6:10 A.M. revealed CNA #391 reported to LPN #398 that Resident #18 was lying on the floor. CNA #391 told LPN #398 that she just left the room for something to finish care and when she returned, the resident was on the floor. LPN # 398 assessed the resident and found her to have no injuries. Proper notification was given to physicians, Power of Attorney (POA) and Director of Nursing (DON). Review of CNA #391’s witness statement revealed that Resident #18 was menstruating and had a bowel movement. CNA #391 left the room to get more supplies in the bathroom, and when she went back to the resident, Resident #18 was on the floor. Review of the fall risk assessment dated [DATE] revealed Resident #18 was not at risk for falls. Resident #18 was noted to require assistance with elimination, was confined to chair, and required physical help for balance. Review of the pain assessment dated [DATE] revealed Resident #18 did not verbalize pain. Review of the nursing progress note dated 08/02/25 revealed the POA of Resident #19 requested that her daughter be sent to the hospital. The physician was called, and a new order was received for Resident #18 to be sent to the hospital. Review of the progress note dated 08/03/25 at 2:19 A.M. revealed Resident #18 returned from the hospital with no new orders. Resident #18 denied pain. Review of the current nursing aide Kardex revealed Resident #18 required assistance of two for mobility and toileting. Review of the Interdisciplinary Team (IDT) note dated 08/12/25 at 5:51 P.M. revealed CNA #391 reported to LPN #398 that Resident #18 was lying on the floor. CNA #391 told LPN #398 that she just left the room for something to finish care and when she returned, the resident was on the floor. LPN #398 assessed the resident and found her to have no injuries. A new intervention was for two staff with all care and a perimeter mattress Interview on 08/21/25 at 2:01 P.M. with CNA #391 revealed she had worked night shift and was assigned to Resident #18 on 08/02/25. CNA #391 stated she was changing Resident #18 and turned her on her side. CNA #391 stated Resident #18 was holding the bed rail when she left the room to get supplies out of the bathroom because Resident #18 was menstruating. CNA #391 stated upon her return Resident #18 had already fallen out of bed. CNA #391 stated she checked on Resident #18 and went to get help from the nurse. CNA #391 stated Resident #18 was dependent on staff for care related to quadriplegia. Interview on 08/20/25 at 3:38 P.M. with LPN #398 revealed that there was only one aide in the room. She stated that she normally was in the skilled section but picked up that night. LPN #398 stated that there should have been two staff in the room at the time of the fall. 4. Review of the medical record for Resident #39 revealed an admission date of 06/09/25 with diagnoses including quadriplegia, Guillain-Barre syndrome, bilateral hand contractures, osteoarthritis of hips, osteopenia, and left knee osteoarthritis. Review of the MDS 3.0 admission assessment dated [DATE] revealed Resident #39 had intact cognition. Resident #39 had range of motion (ROM) impairments to bilateral upper and lower extremities. Resident #39 required partial/moderate assist to roll left and right and was dependent on staff for toileting hygiene, lower body dressing, and transfers. Resident #39 was unable to complete the toileting transfer task. Resident #39 was always incontinent of bowel and bladder. Review of the plan of care dated 06/17/25 revealed Resident #39 had ADL needs. Interventions included dressing and grooming assistance of two staff and toileting assistance of two staff. Review of the physician’s order dated 07/17/25 revealed Resident #39 had an order for grab bar to the left side of the bed for mobility and positioning. Review of an unwitnessed fall incident report dated 08/10/25 revealed the CNA informed the nurse while she was changing Resident #39, she rolled out of bed. Resident #39 was seen on the floor near her nightstand with legs extended in front of her, lying on her left side. Resident #39 stated she bumped her head and was having pain in her left hip and knee. There were no visible injuries, and ROM was within normal limits (WNL) for Resident #39. Resident #39 stated she rolled out of bed while the CNA was changing her. Factors contributing to fall were listed as: during check and change resident rolled out of bed on the right side of the bed in which there was no railing. A side rail to the right side of bed was added for safety precautions and neurological checks were initiated. Review of the fall risk assessment dated [DATE] revealed Resident #39 was not at risk for falls. Resident #39 was noted to require assistance with elimination, was confined to chair, and required physical help for balance. Review of pain assessment dated [DATE] revealed Resident #39 complained of seven out of 10 throbbing pain to front of her left knee. There was no bleeding, bruising, or injury noted. Resident #39 was medicated with 50 milligrams (mg) of Tramadol (opioid pain medication) and 650 mg of Tylenol (analgesic) for pain. Review of the nursing progress note dated 08/10/25 revealed Resident #39 was post-fall and had complaints of pain to left hip and knee. The nurse practitioner (NP) was notified and gave an order for an x-ray of left knee and hip to rule out fracture. Review of the physician’s order dated 08/10/25 revealed Resident #39 had an order for a left hip with pelvis and left knee x-ray. Review of the x-ray results dated 08/10/25 revealed no evidence of dislocation or fracture. There was noted mild osteoarthritis of both hip joints and the left knee joint. Review of the physician’s order dated 08/10/25 revealed Resident #39 had order for a grab bar to the right side of the bed for safety. Review of the employee corrective action form dated 08/11/25 revealed CNA #331 was disciplined with a verbal warning. CNA #331 was educated on always checking the Kardex (a summary tool that provides an overview of a resident’s care information) to see the level of assistance a resident needed as well as other resident specific information. It was noted “when in doubt always take another staff member to assist you.” Review of the current nursing aide Kardex revealed Resident #39 required assistance of two staff for mobility and toileting. Review of the progress note dated 08/12/25 revealed an IDT review of Resident #39’s fall on 08/10/25. The IDT added new intervention of a perimeter overlay to the mattress. Interview on 08/18/25 at 10:12 A.M. with Resident #39 revealed she had a recent fall out of bed. Resident #39 stated a nursing aide had come in to change her and rolled her onto her side. Resident #39 stated the nurse aide then stepped out of the room and she had fallen out of bed before the nurse aide had returned. Resident #39 stated she could help rolling onto her side but she had never been left alone rolled onto her side before. Resident #39 stated the bed was in a high position and she fell out of bed on the right side. Resident #39 stated she was still having pain in her knee since the fall. Resident #39 stated she was being medicated for pain and rubbing her knee helped. Resident #39 stated she had an x-ray of her knee, and it was not broken. Interview on 08/21/25 at 8:36 A.M. with CNA #331 revealed she had worked night shift and was assigned to Resident #39 on 08/10/25. CNA #331 stated it was early in the morning, and she was doing check and change rounds. CNA #331 stated she was changing Resident #39 and turned her on her right side. CNA #331 stated there was no bed rail on the right side for Resident #39 to hold onto. CNA #331 stated while Resident #39 was turned onto her side she went to the bathroom to get wash cloths from the sink in the bathroom. CNA #331 stated upon her return Resident #39 was already falling out of bed. CNA #331 stated she checked on Resident #39 and got her into a comfortable position then went to get help from the nurse. CNA #331 stated Resident #39 was dependent on staff for care related to quadriplegia. CNA #331 stated it would have been more appropriate to have two people in room while changing Resident #39. Interview on 08/26/25 at 8:42 A.M. with RN #306 revealed she had worked night shift and was assigned to Resident #39. RN #306 stated CNA #331 came to her and indicated Resident #39 fell out of bed. RN #306 stated CNA #331 had changed her story of what happened several times and the way Resident #39 fell was not making sense. RN #306 indicated when she questioned Resident #39, she reported CNA #331 left her turned on her side when she fell. RN #306 stated Resident #39 did not have a side rail on the right side of her bed. RN #306 stated Resident #39 should not have been turned onto her right side and left without support. 5. Review of the closed medical record for Resident #99 revealed an admission date of 02/13/25. Diagnoses included pneumonia, malignant neoplasm of esophagus, encephalopathy, attention deficit hyperactivity disorder, anxiety disorder, and bipolar disorder. The resident was discharged to another facility on 03/11/25. Review of the fall risk assessment dated [DATE] revealed Resident #99 was not at risk for falls. Review of the Modification of admission MDS 3.0 assessment dated [DATE] revealed Resident #99 had intact cognition. Resident #99 required supervision or touching assistance for sit-to-stand, chair-to-bed transfers, and walking. Medications received: antipsychotic, antianxiety, antidepressant, antiplatelet, hypoglycemic, anticonvulsant. Antipsychotics received on an as needed (PRN) basis only. Review of the nurse’s note dated 03/04/25 at 5:15 P.M. Resident #99 was returning to the facility from a radiation therapy appointment, when resident fell on the walkway outside of the building. The fall was witnessed by the receptionist and the person transporting the resident. Resident #99 had a right index finger skin tear, a minor right knee scrape, and minor left pinky finger scrape. The nurse cleaned the area and notified all parties. The resident did not have any injuries to the head. Vital signs were taken. Pain was three on scale of zero to ten. Review of the fall investigation dated 03/04/25 revealed the fall was unwitnessed (although nursing note stated it was witnessed by the receptionist and the transporter). Nursing assessed the resident. Vital signs were taken. The resident had a right index finger skin tear, a minor right knee scrape, and minor left pinky finger scrape. The pain assessment form and the fall assessment form were not completed. Interview on 08/22/25 at 1:48 P.M. RDCS #502 verified the pain assessment form and the fall assessment form were not completed. This deficiency represents noncompliance investigated under Master Complaint Number 2589262, and Complaint Numbers 2579574, 1401332 (OH00167486), 1401397 (OH00163878), 1401396 (OH00163306), and 1401401 (OH00162944).

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on observation, review of the meal spreadsheet, interview, and review of the facility policy, the facility failed to ensure accurate portions were served according to the menu diet spread sheet. This affected 22 (Residents #10, #14, #18, #29, #30, #37, #41, #42, #45, #46, #47, #51, #54, #56, #59, #66, #69, #73, #74, #78, #79, and #103) in the main dining room who were not on a pureed diet. The facility identified four (Residents #1, #48, #65, and #90) in the main dining room who received a pureed diet. This had the potential to affect all residents who received meals from the facility. The facility identified four (Residents #4, #19, #49, and #60) who received nothing by mouth (NPO). The facility census was 86. Findings include:Observation on 08/18/25 from 12:00 P.M. through 12:25 P.M. revealed residents were served by table. During the meal service, observation of the chicken and wild rice casserole revealed the portion appeared less than the spread sheet indicated. Interview on 08/18/25 at 12:23 P.M. with Resident #30 revealed that he was still hungry. Business Office Manager (BOM) #311 asked the kitchen for more food for Resident #30. Observation and interview of the lunch tray line on 08/18/25 at 12:24 P.M. revealed the utensil that was being used to serve the chicken and wild rice casserole was a #8 scoop. [NAME] #363 verified that she was giving one #8 scoop portion, which equaled four ounces. Review of the facility's spreadsheet for 08/18/25 lunch meal service revealed that the serving size for chicken and wild rice casserole was one cup, and the serving instructions stated to use either an eight-ounce spoodle or two four-ounce scoops. This was verified by Mobile Dietary Manager (MDM) #500 at time of observation. This deficiency represents noncompliance investigated under Complaint Numbers 1401399 (OH00165474) and 1401394 (OH00163002).

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner. This affected three (Residents #37, #666, and #103) and had the potential to affect all resident receiving food from the kitchen. The facility identified four (Residents #4, #19, #49, and #60) as receiving nothing by mouth (NPO). The facility census was 86. Findings include:Review of the undated facility mealtimes revealed breakfast was served from 7:00 A.M. to 8:45 A.M., lunch was served from 11:30 A.M. to 1:00 P.M., and dinner was served from 4:30 P.M. to 5:30 P.M. The identified order of serving was first dining room, assisted living, premium suites, front hall, middle hall and back hall. Observation of tray line on 08/18/25 at 12:25 P.M. revealed food was above 165 degrees Fahrenheit (F) on the tray line, preferences were honored, condiments were available, and every tray had appropriate silverware including adaptive equipment. Observation on 08/18/25 revealed the food cart left the kitchen at 1:24 P.M. and was delivered to the back hall. Interview on 08/18/25 at 1:24 P.M. with the Mobile Dietary Manager (MDM) #500 verified that the meal trays were delivered 24 minutes late according to the posted mealtimes. Observation during interview with Resident #63, who resided in the Middle Hall, on 08/18/25 at 1:55 P.M. revealed Corporate Registered Nurse (CRN) #410 delivered the lunch tray. Interview on 08/18/25 at 1:56 P.M. with CRN #410 confirmed he had delivered Resident #63's lunch meal tray. CRN #410 indicated he was unsure why the meal trays were late. CRN #410 reported he had been asked to help pass meal trays. During interviews with residents during the Resident Council meeting on 08/20/25 at 11:15 A.M., Residents #37, #666, and #103 voiced concerns that meals were often served late. Review of the posted mealtimes for lunch meal service revealed that the Middle Hall should have had their meal trays delivered at 12:45 P.M. and the Back Hall meal trays should have been delivered by 1:00 P.M. This deficiency represents noncompliance investigated under Complaint Numbers 1401399 (OH00165474) and 1401394 (OH00163002).

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0949 (Tag F0949)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Facility Assessment, personnel record review, and interview, the facility failed to provide behavioral health training upon hire and/or annually to all staff who were employed at the facility. This had the potential to affect all 86 residents in the facility. Findings include:Review of the nursing in-service regarding behaviors on 05/06/25 revealed it included nursing staff but did not include housekeeping, dietary, or maintenance. Review of the facility's Facility assessment dated [DATE] included under staff training, education and competency training would be provided to all staff (beginning July 2023) about caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder. Training included review of competencies and skills to provide patient care services that reflect the resident's goals. Review of the personnel record for Housekeeper #418 revealed he was contract staff with a hire date of 05/27/25 with no documented evidence of behavioral training. Review of the personnel record for Floor Tech #415 revealed he was contract staff with a hire date of 11/03/24 with no documented evidence of behavioral training. Review of the personnel record for Certified Nursing Assistant (CNA) #329 revealed she had a hire date of 07/23/25 with no documented evidence of behavioral training. Review of the personnel record for CNA #313 revealed she had a hire date of 07/25/25 with no documented evidence of behavioral training. Review of the personnel record for CNA #323 revealed she had a hire date of 06/11/25 with no documented evidence of behavioral training. Interview on 08/20/25 at 10:10 A.M. with Corporate Human Resource Manager (CHR) #501 verified that new hires do not get behavioral training during orientation and it was not included on the company mandated 12 hours of annual in-services. Interview on 08/20/25 at 10:36 A.M. with Director of Nursing (DON) revealed that she did in-service staff on behaviors on 05/06/25 because she felt there was a need for staff to be trained on behaviors at the time. Interview on 08/20/25 at 2:56 P.M. with the contracted Regional Housekeeping Director (RHD) #423 verified that there was no documented behavioral training for housekeeping employees. This deficiency represents noncompliance investigated under Complaint Numbers 1401332 (OH00167486), 1401404 (OH00167479), and 14011397 (OH00163878).

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observations, interviews and facility policy review, the facility failed to ensure clean food service areas including opened food that was not labeled or dated. This had the potential to affect all residents who received meals from the kitchen. The facility identified four (Residents #4, #19, #49, and #60) as receiving nothing by mouth (NPO). The facility census was 86. Findings include:Initial tour of the kitchen on 08/18/25 from 8:24 A.M. through 8:40 A.M. revealed potato chips and white cake mix were not dated in the dry storage area. In the prep area, the slicer had dried food on the blade, and the mixer had dried batter on the back splash. In the reach-in refrigerator located under the prep table in the cook's area there was bacon, chicken noodle soup, and lima beans that were not labeled and dated. In the reach-in freezer, there was breaded chicken patties, chicken fingers, unbreaded chicken breasts, onion rings and French fries that were not labeled or dated. The findings were verified by the Administrator at the time of the observation. Review of the undated facility policy titled, Food and Sanitation revealed that open packages and leftovers will be labeled and dated. Review of the undated facility policy titled, General Sanitation of the Kitchen revealed that the food and nutrition will maintain the sanitation of the kitchen through compliance with a written cleaning schedule.

Feb 2025 30 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Deficiency F0697 (Tag F0697)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, hospital record review, facility policy review and staff and resident interview, the facility failed to develop and implement a comprehensive, individualized and effective pain management program for Resident #77 who was admitted with acute pain and difficulty with moving due to pain to the left foot and a vascular wound. Actual Harm occurred beginning on 01/18/25 when Resident #77 did not receive ordered pain medication, Tramadol (an opioid pain reliever). The resident was admitted to the facility (on 01/18/25) with a physician order for Tramadol 25 milligram (mg) every 12 hours as needed for pain for up to seven days; however, the medication was not administered until 01/21/25 (three days after admission). During this time, Resident #77 had complaints of severe and unrelieved pain. This affected one resident (#77) of three residents reviewed for pain management. The facility census was 100. Findings include: Review of Resident #77's medical record revealed an admission date of 01/18/25 with medical diagnoses including type II diabetes mellitus, peripheral vascular disease, protein-calorie malnutrition, anxiety, and acute pain. Review of Resident #77's pre-admission hospital records dated 01/07/25 to 01/18/25 revealed the resident had been admitted to a local hospital on [DATE] for weakness, fatigue, and being unable to move around due to left foot pain. The hospital records noted Resident #77 had difficulty maintaining attention due to pain. Additionally, Resident #77 had a vascular wound ulcer to the top of her left foot with pain in the left foot and leg. Additional imaging was recommended at the hospital, but the record noted the imaging may not be able to be completed due to the resident's high pain ratings to the affected left leg. Review of Resident #77's hospital discharge paperwork dated 01/18/25 revealed Resident #77 had been treated at a local hospital for left arterial ulcer and left foot pain. Resident #77's medication list included Tylenol 500 mg every six hours as-needed for pain and Tramadol 25 mg every 12 hours as-needed for pain for up to seven days. Review of Resident #77's physician's orders revealed an order dated 01/18/25 for Tramadol 25 mg every 12 hours as needed for pain. The order was discontinued on 01/20/25, and a new order was placed for Tramadol 25 mg every 12 hours as needed for pain for a total duration of seven days, with a listed end date of 01/24/25. An order dated 01/23/25 for Oxycodone (narcotic opioid analgesic) 5 mg three times a day routinely for pain was discontinued on 01/24/25. On 01/24/24, Resident #77's order was changed to Oxycodone 5 mg every eight hours as needed for pain. On 01/24/25 Resident #77's Oxycodone order was increased in frequency to Oxycodone 5 mg every six hours as needed for pain. Review of Resident #77's progress notes dated 01/19/25 at 9:25 A.M. authored by Licensed Practical Nurse (LPN) #852 revealed the resident had complaints of pain, and [as needed] Tylenol was administered. A progress note dated 01/19/25 at 5:17 P.M. authored by LPN #852 revealed Nurse Practitioner (NP) #913 had been notified that the pharmacy needed a hard copy of Resident #77's Tramadol prescription. A follow up note dated 01/19/25 at 5:56 P.M. authored by LPN #852 revealed NP #913 had responded ok when asked to send Resident #77's Tramadol prescription to the pharmacy. Review of Resident #77's care plan dated 01/20/25 revealed the resident was at risk for acute pain. Care planned interventions included administering analgesia per orders and one-half hour before treatment or care. Additional interventions included to monitor, record, and report any sight and symptoms of non-verbal pain which included moaning and yelling out. Review of Resident #77's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The assessment revealed Resident #77 required maximum assistance with toileting and moderate assistance with bathing and personal hygiene. Review of Resident #77's Medication Administration Record (MAR) for January 2025 revealed the resident's pain was not consistently assessed. On 01/20/25 and 01/25/24, Resident #77 reported a pain rating of seven out of 10 (with 10 being the most severe pain). Tylenol 500 mg was administered on 01/19/25 at 9:23 A.M. for pain level of six out of 10, 01/20/25 at 11:10 P.M. for a pain level of seven out of 10 and 01/23/25 at 6:06 A.M. for a pain level of five out of 10. Record review revealed Resident #77 received her first dose of Tramadol 25 mg on 01/21/25 at 12:50 P.M. with no associated pain rating recorded. Observation on 01/21/25 at 8:02 A.M. revealed Resident #77 yelled out in pain and was heard from the hallway outside of the resident's closed door. Upon entering Resident #77's room, Registered Nurse (RN) #844 and LPNs #803 and #852 were in Resident #77's room. An interview with LPN #852 at the time of observation revealed she had contacted NP #913 to obtain orders for Resident #77's pain medication and in the meantime had administered as-needed Tylenol while awaiting a return call from NP #913. LPN #852 stated she had contacted NP #913 to inform her of the need for the script for Tramadol to be sent to the pharmacy and stated NP #913 had told her she would send the script. LPN #852 stated she had not returned to work until 01/21/25 and verified, upon her return, Resident #77's needed prescription had not been obtained and Resident #77's Tramadol medication had been unavailable. RN #844 stated she was unaware Resident #77 had complaints of pain and Resident #77 stated to RN #844 I told you all night I was having pain. RN #844 did not respond to Resident #77 and had exited the room. LPN #803 and LPN #852 also proceeded to exit the room and Resident #77 continued to lay in bed and yell out in pain. There was no evidence the resident's pain was addressed at this time. Observation on 01/22/25 at 10:54 A.M. of Resident #77 with LPN #847 revealed Resident #77 had complaints of pain to a wound on her left foot. LPN #77 stated she was unaware of Resident #77 having pain and stated she would check if Resident #77 had been given pain medication earlier. At the time of observation, the Director of Nursing (DON) and Administrator entered Resident #77's room. The DON stated she was unaware of Resident #77's complaints of pain related to the wound on her left foot and stated she would have the wound nurse come in and assess the area. Observation and interview on 01/22/25 at 11:04 A.M. revealed LPN #903 entered Resident #77's room with the DON and the Administrator. LPN #903 stated she had been unaware of Resident #77's left foot wound. LPN #903 proceeded to assess the area and Resident #77 yelled out in pain. Resident #77 was noted with facial grimacing. During the assessment and cleansing, when the area was manipulated, the resident attempted to withdraw her left leg from the painful stimuli. LPN #903 had continued to assess the area and neither LPN #903 nor the DON asked Resident #77 about her pain or offered her any pain medication. LPN #903 stated she would gather supplies to cleanse the wound and had exited the room. The DON remained at Resident #77's bedside and asked Resident #77 about the pain in her foot. The DON asked Resident #77 if the pain was present only when touched, and Resident #77 stated It hurts all the time. Interview on 01/22/25 at 12:10 P.M. with the DON confirmed Resident #77 was admitted to the facility with care needs which included ulcer care for the left foot wound and pain control. Observation on 01/23/25 at 6:32 A.M. revealed Resident #77 was heard yelling out in pain. Interview with Resident #77 at time of observation revealed she was having pain rated a 10 out of 10 in her foot and stated she wasn't sure if she had received pain medication. Review of facility policy titled Pain Management revised 02/2023 revealed the purpose of the policy was to ensure residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The licensed nurse will perform a pain assessment upon admission, quarterly, with significant change, and with new onset of pain and incident. If the resident is assessed to be experiencing pain, the nurse will explore pharmacological and non-pharmacological interventions, as appropriate, per the resident's comprehensive assessment, plan of care, and standards of practice. This deficiency represents an incidental finding identified while investigating Master Complaint Number OH00162102 and Complaint Numbers OH00161890, OH00161859, OH00161556, OH00161410, OH00161144, OH00161142, and OH00161136.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of camera footage, medical record review, interview, and review of facility policy, the facility failed to ensure call lights were within reach of residents. This affected one resident (#61) out of five observed for call lights. The facility census was 100. Findings include: Review of Resident #61's medical records revealed an admission date of 08/21/24. Diagnoses included falls, chronic heart failure and chronic obstructive pulmonary disease. Review of the care plan dated 05/08/24 revealed Resident #61's room had continuous video monitoring. Resident #61 had noted self-care deficits. Interventions included to encourage Resident #61 to use call bell for assistance. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had intact cognition. Resident #61 was dependent with toileting and required maximum assistance with bathing and personal hygiene. Interview on 01/21/25 at 1:41 P.M. with Resident #61's wife revealed on 12/26/24 she had reviewed camera footage that had shown an unnamed aide that had taken Resident #61's call light and had placed it on the floor. Resident #61's wife stated she had shown the video to the Director of Nursing (DON) the following day. Review of camera footage (unable to obtain the date and time of footage) at time of interview provided by Resident #61's wife had shown an aide in Resident #61's room, she had turned the call light off and had then proceeded to take the call light from Resident #61's hand and the call light had then dropped to the floor. The video footage showed Resident #61 was sleeping at that time. Review of the video footage on 02/05/25 at 1:41 P.M. with the DON confirmed an aide (unable to provide a name) had turned Resident #61's call light off and the light had then fallen on the floor. At time of interview, Central Supply (CS) #814 had entered and stated the aide was Certified Nursing Assistant (CNA) #918 and she was no longer employed at the facility. Review of the policy Resident Call System revised 03/2023 revealed the staff will provide an environment to assist in meeting the needs of the resident and to provide an environment which supports and enhances each resident's quality of life, providing the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. The procedure stated when leaving the room, be sure the call light is placed within the resident's reach. This deficiency represents an incidental finding identified while investigating Master Complaint Number OH00162102 and Complaint Numbers OH00161890, OH00161859, OH00161556, OH00161410, OH00161144, OH00161142, and OH00161136.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the Ohio Department of Health (ODH) Certification and Licensure System (CALS), and review of facility policy, the facility failed to timely report an injury of unknown origin to the State Agency as required. This affected one resident (#64) of three residents reviewed for self reported incidents. The facility census was 100. Findings include: Review of Resident #64's medical record revealed an admission date of 01/09/25. Diagnoses included muscle weakness, difficulty walking and dementia. Review of the care plan dated 01/09/25 revealed Resident #64 was at risk for falls. Interventions included maintain a safe and clutter free environment. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had intact cognition and required moderate assistance with sit-to-stand transfers and bed-to-chair transfers. Review of a progress note dated 01/20/25 timed 10:16 P.M. with a created date of 01/22/25 at 11:26 A.M. authored by Registered Nurse (RN) #801 revealed the Nurse Practitioner (NP) had assessed Resident #64 and had informed him of a new order for an x-ray. The progress note stated RN #801 asked why the x-ray was being ordered and NP stated Resident #64 had stated he had fallen in December and his ankle was now bothering him. RN #801 had assessed Resident #64 and his ankle was swollen, painful to touch, and the resident reported pain during ambulation. Review of a progress note dated 01/22/25 timed 7:14 A.M. authored by RN #801 revealed Resident #64's x-ray examination report showed the resident had a fracture of the ankle. Review of a progress note dated 01/22/25 time 10:40 A.M. authored by Assistant Director of Nursing (ADON) #898 revealed orders were given to send Resident #64 to the hospital. Review of progress note dated 01/20/25 timed 10:16 P.M. with a created date of 01/24/25 timed 2:32 P.M. authored by the Director of Nursing (DON) revealed on 01/20/25 at 10:16 P.M. Nurse Practitioner had performed an evaluation of Resident #64 and he had reported complaints of left ankle pain related to a fall in December while living at a group home. Resident #64 had reported no pain unless ambulating and an order for an x-ray was placed. Assessment of Resident #64's ankle by NP revealed left ankle was swollen and pain during palpation. Resident #64 denied he had told anyone about the fall. Review of the ODH CALS website revealed on 01/22/25 at 11:37 A.M., the facility initiated a SRI for an injury of unknown origin related to Resident #64's ankle fracture. Interview on 02/03/25 at 1:37 P.M. with the DON revealed the SRI was initiated as soon as they had been made aware of the injury for Resident #64. Resident #64's progress notes dated 01/20/25 were reviewed with the DON and compared to the created date of the SRI. The DON shrugged her shoulders and was unable to provide further explanation. Review of the undated policy titled Abuse Prohibition revealed injuries of unknown source must be reported immediately, but no later than two hours after the allegation is made, to the the Administrator and State Agency. This deficiency represents non-compliance investigated under Complaint Number OH00161859.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident record review, staff interviews, and facility policy review, the facility failed to ensure residents were provided assistance with meals. This affected two residents (#26 and #71) of three residents reviewed for meal assistance. The facility census was 100. Findings include: 1. Review of the medical record for Resident #71 revealed she was admitted to the facility on [DATE] with diagnoses that included polyosteoarthritis, dementia, and hypertensive heart disease with heart failure. Review of the quarterly Staff Assessment for Mental Status (SAMS) assessment dated [DATE] revealed Resident #71 had short and long-term memory loss and was severely impaired regarding tasks of daily life. Review of the SAMS assessment revealed Resident #71 was dependent on staff for Activities of Daily Living (ADLs). Review of the physician orders dated 12/10/24 revealed Resident #71 had an order for a regular diet, pureed texture with thin consistency liquids. Review of the physician orders dated 01/17/25 revealed Resident #71 was to be encouraged to be in the main dining room for meals every shift for fall prevention. Review of the physician orders dated 01/22/25 revealed Resident #71 required feeding assistance for all meals. Review of the progress note dated 01/22/25 at 7:18 P.M. revealed Resident #71 was now a feed assist as of 01/22/25 and for staff to assist with feeding of all meals every shift to start 01/23/25. Review of the care plan dated 02/27/24 revealed Resident #71 had a self-care deficit due to dementia and limited mobility with interventions that included eating supervised with assistance. Observation on 01/27/25 at 9:34 A.M. revealed Resident #71 lying in bed with her breakfast tray on her over-the-bed table and positioned over her body. Resident #71 was observed attempting to eat her breakfast meal with no staff present. Observation and interview on 01/27/25 at 9:37 A.M. revealed Certified Nursing Assistant (CNA) #889 entered Resident #71's room with Resident #26's finished breakfast tray in her hand. CNA #889 revealed he was entering Resident #71's room to assist with her breakfast meal. CNA #889 approached Resident #71, while standing, begin to spoon feed the resident with his right hand, while he continued to hold Resident #26's completed tray still in hand. CNA #889 continued to feed Resident #71, while standing, 3 scoops of her breakfast meal before he exited the room. Resident #71 was then observed attempting to continue to eat her breakfast meal. Resident #71 spoon was upside down as she tried to feed herself. CNA #889 was then observed to re-enter the room and stated Resident #71 was capable of feeding herself. CNA #889 confirmed and verified the findings at the time of the observation. Observation on 01/28/25 at 12:15 P.M. revealed CNA #885 transported Resident #71 to the main dining room which was located adjacent to the activities room. CNA #885 seated Resident #71 at a table. Observation and interview on 01/28/25 at 12:56 P.M. revealed Resident #71 was seated at the table in the main dining room with an unfinished meal still in front of her on the table. Resident #71 was observed lifting up her glass to drink a clear liquid with no staff seated near her. Observation revealed the Business Office Manager (BOM) #822 was standing approximately 5 feet in front of Resident #71 on the opposite side of the table. Interview with BOM #822 confirmed and verified no staff assisted Resident #71 with her lunch meal. Observation on 01/29/25 at 12:03 P.M. revealed Resident #71 seated at table in the main dining room. Resident #71 was observed seated with her lunch meal in front of her with no staff present to assist with her meal. Interview on 01/29/25 at 12:07 P.M. with the Director of Nursing (DON) revealed Resident #71 was on hospice services and could feed herself. The DON acknowledged Resident #71 was seated at the table staring at her plate of food. The DON revealed she would have hospice and speech therapy to evaluate her further to determine her dietary needs. Review of Resident #71's medical record with the DON, at the time of the observation on 01/29/25 at 12:07 P.M., confirmed approximately 7 days prior, Resident #71 had received a new order for feeding assistance. The DON confirmed and verified the findings at the time of the observations. Interview on 01/29/25 at 12:18 P.M. with Licensed Practical Nurse (LPN) #836 revealed Resident #71 was on hospice and received a new order to be assisted with all her meals. LPN #836 revealed Resident #71 physically needed help to eat her meals because she would get tired quickly. LPN #836 revealed when staff assists her with her meals, she eats all her food, but if not assisted, she would not be able to finish her meals. LPN #836 confirmed and verified Resident #71 required assistance with her meals as reconciled with her new orders to maintain her dietary and nutritional needs. 2. Review of the medical record for Resident #26 revealed an admission date of 02/11/23. Diagnoses included but were not limited to hemiplegia and hemiparesis, morbid obesity, unilateral osteoarthritis. Review of 01/11/25 annual Minimum Data Set (MDS) 3.0 for Resident #26 revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Review of activities of daily living (ADLs) revealed Resident #26 required supervision for eating meals. Review of Resident #26's care plan revealed it was last reviewed on 07/16/24. Resident #26 was noted to demonstrate extrapyramidal symptoms (EPS) and subacute dyskinesia. Intervention dated 07/16/24 was a speech therapy referral for speech and eating difficulty. Review of physician order dated 07/12/24 revealed Resident #26 required supervision with each meal to for signs of choking with meals related to tardive dyskinesia (mild to severe involuntary movements which impair eating safety and ability) Review of physician order dated 07/17/24 revealed Resident #26 required feeding assistance and to aides were to assist with feeding of all meals related to drug induced subacute dyskinesia. Review of electronic medical record Activities of Daily Living (ADL) feeding task for Resident #26 dated 01/28/25 revealed over the past 30 days only two days (01/05/25 and 01/13/25) supervision was indicated as provided. Observation on 01/27/25 at 9:16 A.M. revealed CNA # 814 cutting up food for Resident #26 in her room. Interview with CNA #814 after leaving Resident #26's room confirmed she was unaware Resident #26 required assistance and supervision with meals, stating she was told she just required meal set up and was able to feed herself. Interview on 02/03/25 at 8:11 A.M. with Licensed Practical Nurse (LPN) #903 stated Resident #26 required set up for meals. LPN #903 confirmed she was unaware Resident #26 had orders for staff supervision and assistance with meals. Interview on 02/04/25 at 8:00 A.M. with CNA #835 confirmed was unaware of active order for supervision for meals for Resident #26 and thought she was just set up for meals. Interview on 02/04/25 at 11:05 A.M. with the Assistant Director of Nursing (ADON) there was an active order for supervision of meals for Resident #26 which should have been changed to meal set up but was not updated. Review of the policy Activities of Daily Living dated 03/2023 revealed the facility will provide care and services for activities of daily living, including eating meals and snacks. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out activities of daily living. This deficiency represents non-compliance investigated under Complaint Numbers OH00161859, OH00161142, and OH00161136.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and review of facility policy, the facility failed to ensure Resident #17's newly-identified pressure ulcer was timely assessed and had a treatment implemented. This affected one (Resident #17) of three residents reviewed for wounds. The facility census was 100. Findings include: Review of Resident #17's medical record revealed an admission date of 04/13/22 with medical diagnoses including stroke with right-sided weakness, aphasia (difficulty speaking) and falls. Review of Resident #17's Minimum Data Set (MDS) assessment dated [DATE] revealed she was rarely or never understood. Resident #17's cognition was not assessed on the assessment. Resident #17 was noted to be occasionally incontinent of bowel and bladder. She required moderate assistance with toileting and maximum assistance with bathing and personal hygiene. Review of Resident #17's care plan dated as revised 01/18/25 revealed the resident was at risk for altered skin integrity due to incontinence of bowel and bladder. Listed interventions included immediately reporting any changes to the nurse of redness and skin breakdown, and applying treatments as ordered. Review of Resident #17's physician's orders revealed an order was placed on 01/23/25 for a wound treatment to the resident's right buttock. The treatment called for the wound to be cleansed with normal saline, a calcium alginate wound dressing applied, to be covered with a silicone dressing and changed daily and as needed. There was no listed treatment for a left buttock wound. Observation on 01/21/25 at 10:42 A.M. of toileting assistance revealed the Director of Nursing (DON) assisting Resident #17 with toileting. Resident #17 was observed to have a quarter-sized red, open area to her left buttock that was bleeding. A small amount of blood was additionally noted on Resident #17's incontinence brief. There was no area of skin impairment observed on Resident #17's right buttock. During the observation, Resident #17 stated the area to her left buttock hurts. An interview with the DON at the time of observation confirmed Resident #17's had an open area that she had been unaware of previously. Interview on 01/23/25 at 12:10 P.M. with Wound Nurse Practitioner (WNP) #925 revealed she just been informed moments earlier of Resident #17's open area to her left buttock and was going to see Resident #17 to assess the area. Interview on 01/23/25 at 12:11 P.M. with Licensed Practical Nurse (LPN) #903 revealed she had been notified by an unnamed nurse on 01/20/25 that Resident #17 had a wound on her buttock. LPN #903 confirmed she had not assessed the area and had been waiting for weekly wound rounds with WNP #925. Observation on 01/23/25 at 12:16 P.M. of Resident #17 with WNP #925 and LPN #903 revealed the area to the Resident #17's left buttock was classified as a stage two pressure ulcer (partial thickness skin loss that exposes the deeper layer of skin). WNP #925 stated the area to the left buttock measured 0.6 centimeters (cm) in length by 0.5 cm in width by 0.1 cm in depth. There was no wound observed to Resident #17's right buttock. Review of the policy titled Pressure Ulcer Prevention and Risk Identification revised January 2023 revealed if a new skin area was identified the licensed nurse will initiate a skin grid flow record. The physician and responsible parties were to be notified and treatment will be initiated according to physician orders. This deficiency represents an incidental finding identified while investigating Master Complaint Number OH00162102 and Complaint Numbers OH00161890, OH00161859, OH00161556, OH00161410, OH00161144, OH00161142, and OH00161136.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a hand splint was re-ordered and applied as requested. This affected one (Resident #26) of three residents reviewed for range of motion. The facility census was 100. Findings include: Review of the medical record for Resident #26 revealed an admission date of 02/11/23. Diagnoses included but were not limited to hemiplegia and hemiparesis, morbid obesity, and unilateral osteoarthritis. Resident #26 was recorded as being hospitalized from [DATE] to 07/10/24. Review of the physician order dated 08/15/23 revealed and order for Resident #26 to wear left hand resting splint daily for six hours as tolerated. The order was noted to be discontinued on 07/10/24. Review of Resident #26's Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Review of activities of daily living (ADLs) revealed Resident #26 required supervision for meals and was dependent on staff for mobility and transfers. Observation on 01/21/25 at 9:48 A.M. on the wall in Resident #26's room revealed a sign dated 07/26/23 that stated a left-hand splint was to be applied daily. Interview at the time of observation with Resident #26 revealed she used to have a splint and had left the splint at the hospital several months ago. Resident #26 stated she had previously asked the therapist for a new one but had not been given one. Interview at the time of the observation with Certified Nursing Assistant (CNA) #883 confirmed she had not seen the splint for a long time. Review of Resident #26's Rehabilitation Screen Form dated 01/23/25 (initiated after surveyor brought concern to staff attention on 01/21/25) revealed a request for a left-hand splint. Observation on 01/28/25 at 11:45 A.M. of Resident #26 revealed call light was on. Interview at the time of the observation with Resident #26 revealed her left hand was bothering her and she said it was supposed to be on a pillow but staff did not assist her with the pillow. Resident #26 stated she had also previously told a nurse several months ago about wanting to get another splint, but was unsure which one she told. Interview on 01/28/25 at 1:52 P.M. with Therapy Director #912 confirmed Resident #26 previously had an order for a hand splint from 08/15/23 and had gone out to the hospital in July of 2024. Therapy Director #912 confirmed and the order was not re-ordered or re-activated when the resident returned from the hospital and should have been. Review of the invoice dated 01/31/25 (ten days after surveyor brought it to staff attention) revealed an order for Resident #26's left hand splint had been placed. This deficiency represents non-compliance investigated under Complaint Number OH00161144.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to ensure Resident #97 and #110 had accurate and thorough fall investigations completed, and failed to ensure admission nursing care plans with individualized fall prevention interventions were implemented. This affected two (Residents #110 and #97) of three residents reviewed for falls. Additionally, the facility failed to ensure only clinical and trained staff members provided assistance with transfers. This affected one (Resident #115) of three residents observed for safe transfers. The facility census was 100. Findings include: 1. Review of the facility incident log from 11/22/24 through 01/22/25 did not revealed no indication Resident #110 had experienced a fall on 01/14/25. Review of an updated facility incident log from 11/22/24 through 01/22/25 revealed Resident #110 had a witnessed fall on 01/14/25 at 9:21 P.M. Review of Resident #110's medical record revealed an admission date of 01/14/25 and diagnoses included pneumonia, unspecified organism, congestive heart failure, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, muscle weakness, and repeated falls. Resident #110 was discharged from the facility on 01/16/25. Review of Resident #110's progress notes revealed a note dated 01/14/25 at 5:21 P.M. which stated Resident #110 had a fall five minutes after being admitted to the facility. Resident #110 was found lying on her back. Resident #110 stated she was trying to go through her belongings and lost her balance. Resident #110 complained of back pain. No skin issues were found. The noted stated Nurse Practitioner (unidentified) was in to assess Resident #110 right away. No new orders were given. Review of Resident #110's Fall Investigation Checklist included Resident #110 had a witnessed fall on 01/14/25 at 9:21 P.M. (the fall was documented in the progress notes on 01/14/25 at 5:21 P.M.). Resident #110 had a fall five minutes after her admission. The daughter was with Resident #110. Resident #110 said she lost her balance looking for something in her purse. The doctor was in to see her and we helped her up after assessing her. There were no fall risk assessments, pain assessments, 72-hour post-fall assessments, or an admission care plan documented in the Investigation Checklist. Review of Resident #110's medical record including progress notes dated between 01/14/25 through 01/16/25 did not reveal evidence Resident #110 had an evaluation due to a fall by her Nurse Practitioner. The facility was unable to provide documentation Resident #110 was evaluated by the unnamed Nurse Practitioner on 01/14/25 after a fall. Review of Resident #110's medical record revealed no evidence a Nursing admission Assessment was completed. There was no evidence that a Fall Risk Assessment was completed, and there was no evidence 72-hour post-fall documentation was completed following the fall on 01/14/25. There was no evidence Resident #110 had an admission care plan completed within 48 hours of her admission to the facility and there was no evidence a Pain Assessment had been completed. Review of Resident #110's physician orders dated 01/14/25 through 01/16/25 revealed the resident did not have an orders for Tylenol. Review of Resident #110's progress notes dated 01/14/25 through 01/16/25 revealed no evidence Resident #110 had denied need for pain management due to chronic back pain. A late entry progress note written on 01/29/25 stated Resident #110 denied need for pain management due to chronic back pain. Review of Resident #110's Medication Administration Record (MAR) dated 01/14/25 through 01/15/25 revealed Resident #110's pain was recorded at a zero on a zero-to-ten scale, with zero being no pain, and ten being the worst pain. Review of Resident #110's Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 was cognitively intact. Resident #110 required partial to moderate assistance with toileting hygiene, bathing, the ability to come to a standing position from sitting in a chair, wheelchair or on the side of the bed and the ability to transfer to and from a bed to a chair or wheelchair. Further review of the assessment revealed Resident #110 occasionally had pain or hurting in the last five days, occasionally pain interfered with Therapy activities, and occasionally day-to-day activities were limited because of pain. Resident #110's pain was rated as a five on a scale of zero to ten, zero being no pain and ten the worst pain you could imagine. Review of Resident #110's care plan dated 01/16/25 (two days after her fall) included Resident #110 was at risk for falls, was a safety risk, and an elopement risk. A listed goal included Resident #110 would remain free of injuries and falls. Interventions included encouraging use of call light, keeping call bell in reach, and instruct Resident #110 on safety measures. Review of Resident #110's Pain assessment dated [DATE] and signed and locked on 01/29/25 included Resident #110 had a diagnosis which gave reason to believe she would be in pain. Resident #110 had osteoarthritis (not included in medical diagnoses) and decreased mobility. Resident #110 verbalized she had pain described as aching. Pain was relieved by medication (there was no evidence of medication administered related to pain) and deep relaxation. The area for intensity of pain using a scale of zero-to-ten was not completed. The area for location and frequency of pain was not completed. Review of Resident #110's late entry progress note dated for 01/14/25 at 5:05 P.M. but recorded on 01/29/25 at 9:00 A.M. revealed Resident #110 was observed in a supine position to the right side of resident's bed, parallel to the bed. Resident #110 was admitted to the facility five minutes before the fall with daughter at bedside. Resident #110 stated I lost my balance trying to get something out of my bag. Neurological checks were initiated with no abnormalities observed. Resident #110 complained of generalized pain in her back. Skin dry and intact. The NP (Nurse Practitioner) was at the bedside post fall with a complete evaluation and no new orders. Neurological checks were discontinued due to denial of hitting head and no abnormalities during assessment. No injuries observed upon head-to-toe assessment. ROM (Range of Motion) at baseline per Resident #110's daughter. Resident #110 was oriented to the facility to acclimate to the new environment. Resident #110's bed was in the lowest position with call light in reach. Resident #110's daughter notified the nurse on duty that Resident #110 had a history of frequent falls. Resident #110 denied any need for pain management due to chronic back pain. IDT (interdisciplinary team) reviewed and initiated an admission care plan with updates as needed. Telephone interview on 01/27/25 at 12:36 P.M. of Licensed Practical Nurse (LPN) #836 revealed Resident #110 was admitted toward the end of her shift and she had a fall. LPN #836 stated Human Resource Manager (HRM) #871 saw Resident #110 on the floor, told an unidentified CNA, and the CNA told her and she immediately went in Resident #110's room to evaluate her. LPN #836 stated Resident #110 said she was reaching for something and fell, she was lying on her back when she entered the room and complained of back pain. LPN #836 stated an unidentified NP was at the facility and saw her at the time of the fall and was aware of Resident #110's complaints of pain. LPN #836 stated she gave Resident #110 Tylenol for complaints of pain. LPN #836 stated she called Resident #110's daughter, who was not present at the facility but on her way to the facility when she called. LPN #836 stated she told Unit Manager (UM) #874 she had not done Resident #110's incident report and thought UM #874 was going to complete it. Interview on 01/29/25 at 11:17 A.M. of Licensed Practical Nurse (LPN) #836 revealed Resident #110 had a fall on 01/14/25 and she did not remember if Resident #110 said she hit her head, but her back hurt. LPN #836 stated she worked on 01/14/25 until 3:00 P.M. and passed it to the next nurse about Resident #110's back pain. LPN #836 stated she was off shift and just finished up my charting and that was why it has a time of 5:00 P.M. LPN #836 stated she gave the keys to UM #874 and UM #874 stated she would handle the incident report, nursing assessment, and back pain. Interview on 01/29/25 at 12:33 P.M. of UM #874 revealed LPN #836 gave her report and the keys on 01/14/25 at 5:00 P.M. UM #874 stated LPN #836 worked until 5:00 P.M. UM #874 stated the NP (unidentified) was in the building, she did not see the NP, and by the time I got there everything was handled. UM #874 stated she saw Resident #110 with her daughter, Resident #110 was lying in bed, and she seemed fine. UM #874 stated LPN #836 should have done the assessments and notifications to the management team and to the physician because she was the nurse who had Resident #110 in her assignment when the fall occurred. UM #874 stated LPN #836 told her Resident #110 fell as soon as she was admitted to the facility and was seen by an unidentified NP and no new orders were given. UM #874 stated Resident #110's daughter had a conversation with the NP and the DON came over at that point. UM #874 indicated assessments for pain and fall risk should be completed and 72-hour fall assessments should be completed every shift for a duration of 72 hours. UM #874 revealed she was only filling in for a couple hours, she was not the Unit Manager for the unit Resident #110 resided on, confirmed the assessments were not completed and she did not know why the assessments were not completed and contained in the resident's medical record. UM #874 stated she asked LPN #836 if she needed help and she said she had it. Interview on 01/29/25 at 12:02 P.M. of Human Resources Manager (HRM) #871 revealed she was conducting an orientation class and was walking in the hall with her class, heard Resident #110 yelling, went in her room and found Resident #110 lying on the floor by her bed. HRM #871 stated she placed a pillow under Resident #110's head, did not notice bleeding or bruises, and she told an aide, and the aide told the nurse assigned to Resident #110. HRM #871 indicated she did not remember which aide she told or the nurse who came to the room. HRM #871 stated she asked Resident #110 what she was trying to do and she said, I do not know. Interview on 01/29/25 at 1:02 P.M. of the Director of Nursing (DON) and the Administrator revealed Resident #110 was admitted to the facility on [DATE] and tried to get something out of her purse, lost her balance and fell. The DON stated Resident #110 was lying supine by her bed and was fully evaluated. The DON stated she was not in the facility when Resident #110 fell and she was admitted at 5:00 P.M. The DON indicated Resident #110 had generalized complaints of pain after her fall, was here two days and had no complaints of pain. The DON stated Resident #110 's fall should have an IDT review in the progress notes and it was usually completed the next day. The DON confirmed Resident #110 did not have a fall risk assessment, a pain assessment, 72-hour post-fall assessments every shift, a baseline care plan and stated they were probably in the fall investigation. The DON confirmed Resident #110's fall was not documented on the incident log and provided an updated incident log with the fall documented on it. The DON confirmed the time of Resident #110's fall was documented on 01/14/25 at 9:21 P.M. and that was incorrect. Interview on 01/30/25 at 7:41 A.M. with CNA #819 revealed she worked on 01/14/25 and had Resident #110 in her assignment, but did not remember anything about her fall. Interview on 01/30/25 at 9:57 A.M. of Family Member (FM) #926 revealed Resident #110 was on the phone talking to her sister when she fell. FM #926 stated she was not called by anyone from the facility, but Resident #110's sister told her she fell and FM #926 rushed to the facility. FM #926 stated Resident #110's back was hurting a lot, FM #926 talked to the doctor and the doctor said she was fine, but Resident #110 was later found to have a fracture of her lower back. FM #926 stated Resident #110 was transferred to another facility on 01/16/25, was still having severe pain and FM #926 transported her to the local Emergency Department. FM #926 stated an x-ray was taken and the x-ray showed a fracture of Resident #110's lower back. FM #926 stated on 01/14/25, the nurse gave Resident #110 Tylenol, but it did not work, and by the next day the pain was so bad Resident #110 could hardly be touched. The nurse said she would get something ordered for pain but only gave Tylenol. 2. Review of Resident #97's medical record revealed an initial admission date of 07/12/24 and a re-entry date of 01/10/25. Resident #97's diagnoses included chronic obstructive pulmonary disease with acute exacerbation, acute and chronic respiratory failure, congestive heart failure, and weakness. Review of Resident #97's progress notes dated 11/21/24 included Resident #97 was discharged home. Review of Resident #97's Fall Risk Assessments dated 01/10/25 and 01/19/25 revealed Resident #97 was at risk for falls. Review of Resident #97's medical record including assessments dated 01/10/25 through 01/30/25 did not reveal evidence a Nursing admission Care Plan was completed. Review of Resident #97's admission Minimum Data Set assessment dated [DATE] revealed Resident #97 was cognitively intact. Resident #97 occasionally had pain or hurting in the last five days and occasionally pain interfered with Therapy activities and pain occasionally limited his day-to-day activities. Resident #97's worst pain was rated as a 7 on a scale of zero-to-ten. Resident #97 had shortness of breath with exertion, when sitting at rest and when lying flat. Resident #97 used a walker and a wheelchair. Resident #97 required partial to moderate assistance with toileting hygiene and bathing. Resident #97 required supervision or touching assistance with the ability to transfer to and from a bed to a chair or wheelchair and the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. Review of Resident #97's progress notes dated 01/19/25 at 3:48 P.M. included Resident #97 had a witnessed fall. Resident #97 had no complaints of pain or discomfort. The note referenced the NP and Unit Manager were notified A voicemail was left for the resident's family member. Resident #87's blood pressure was 139/70, pulse 65, oxygen saturation 97 percent and respirations 17 per minute. There was no description of events leading up to the fall or how the fall occurred. Review of Resident #97's Fall Investigation Checklist dated 01/19/25 at 3:57 P.M. included Resident #97 had a witnessed fall. Resident #97 had no complaints of pain or discomfort. Notified NP (Nurse Practitioner) and Unit Manager (both were unidentified). Contacted family via voicemail. Resident #87's blood pressure was 139/70, pulse 65, oxygen saturation 97 percent and respirations 17 per minute. CNA #835 stated she was helping Resident #97 with his care; she turned around to get supplies and when she turned back Resident #97 had fallen backwards. CNA #835's statement did not include details of what she saw when Resident #97 fell backwards. The statement did not include if Resident #97 hit his head when he fell backwards. Resident #97's statement indicated he was trying to get the aides' attention so they could shave him and he fell backwards trying to sit in his chair. The statement did not include if Resident #97 was asked if he hit his head. Resident #97's Fall Investigation Checklist did not reveal evidence that an immediate fall intervention was implemented. The Fall Investigation Checklist did not include a statement from the nurse who evaluated Resident #97 after the fall. Review of Resident #97's medical record including assessments dated 01/19/25 through 01/30/25 did not reveal evidence a pain assessment was completed or 72-hour post-fall documentation was completed every shift. Review of Resident #97's care plan dated 01/24/25 (five days after a fall) included Resident #97 was high risk for falls related to deconditioning, gait and balance problems and incontinence. A listed goal included Resident #97 would not sustain serious injury through the review date. Interventions included to anticipate and meet Resident #97's needs; ensure Resident #97 was wearing appropriate footwear when ambulating or mobilizing in the wheelchair; follow facility fall protocol. Review of Resident #97's progress notes dated 01/19/25 through 01/30/25 revealed no additional documentation regarding his fall on 01/19/25. Observation on 01/21/25 at 1:50 P.M. of Resident #97 revealed he was lying in bed with the head of his bed elevated and was using oxygen via nasal cannula. Resident #97's brother was at the bedside. Resident #97's brother stated he was his Power of Attorney (POA) and he received a voicemail about Resident #97's fall and the call only said he had a fall and he was okay and nothing else. Resident #97 stated the aides rush his care, never check on him and did not do any follow up for his fall. Interview on 01/21/25 at 2:20 P.M. of Licensed Practical Nurse (LPN) #832 and Unit Manager (UM) #874 revealed Resident #97 had a witnessed fall but they did not give details of the fall. Interview on 01/30/25 at 3:52 P.M. of the DON confirmed Resident #97's admission Care Plan was not completed. The DON confirmed Resident #97 did not have a Pain Assessment completed after his fall or 72-hour post-fall documentation every shift following the fall. The DON confirmed the Fall Investigation Checklist statement did not specify if Resident #97 hit his head when he fell and the progress notes did not have documentation of the details leading up to Resident #97's fall and no details and how the fall occurred. The DON confirmed there was no evidence that an immediate fall intervention was implemented to prevent additional falls.3. Review of Resident #115's closed medical records revealed an admission date of 01/21/25 and a discharge date of 01/29/25. Diagnoses included right arm fracture, muscle weakness and difficulty walking. Review of MDS assessment dated [DATE] revealed Resident #115 had intact cognition. Resident #115's functional assessment was still in progress at time of review. Review of the care plan dated 01/22/25 revealed Resident #115 had functional incontinence and required staff assistance with toileting. Observation on 01/29/25 at 8:15 A.M. revealed Resident #115's call light was active. Observation further revealed Resident #115 was attempting to self-transfer from her bed into a wheelchair. Interview with Resident #115 at time of observation revealed no staff had come in to assist her out of bed when she requested. At 8:23 A.M., Admissions Director (AD) #825 entered Resident #115's room and had observed Resident #115 attempting to self-transfer. AD #825 assisted Resident #115 up out of bed and into a wheelchair and AD #825 had then exited the room. Interview on 01/29/25 at 11:23 A.M. with AD #825 revealed she was not a certified nursing assistant and stated she was only able to provide limited care that included answering call lights. AD #825 stated Resident #115 had requested assistance out of bed and into a wheelchair and AD #825 confirmed she had assisted Resident #115. AD #825 confirmed she was not trained to provide assistance with hands-on transfers and should have waited for a clinical staff member. Review of the facility policy titled Fall Management revised 12/2022 included the facility would identify each resident who was at risk for falls and would develop a Plan of Care and implement interventions to manage falls. The licensed nurse would perform a Fall Risk Assessment immediately if the resident was deemed to be at risk. If a fall occurred the licensed nurse would assess the resident for injury from the fall immediately and initiate an investigation of the reason for the fall and implement an immediate intervention to attempt to prevent future falls. The licensed nurse would update the Fall Risk and Pain Assessment at the time of the fall. A care plan would be implemented upon admission for residents who were identified as at risk for falls with interventions to attempt to prevent further incidents. This deficiency represents non-compliance investigated under Master Complaint Number OH00162102 and Complaint Numbers OH00161142 and OH00161136.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to provided timely and appropriate incontinence care for dependent residents. This affected three residents (#26, #49 and #54) of three residents reviewed for incontinence care. The facility census was 100. Findings include: 1. Review of Resident #26's medical record revealed an admission date of 02/11/23. Diagnoses included stroke with left sided weakness, overactive bladder and muscle weakness. Review of Resident #26's care plan revised 11/01/24 revealed Resident #26 was incontinent of bowel and bladder. Interventions included check for incontinence every two hours. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had intact cognition. Resident #26 required maximum assistance with toileting and bathing. Resident #26 was incontinent of bowel and bladder. Observation on 01/21/25 at 7:47 A.M. revealed Resident #26's call light was active. Interview with Resident #26 at time of observation revealed she needed incontinence care and Resident #26 stated she had not been changed since 10:00 P.M. the previous evening. At 8:31 A.M., Resident #26's call light remained active. Resident #26 stated staff had come in and she had told them she needed to be changed, however they had not provided her with incontinence care. At 9:00 A.M. observation revealed Registered Nurse (RN) #848 entered Resident #26's room and had turned off the call light, however had not provided Resident #26 with care. Interview with RN #848 at time of observation revealed Resident #26 had stated she needed incontinence care and RN #848 stated Resident #26 had informed him she had not received incontinence care since 10:00 P.M. the previous evening. Observation of incontinence care on 01/21/25 at 9:48 A.M. for Resident #26 with Certified Nursing Assistant (CNA) #824 and #885 revealed Resident #26 was saturated with urine that had soaked through her sheets and onto her mattress. Resident #26's sheets had areas of dried yellow stains and Resident #26 was wearing two incontinence briefs. Interviews with CNA #885 stated she had observed residents who had been heavily saturated when she arrived to start her shifts at 7:00 A.M. CNA #824 and #885 confirmed Resident #26 was heavily saturated and was wearing two incontinence briefs and stated residents should not be wearing more than one incontinence product. 2. Review of Resident #49's medical records revealed an admission date of 11/04/23. Diagnoses included muscle weakness, falls, and vision loss. Review of MDS assessment dated [DATE] revealed Resident #49 had intact cognition. Resident was dependent with toileting and bathing. Resident #49 was incontinent of bowel and bladder. Review of care plan dated 11/19/24 revealed Resident #49 was incontinent of bowel and bladder. Interventions included check and change on care rounds. Observation on 01/22/25 at 5:45 A.M. for Resident #49 with CNA #883 revealed Resident #49 was heavily saturated with urine that had soaked through his sheets and onto his mattress and was wearing two incontinence briefs. CNA #883 stated she was unable to recall when she had last changed Resident #49 and Resident #49 stated he last been changed sometime before bed the previous evening. 3. Review of Resident #54's medical records revealed an admission date of 10/20/23. Diagnoses included respiratory failure, chronic obstructive pulmonary disease (COPD), and heart failure. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had intact cognition. Resident #54 required moderate assistance with toileting and bathing. Resident #54 was incontinent of bowel and bladder. Review of care plan dated 10/23/23 revealed Resident #54 was incontinent of bowel and bladder. Interventions included changed brief every two hours and as needed. Observation on 01/27/25 at 8:25 A.M. revealed Resident #54's call light was active. Interview with Resident #54 at time of observation revealed she was soaked with urine and stated she had not been changed since 11:00 P.M. the previous evening. At 8:42 A.M. CNA #817 entered Resident #54's room and Resident #54 informed CNA #817 she needed to be changed and CNA #817 informed Resident #54 she would provide her with incontinence care after she had finished passing out the breakfast trays. Resident #54 informed CNA #817 she had not been changed since 11:00 P.M. the previous evening. Observation on 01/27/25 at 10:45 A.M. with CNA #817 for Resident #54 revealed Resident #54 was saturated with urine that had soaked through her sheets and onto her mattress. CNA #817 stated she had not provided Resident #54 with incontinence care since the start of her shift at 7:00 A.M. Review of the policy Activities of Daily Living revised March 2023 revealed the facility will provide care and services for activities of daily living, including elimination (toileting). A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal hygiene. This deficiency represents non-compliance investigated under Master Complaint Number OH00162102 and Complaint Numbers OH00161890, OH00161859, OH00161144, OH00161142, and OH00161136.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on interview, review of photographs, and review of the facility policy, the facility failed to ensure medications were not left unattended in residents' room. This affected three residents (#27, #61 and #115) of five residents reviewed for . The facility census was 100. Findings include: 1. Interview on 01/22/25 at 1:34 P.M. with Resident #27's daughter revealed the resident's morning medications had been administered in the afternoon on 01/21/25. When she arrived at the facility on the afternoon of 01/21/25, she observed two cups of medications in Resident #27's room containing various pills. Resident #27's daughter stated she had taken a photo of the medication cups on 01/21/25 at 3:16 P.M. The photograph was provided at the time of interview and two cups of medications were observed in the photo. 2. Interview on 01/27/25 at 11:55 A.M. with Registered Nurse (RN) #874 revealed on 01/24/25 sometime before lunch (couldn't recall exact time), Resident #115's daughter had informed her that Resident #115 had unknown medications in her oatmeal. RN #874 stated she had went to Resident #115's room at that time and observed three unknown pills in Resident #115's oatmeal. RN #874 stated Resident #115's daughter had requested the oatmeal be saved in order to show the Director of Nursing (DON). RN #874 stated she had placed the oatmeal in Resident #115's drawer. RN #874 stated she had unsure how the medications had gotten in Resident #115's oatmeal and stated she had shown the medications in the oatmeal to the DON. RN #874 stated she had been aware of recent reports from various residents' family members of medications left unattended at the bedside. 3. Interview on 01/27/25 at 2:12 P.M. with Resident #61's wife had stated on 01/24/25 Resident #61's morning medications had been given after 2:00 P.M. and stated she had observed a cup of medications on his bedside table. Resident #61's wife stated she had taken a picture of the medications left in his room. The photograph was provided at the time of interview and showed a single pill in a medication cup. Review of facility policy titled Medication Administration revised 08/14 revealed residents are always observed after administration to ensure that the dose was completely ingested. This deficiency represents non-compliance investigated under Complaint Number OH00161136.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0777 (Tag F0777)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #64's diagnostic test for a suspected injury was ordered, reported, and treatment was initiated timely. This affected one resident (Resident #64) out of three residents reviewed for diagnostic testing. The facility census was 100. Findings include: Review of Resident #64's medical record revealed an admission date of 01/09/25 and diagnoses included acute embolism and thrombosis of unspecified deep veins of the left lower extremity, encephalopathy and type two diabetes mellitus without complications. Review of Resident #64's care plan dated 01/09/25 included Resident #64 was a high risk for falls related to deconditioning, gait and balance problems and history of falls. Resident #64 would be free of falls through the review date. Interventions included to follow the facility fall protocol; anticipate and meet Resident #64's needs. Review of Resident #64's MDS admission assessment dated [DATE] revealed Resident #64 was cognitively intact. Resident #64 used a walker. Resident #64 required partial to moderate assistance for the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, and for the ability to transfer to and from a bed to a chair or wheelchair. Review of Resident #64's physician orders dated 01/20/25 written by Nurse Practitioner (NP) #927 revealed x-ray of the left ankle, 2 view, status post fall, pain, edema. Review of Resident #64's electronic record physician orders dated 01/21/25 at 7:20 A.M. revealed left ankle, 2 views, one time only. The physician order was not placed in the electronic record until nine hours after it was ordered. Review of Resident #64's radiology results report dated 01/21/25 at 8:21 P.M. revealed the examination date was 01/21/25 at 00:00. Resident #64 had an acute distal fibular fracture with adjacent soft tissue swelling. The result was not reported to NP #927 until 01/22/25 at 7:14 A.M. which was eleven hours after the report date and time. Review of Resident #64's progress notes dated 01/22/25 at 7:14 A.M. revealed Resident #64's x-ray was done; result was positive and Resident #64 had a fracture of his ankle. Results were sent to NP #927 and the nurse was awaiting new orders. Review of Resident #64's progress notes dated 01/22/25 at 10:40 A.M. included NP #927 gave orders to send Resident #64 to the local hospital for a fracture of the left fibula. Review of Resident #64's progress notes dated 01/22/25 at 11:26 A.M. included on 01/20/25 at 10:16 P.M. NP #927 gave an order for an x-ray of Resident #64's left ankle after assessing and talking to him. Resident #64 stated he fell in December 2024 and did not report it, the left ankle was bothering him, it was swollen and painful to touch. Resident #64 stated his ankle only hurt when he walked or when it was pressed. Observation on 01/29/25 at 3:32 P.M. of Resident #64 revealed he was sitting in a wheelchair in his room. Resident #64's left lower leg had a splint applied. Resident #64 stated he broke his bone in his left ankle and was not sure how it happened. Resident #64 stated before he was admitted to the facility he was at a local discount store, it was slushy outside, he slipped, and his legs went in different directions. Resident #64 indicated this might have been when he fractured his ankle. Interview on 01/29/25 at 3:39 P.M. of RN #801 revealed on 01/20/25 he arrived for work at 7:00 P.M. and NP #927 was finishing her rounds and ordered a STAT (immediate) x-ray for Resident #64 and he placed the x-ray order in the system. RN #801 stated Resident #64 had a fall in December 2024 and his leg was swollen. RN #801 stated he did not know if Resident #64's leg was swollen before 01/20/25 because he had not had Resident #64 in his previous assignments, and this was the first day he met him. Interview on 01/29/24 at 4:06 P.M. of RN #890 revealed he worked night shift and usually had Resident #64 in his assignment and did not notice Resident #64's left ankle was swollen before 01/20/25. RN #890 stated Resident #64 never complained about pain or swelling in his left leg or ankle. Interview on 01/30/25 at 11:15 A.M. of NP #927 revealed she saw Resident #64 on 01/20/25 later in the afternoon and told the nurse he needed an x-ray of the left ankle. NP #927 stated she did not remember if the x-ray was ordered STAT, but it was not an emergency, and Resident #64 had not been complaining about his left ankle before 01/20/25. NP #927 indicated Resident #64 told her his ankle was swollen and kind of bothering him and he did not tell anyone before he told her. Interview on 02/03/25 at 12:20 P.M. of the Administrator confirmed the x-ray results were not reported to the physician for almost twelve hours after the results were reported to the facility and she would ask the Director of Nursing about it. Interview on 02/04/25 at 7:55 A.M. of the Director of Nursing (DON) revealed Resident #64's x-ray was reported to the facility via fax on 01/22/25 in the morning, and she would look into why it was not reported on 01/21/25 at 8:21 P.M. The DON confirmed the x-ray was ordered on 01/20/25 and she did not know why it was not placed in the system until 01/21/25 at 7:20 A.M. The DON did not provide additional information about why Resident #64's x-ray order was not placed in the system on 01/20/25 when it was ordered or why the results were not reported to the physician until 01/22/25. Review of the facility policy titled Resident Change in Condition dated 07/28/22 included ensuring staff provide timely and appropriate are and services when residents experience a change in condition that has or was likely to cause serious life-threatening harm or injuries and or adverse negative health outcomes. Change of condition might include a significant or acute change in the resident's physical, mental, or psychosocial status including abnormal lab values; there was a need to alter the resident's treatment significantly; deemed necessary or appropriate in the best interest of the resident. This deficiency represents an incidental finding identified while investigating Master Complaint Number OH00162102 and Complaint Numbers OH00161890, OH00161859, OH00161556, OH00161410, OH00161144, OH00161142, and OH00161136.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident record review, and staff interview, the facility failed to ensure resident meals were served in the proper, safe form. This affected one resident (#60) of one reviewed for therapeutic diets. The facility census was 100. Findings include: Review of the medical record for Resident #60 revealed she was admitted to the facility on [DATE] with diagnoses that included dementia, type 2 diabetes, and hypertension. Review of the quarterly Staff Assessment for Mental Status (SAMS) assessment dated [DATE], revealed Resident #60 had a short and long-term memory problem and was severely impaired regarding tasks of daily life with inattention that fluctuated. Resident #60 was dependent on staff for Activities of Daily Living (ADLs) Review of the care plan dated 08/17/23 revealed Resident #60 had potential for altered nutrition with interventions that included providing and serving prescribed diet as ordered by the physician. Review of the physician orders dated 05/23/24 revealed Resident #60 had an order in place for a low concentrated sweets diet, mechanical soft (minced and moist MM5) texture, and thin liquids consistency. Observation on 01/22/25 at 9:58 A.M. revealed Resident #60 sitting in the dining room with her breakfast meal tray. Observation of Resident #60 breakfast meal ticket revealed Resident #60 required a mechanical soft diet. Observation revealed Resident #60 had one whole crunchy hard hashbrown on her tray. Interview on 01/22/25 at 10:00 A.M. with Licensed Practical Nurse (LPN) #832 revealed Resident #60 required a mechanical soft diet as indicated on her meal ticket. LPN #832 revealed the hashbrown was too hard for Resident #60 to eat. LPN #832 confirmed and verified Resident #60 did not receive her appropriate therapeutic diet of mechanical soft for her breakfast meal. This deficiency represents an incidental finding identified while investigating Master Complaint Number OH00162102 and Complaint Numbers OH00161890, OH00161859, OH00161556, OH00161410, OH00161144, OH00161142, and OH00161136.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0810 (Tag F0810)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident record review, and staff interview, the facility failed to ensure residents were provided with the appropriate assistive devices for meals. This affected one resident (#60) of one reviewed for assistive devices. The facility census was 100. Findings include: Review of the medical record for Resident #60 revealed she was admitted to the facility on [DATE] with diagnoses that included dementia, type 2 diabetes, and hypertension. Review of the quarterly Staff Assessment for Mental Status (SAMS) assessment dated [DATE], revealed Resident #60 had a short and long-term memory problem and was severely impaired regarding tasks of daily life with inattention that fluctuated. Resident #60 was dependent on staff for Activities of Daily Living (ADLs) Review of the care plan dated 08/17/23 revealed Resident #60 had potential for altered nutrition with interventions that included utilizing a red divided plate as an assistive device for meals. Review of the physician orders dated 05/23/24 revealed Resident #60 had an order in place for a low concentrated sweets diet, mechanical soft (minced and moist MM5) texture, and thin liquids consistency. Review of the physician orders dated 01/19/25 revealed Resident #60 had an order in place for a red plate with a lid. Observation on 01/22/25 at 9:58 A.M. revealed Resident #60 sitting in the dining room with her breakfast meal tray. Observation of Resident #60 breakfast meal ticket revealed Resident #60 required a red plate. Observation revealed Resident #60 did not have a red plate, but a regular flat plate. Interview on 01/22/25 at 10:00 A.M. with Licensed Practical Nurse (LPN) #832 revealed Resident #60 required an divided plate. LPN #832 revealed all divided plates were red. LPN #832 confirmed and verified Resident #60 required a red divided plate and her meal was served without one. This deficiency represents an incidental finding identified while investigating Master Complaint Number OH00162102 and Complaint Numbers OH00161890, OH00161859, OH00161556, OH00161410, OH00161144, OH00161142, and OH00161136.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and facility policy review, the facility failed to ensure facility staff followed infection control policies, protocols, and failed to ensure residents were care planned for infection control. This affected two residents (#9 and #44) of three reviewed for infection control. The facility census was 100. Findings include: 1. Review of the medical record for Resident #44 revealed she was admitted to the facility on [DATE] with diagnoses that included bilateral primary osteoarthritis of knee, hypertensive heart disease without heart failure, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 13 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #44 required assistance from staff for Activities of Daily Living (ADLs). Review of the progress note dated 01/20/25 at 2:54 P.M. revealed Resident #44 complained of cold-like symptoms, COVID-19 tested, and received positive results. Resident #44 placed on isolation precautions. Review of the physician orders dated 01/21/25 revealed Resident #44 had an order for droplet isolation for COVID-19 with all activities to take place in her room. Review of Resident #44's comprehensive care plan revealed no evidence of a care plan in place for infection control. Interview on 01/21/25 at 7:48 A.M. with Certified Nursing Assistants (CNAs) #835 and #878 revealed there was no COVID-19 positive residents in the facility. Interview revealed all residents diagnosed with COVID-19 were discharged from the building. Interview on 01/21/25 at 8:25 A.M. with the Director of Nursing (DON) revealed the facility had one positive case of COVID-19 and that was for Resident #44. The DON revealed Resident #44 tested positive for COVID-19 on 01/20/25. Observation and interview on 01/21/25 at 9:22 A.M. revealed a bin sitting outside of Resident #44 room with personal protective equipment (PPE) inside that included masks, gowns, and gloves. Resident #44 room door had a sign that read REPORT TO NURSES STATION BEFORE ENTERING and another sign above the PPE bin that read AIRBOURNE PRECAUTIONS. CNA #889 entered Resident #44 room to provide breakfast tray and entered without no PPE in place. Upon exiting Resident #44 room, CNA #889 revealed he did not pay attention to the sign on the door or the bin outside of Resident #44 room. CNA #889 revealed after he entered Resident #44 room, Resident #44 informed him that she did not feel well. CNA #889 confirmed and verified the above findings at the time of the observation. Interview on 01/21/25 at 9:23 A.M. with CNA #885 revealed she was not aware of Resident #44 isolation precautions, and she did not know what or why the precautions were in place. Interview on 01/21/25 at 11:09 A.M. with the DON confirmed and verified that she was aware of CNA #889 entering and exiting Resident #44 room without donning and doffing PPE. Follow-up interview on 01/22/25 at 1:23 P.M. with the DON, with the Administrator present, while reviewing Resident #44 electronic medical record, revealed no care plan in place for COVID-19, isolation precautions, and/or droplet precautions. The DON confirmed and verified Resident #44 care plan was not updated. Observation and interview on 01/28/25 at 12:44 P.M. revealed CNA #885 entered Resident #44 room without donning PPE. CNA #885, upon exiting Resident #44 room, without doffing PPE, revealed she entered and exited Resident #44 room without donning and doffing the required PPE. CNA #855 confirmed and verified Resident #44 was still on isolation precautions related to COVID-19. Interview on 01/28/25 at 12:46 P.M. with Licensed Practical Nurse (LPN) #852 confirmed and verified Resident #44 was currently on isolation precautions for COVID-19 and PPE was required when entering the room. Review of the facility document provided by the DON titled Isolation Residents undated, revealed Resident #44 was positive for COVID-19 as of 01/20/25. Review of the facility document titled COVID-19; SARS-CoV-2 revised August 2023, revealed the facility had a policy in place that staff who entered the room of a suspected or confirmed COVID-19 infection should don an N95 respirator, gown, gloves, and eye protection. Review of the document revealed the facility did not implement the policy. 2. Review of Resident #9's medical records revealed an admission date of 10/06/22. Diagnoses included obesity, muscle weakness and diabetes. Review of MDS assessment dated [DATE] revealed Resident #9 had intact cognition. Resident #9 was dependent with toileting and required maximum assistance with bathing. Review of care plan dated 11/18/24, revised 01/08/25 revealed Resident #9 had scabies. Interventions included infestation may occur with direct skin to skin contact with an infected person, give prescribed lotions to treat scabies as ordered and a second treatment may be indicated in one week to ten days. Review of physician orders for January 2025 revealed Resident #9 was ordered Permethrin (cream used to treat scabies infection) 60 grams one time applied all over the body from the neck down and wash off skin within 8-14 hours. Orders were active from 01/20/25-01/27/25 and review of the Medication Administration Report (MAR) for January 2025 revealed Permethrin cream was administered on 01/22/25, 01/23/25, 01/25/25, 01/26/25 and 01/27/25. Physician orders for January-February 2025 had another order for Permethrin from 01/29/25-02/04/25. Review of MAR revealed cream was administered on 01/31/25, 02/01/25, 02/02/25 and 02/03/25. Observation on 01/23/25 at 6:40 A.M. revealed a sign posted outside of Resident #9's room that indicated contact precautions as well as an isolation bin that contained gowns, gloves and masks. Interview with CNA #829 and CNA #902 revealed Resident #9 was on contact precautions for scabies. CNA #829 and #902 stated Resident #9 has been on precautions for a long time and stated she they were unaware of when she had last received a shower, however their assignment sheet for 01/23/25 specifically stated for Resident #9 to receive a shower and stated it may have had something to do with a cream the nurses applied. Interview with Resident #9 at time of observation revealed she could not recall when she had last had cream applied and stated she had not received a shower for several months. Observation on 02/04/25 at 8:40 A.M. revealed contact precaution sign and isolation bin remained outside of Resident #9's room. Interview on 02/04/25 at 10:06 A.M. with Licensed Practical Nurse (LPN) #928 revealed he had applied two tubes of Resident #9's cream on 01/31/25 and also on 02/03/25. Observation on 02/04/25 at 10:39 A.M. revealed LPN #826 had entered Resident #9's room and had obtained a blood pressure reading and had not donned PPE prior to entering. After observation LPN #826 had exited Resident #9's room and had left the area. At 10:49 A.M. LPN #826 had returned with the Assistant Director of Nursing (ADON) and ADON had removed the contact precaution sign and isolation bin. ADON had not explained why she had removed the sign and isolation bin and had left the area. Telephone interview on 02/04/25 at 12:05 P.M. with pharmacy revealed one tube of Resident #9's Permethrin cream was sent on 01/10/25 and 01/12/25. Interview with LPN #826 at time of observation revealed she had asked the ADON if Resident #9 was still in active isolation and LPN #826 stated the ADON had told her no and then she had removed the isolation materials. Interview on 02/04/25 at 2:53 P.M. with Director of Nursing (DON) confirmed Resident #9's Permethrin cream was a one time dose and stated a second dose had been ordered on 01/12/25. DON stated Resident #9 should not have been on isolation after she had received her cream on 01/12/25 due to Resident #9 was not considered contagious after cream was applied and washed off. DON confirmed the physician orders were active for isolation from 01/21/25-01/31/25 and had not been able to provide a clear explanation or clarification of the orders. DON stated Resident #9 had an upcoming dermatologist appointment and would await the results of the appointment and stated until the appointment Resident #9 was no longer considered contagious and did not require isolation. Review of facility policy titled Scabies Identification. Treatment and Environmental Cleaning revised 08/2016, revealed an infected individual was to be placed on contact precautions for 24 hours after treatment. This deficiency represents non-compliance investigated under Complaint Number OH00161410.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record for Resident #71 revealed she was admitted to the facility on [DATE] with diagnoses that included polyosteoarthritis, dementia, and hypertensive heart disease with heart failure. Review of the care plan dated 02/27/24 revealed Resident #71 had a self-care deficit due to dementia and limited mobility with interventions that included eating supervised with assistance. Review of the physician orders dated 12/10/24 revealed Resident #71 had an order for a regular diet, pureed textured with thin liquid consistency. Review of the quarterly, Staff Assessment for Mental Status (SAMS) assessment dated [DATE] revealed Resident #71 had short and long-term memory loss and was severely impaired regarding tasks of daily life. Review of the SAMS assessment revealed Resident #71 was dependent on staff for Activities of Daily Living (ADLs). Review of the physician orders dated 01/17/25 revealed Resident #71 was to be encouraged to be in the main dining room for meals every shift for fall prevention. Review of the physician orders dated 01/22/25 revealed Resident #71 was now a feed assist for all meals. Review of the progress note dated 01/22/25 at 7:18 P.M. revealed Resident #71 was a feed assist as of 01/22/25 and for staff to assist with feeding of all meals, every shift, to start 01/23/25. Observation and interview on 01/23/25 at 8:25 A.M. of the dining room, located adjacent to the nursing station on the 200-hall unit, revealed Resident #71 and #98 seated together at a table. Resident #98 was observed eating her breakfast meal and Resident #71 was observed without a breakfast tray. Certified Nursing Assistant (CNA) #889 confirmed the findings at the time of the observation. Observation and interview on 01/23/25 at 8:38 A.M. revealed, approximately 13 minutes later, Resident #71 received her breakfast lunch tray. Dietary Manager (DM) #908, with the Director of Nursing (DON) present, confirmed and verified Resident #71 was seated at a table with Resident #98 and was without a breakfast meal tray until 8:38 A.M. Observation on 01/27/25 at 9:34 A.M. revealed Resident #71 laying in bed with her breakfast tray on her over-the-bed table and positioned over her body. Resident #71 was observed attempting to eat her breakfast meal with no staff present. Observation and interview on 01/27/25 at 9:37 A.M. revealed CNA #889 entered Resident #71's room with Resident #26's finished breakfast tray in her hand. CNA #889 revealed he was entering Resident #71's room to assist with her breakfast meal. CNA #889 approached Resident #71, while standing, begin to spoon feed the resident with his right hand, while he continued to hold Resident #26's completed tray still in hand. CNA #889 continued to feed Resident #71, while standing, 3 scoops of her breakfast meal before he exited the room. Resident #71 was then observed attempting to continue to eat her breakfast meal. Resident #71 spoon was upside down as she tried to feed herself. CNA #889 was then observed to re-enter the room and stated Resident #71 was capable of feeding herself. CNA #889 confirmed and verified the findings at the time of the observation. Review of the facility document titled Resident Rights revised October 2022, revealed the facility had a policy in place to ensure residents' personal dignity, well-being, and self-determination was maintained. Review of facility policy titled Foley Catheter Care revised 08/22 revealed privacy will be provided to drainage bags to ensure resident dignity. This deficiency represents an incidental finding identified while investigating Master Complaint Number OH00162102 and Complaint Numbers OH00161890, OH00161859, OH00161556, OH00161410, OH00161144, OH00161142, and OH00161136. Based on observation, resident record review, staff interviews, and facility policy review, the facility failed to ensure residents were treated with dignity and respect. This affected four residents (#50, #59, #70, and #71) of four residents reviewed for dignity and respect. The facility census was 100. Findings include: 1. Review of Resident #50's medical records revealed an admission date of 11/27/24. Diagnoses included paraplegia and bladder dysfunction. Review of the care plan revised 01/22/25 revealed Resident #50 had an indwelling urinary catheter. Interventions included ensure Resident #50 had a privacy bag on catheter. Observation on 01/21/25 at 3:02 P.M. revealed Resident #50 was in a wheelchair in the entrance foyer and Resident #50's urinary catheter drainage bag was not covered by a privacy bag. The Administrator confirmed the finding at the time of observation. 2. Review of Resident #70's medical records revealed an admission date of 07/11/24. Diagnoses included urinary retention and bladder dysfunction. Observation on 01/21/25 at 3:17 P.M. revealed Resident #70 was in bed with an indwelling catheter. Resident #70's catheter was not covered by a a privacy bag. Human Resources (HR) #871 confirmed the finding at the time of observation. 3. Review of Resident #59's medical records revealed an admission date of 10/03/22. Diagnoses included falls, muscle weakness, and dementia. Observation on 01/27/25 at 6:52 A.M. revealed Resident #59 was in a common dinning area and Resident #59's catheter had not been covered by a privacy bag. Licensed Practical Nurse (LPN) #834 confirmed the finding at the time of observation and stated she was unsure if the facility had privacy bags.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident record review, resident interview, staff interview, and facility policy review, the facility failed to ensure the resident environment was maintained in a clean and sanitary manner, and failed to ensure water temperatures were at a comfortable level. This affected seven residents (#6, #29, #42, #49, #70, #82, and #83) of seven reviewed for physical environment. The facility census was 100. Findings include: 1. Review of the medical record for Resident #82 revealed he was admitted to the facility on [DATE] with diagnoses that included schizophrenia, syncope and collapse, and hypertensive heart disease. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 7 that indicated he was alert with cognition impairment. Review of the MDS assessment revealed Resident #82 required assistance from staff for Activities of Daily Living (ADLs). Review of the care plan dated 01/17/24 revealed Resident #82 was at risk for ADL decline due to schizophrenia and impaired cognition and was at risk for bowel and bladder incontinence related to episodes of incontinence. Interventions included toileting assist of one and resident care per facility protocol. Observation and interview on 01/21/25 at 7:57 A.M. revealed Resident #82's bathroom had a soiled brief sitting atop of a soiled shirt and pair of pants in the middle of the floor. Observation of Resident #82's bathroom toilet revealed the inside of the toilet bowl was full to the rim with urine, feces, and toilet paper. Resident #82 revealed staff did not assist him to the bathroom or help clean him up. Observation and interview on 01/21/25 at 8:00 A.M. with Registered Nurse (RN) #844 revealed she was not aware which Certified Nursing Assistant (CNA) was assigned to Resident #82. RN #844 entered Resident #44 bathroom, confirmed and verified Resident #82's bathroom at the time of the interview. 2. Review of the medical record for Resident #42 revealed she was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, and chronic obstructive pulmonary disease. Review of the MDS assessment dated [DATE] revealed Resident #42 had an ADL self-care deficit with interventions that included assist with ADLs as needed. Observation and interview on 01/28/25 at 12:26 P.M. revealed Resident #42 standing in the hallway outside her room, pacing back and forth. Resident #42 revealed she was trying to locate staff to remove her old meal trays from her room. Observation of Resident #42's room revealed two old meal trays. Resident #42 revealed one tray was from her dinner meal on 01/27/25 and the second tray was from her breakfast tray on 01/28/25. Observation and interview on 01/28/25 at 12:36 P.M. during the lunch meal tray pass, revealed CNA #889 walking into Resident #42 room with her lunch meal tray in hand. CNA #889 was observed attempting to find a place to sit Resident #42's lunch tray down. CNA #889 stated to Resident #42 Oh, you still have two trays in here. I will get them when I come back later. CNA #889 stated another staff member must have forgotten to remove the resident's old trays prior to serving her new tray. CNA #889 confirmed and verified the findings at the time of the observation. 3. Review of the medical record for Resident #29 revealed he admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, epilepsy, and transient cerebral ischemic attack. Review of the care plan dated 01/05/25 revealed Resident #29 had a self-care deficit with interventions that included staff assistance with ADLs. Observation and interview on 01/22/25 at 6:14 A.M. revealed a dirty dinner tray in Resident #29 room. Resident #29 dinner plate was observed to have dried crusted food and a drink cup with an unknown object floating in it. Resident #29 revealed staff always left his used dishes and trays in his room even though he requests them to be removed. Resident #29 stated the staff sit around all night on their do-nothing stools. 4. Review of the medical record for Resident #70 revealed she was admitted to the facility on [DATE] with diagnoses that included saddle embolus pulmonary artery, metabolic encephalopathy, and acute respiratory failure. Review of the care plan dated 07/12/24 revealed Resident #70 had a self-care deficit with interventions that included staff assistance with ADLs. Observation on 01/22/25 at 6:20 A.M. revealed a dried crusted dinner dishes in Resident #70 room. Resident #70 was non-interviewable at the time of the observation. Observation and interview on 01/22/25 at 6:20 A.M. with Business Office Manager (BOM) #822 revealed the evening shift staff were responsible for removing the dishes from residents rooms. BOM #822 confirmed and verified the findings at the time of the observation of Residents #29 and #70 room. Review of the facility document titled Activities of Daily Living (ADLs) dated March 2023, revealed the facility had a policy in place that residents would be given appropriate treatment and services to maintain or improve their ability to carry out ADLs including but not limited to, bathing and dining. Review of the facility provided document titled 7-Step Daily Washroom Cleaning undated, revealed the facility had a protocol in place that resident's commodes would be cleaned daily to include the tank, the seat, the bowl, and the base. 5. Review of the medical record for Resident #6 revealed she admitted to the facility on [DATE] with diagnoses that included sepsis, Alzheimer's disease, and muscle weakness. Review of the medical record for Resident #49 revealed he was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, traumatic subarachnoid hemorrhage, and legal blindness. Review of the medical record for Resident #83 revealed he was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, dementia, and epilepsy. Interview on 01/21/25 at 9:07 A.M. with Resident #54 revealed she had not received a bed bath or shower due to no hot water in her bathroom. Interview on 01/21/25 at 9:38 A.M. with Resident #3 revealed the water in her bathroom was ice cold. Interview on 01/21/25 at 1:41 P.M. with Resident #61 family member revealed Resident #61 was without hot water for 7 days. Resident #61 family member revealed residents went without being showered for at least a week and the water came back on, on 01/20/25. Interview on 01/21/25 at 1:34 P.M. with Resident #27 family member, revealed she contacted the Director of Nursing (DON) on 01/19/25 regarding the lack of hot water, and was told the water in the facility would be fixed within a few hours. Resident #27 family member revealed she was informed by other resident's families about the hot water issues. Resident #27 family member revealed she spoke with the Administrator on 01/20/25, who stated she was on bereavement, and informed her that the water issues would be fixed on 01/17/25. However, as of 01/21/25, the facility was still having issues with the lack of hot water. Interview on 01/21/25 at 3:03 P.M. with Resident #50 revealed he was without hot water for 3 days. Interview on 01/21/25 at 3:19 P.M. with LPN #852 revealed the facility was without hot water for a couple days, but she could not recall the day it started. LPN #852 revealed resident water temperatures fluctuated throughout the day. Tour of the facility on 01/21/25 at 3:12 P.M. with Maintenance Supervisor (MS) #853 revealed Resident #83 bathroom sink water had a temperature reading of 87.5 degrees Fahrenheit, Resident #6 bathroom sink water had a temperature reading of 96.6 degrees Fahrenheit, and Resident #49 bathroom sink water had a temperature reading of 91 degrees Fahrenheit. MS #853 revealed he was notified that the water temperatures were below regulation standards on 01/13/25 and placed a call to Standard Plumbing and Heating Company Mechanical Contractors and Engineers but no repairs had been made at this time. MS #853 revealed he attempted to adjust the water temperatures on his own, but he was still trying to adjust them. MS #853 confirmed and verified at the time of the observation the water temperatures were not meeting regulation standards and were supposed to be between 105 degrees and 120 degrees Fahrenheit. Observation and interview on 01/22/25 at 5:44 A.M. revealed Resident #26 bathroom sink water was on and running at a steady flow. Resident #26 revealed staff turned her water on to try to let it warm up because it was cold. Interview on 01/22/25 at 5:45 A.M. with CNA #894 revealed she turned on Resident #26 bathroom sink water to ensure it warmed up prior to attempting to wash her up bedside. CNA #894 revealed she always turned on the sink water to warm up before starting morning care due to fluctuating water temperatures. Interview on 01/22/25 at 5:48 A.M with CNA #883 revealed resident rooms with running water was due to no hot water in the building and staff were attempting to let it warm up enough to provide morning care. Interview on 01/22/25 at 8:38 A.M. with CNA #861 revealed the Administrator and Director of Nursing (DON) were aware of the hot water issues. CNA #861 revealed she had refused to give residents showers in cold water and did not give showers for a week. CNA #861 revealed she had not completed shower sheets from 01/13/25 through 01/20/25 and the water still wasn't getting hot. Review of the water temperature logs dated 11/25/24 through 01/17/25 revealed no logs dated 01/13/25 through 01/23/25. Review of the quote regarding estimation for services regarding exhaust motors for two [NAME] Hot Water Tanks revealed Standard Plumbing and Heating Company Mechanical Contractors and Engineers were contacted on 01/21/25, approximately 8 days after acknowledgment of water temperatures issues. Interview on 01/22/25 at 2:30 P.M. with the Administrator revealed she was aware of the hot water issues regarding the building. The Administrator revealed she was made aware by MS #853 the hot water went out in the facility on 01/13/25 and at that time she was on leave. The Administrator revealed Standard Plumbing and Heating Company Mechanical Contractors and Engineers were contacted on 01/13/25 but was unable to provide documentation regarding services requested. The Administrator revealed she received a quote on 01/22/25, approximately 9 days later, regarding the hot water issues. The Administrator revealed the exhaust motors related to the hot water tanks went out and she was in the process of speaking to the regional director to get approval to determine which company to use to fix the issues. The Administrator revealed the water temps were retested and were fluctuating due to MS #853 temporarily adjusting the water temperatures manually. The Administrator revealed only a small section of the facility was affected by the hot water tanks. The Administrator confirmed and verified at the time of the interview the hot water tanks were not repaired. Review of the facility document titled Water Temperatures revised January 2023, revealed the facility had a policy in place that water temperatures would be monitored routinely to promote a comfortable and safe environment. Review of the policy revealed the facility would ensure appropriate water temperatures between the range of 105-120 degrees Fahrenheit. Review of the document revealed the facility did not implement the policy. This deficiency represents non-compliance investigated under Master Complaint Number OH00162102 and Complaint Numbers OH00161410, OH00161142, and OH00161136.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

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Based on interview, policy review, grievance log review, and personnel file review the facility failed to ensure resident concerns were addressed. This affected four residents (Resident #9, Resident #27, Resident #61, and Resident #73) and had the potential to affect all 100 residents residing in the facility. Findings include: Telephone interview on 01/21/25 at 11:26 A.M. with Resident #73's family revealed she had a camera placed in Resident #73's room due to care concerns. Resident #73's family stated she had observed Resident #73 had not received care for several hours and stated she had emailed the Administrator and had sent text messages to the Director of Nursing (DON) to express her concerns. Resident #73's family stated the issues had been addressed, however it had not lasted long and the same issues had continued to occur. Telephone interview on 01/21/25 at 12:50 P.M. with Resident #9' family revealed she had expressed concerns to the DON related to Resident #9's care as well as the cleanliness of her room and stated the DON had not addressed her concerns and the issues had still being going on. Interview on 01/21/25 at 1:41 P.M. with Resident #61's family revealed she had sent a text message to the DON regarding the lack of hot water the previous week, however Resident #61's family stated the DON had not responded to her text messages. Resident #61's family further stated she had sent text message to the DON regarding the lack of incontinence care, not assisting Resident #61 back into bed timely and a wound to Resident #61's penis. Resident #61's family stated her phone calls and text messages had not been answered. Interview on 01/22/25 at 1:34 P.M. with Resident #27's family revealed she had a camera placed in Resident #27's room and had observed Resident #27 not being changed for over 12 hours. Resident #27's family stated she had discussed her concerns with the DON and stated the issue had gotten better for a short time and then the issue had occurred again. Interview on 01/27/25 at 11:55 A.M. with Registered Nurse (RN) #874 revealed she had observed Certified Nursing Assistant (CNA) #823 and #905 (unable to recall exact dates, however stated it was during an evening shift) in a common area watching TV with blankets wrapped around them and were observed to have been using their phones. RN #874 stated she had written up statements regarding CNA #823 and #905 and had given them to the DON and stated she was unsure of the outcome. Interview on 01/27/25 at 12:59 P.M. with Resident #27's family revealed she had sent a text message to the DON on 01/26/25 1:16 P.M. that stated Resident #27 was out of incontinence briefs. Resident #27's family stated the DON had not responded to her text message. Review of personnel files on 01/29/25 at 10:53 A.M. for CNA #823 and #905 revealed no disciplinary actions in their files. Interview with HR #871 confirmed no disciplines in their files. Interview on 02/04/25 at 2:53 P.M. with DON revealed she had responded to families regarding their concerns and stated she had not been given statements from RN #874 regarding CNA #823 and #905. Review of the facility grievances revealed the facility did not have any resident concerns logged since September 2024. Review of the facility Grievance Policy revealed the purpose was to ensure the facility makes prompt effort to resolve grievances a resident may have. The intent of the grievance process is to support each residents right to voice grievances and to assure that after receiving a concern/grievance, the facility actively seeks a resolution and keeps the resident appropriately apprised of it's progress toward resolution. Response to grievances include any employee of the facility who receives a concern shall immediately attempt to resolve the concern within their role and authority. If a concern cannot be immediately resolved the employee shall escalate the concern to their supervisor and the facility grievance official. Resolution to grievances include the facility will strive for a prompt resolution outcome of all grievances or concerns rendered. A reasonable time frame will be agreed upon with all parties involved. This deficiency represents non-compliance investigated under Complaint Numbers OH00161890, OH00161410, and OH00161142.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, staff interview, and facility policy review, the facility failed to ensure resident care plans were up-to-date and reviewed on a quarterly basis as required. This affected four residents (#9, #26, #44, #54) of four residents reviewed for care planning. The facility census was 100. Findings include: 1. Review of the medical record for Resident #44 revealed she was admitted to the facility on [DATE] with diagnoses that included bilateral primary osteoarthritis of knee, hypertensive heart disease without heart failure, and major depressive disorder. Review of the quarterly, Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated she cognitively intact. Review of the MDS assessment revealed Resident #44 required assistance from staff for Activities of Daily Living (ADLs). Review of the physician orders dated 01/21/25 revealed Resident #44 had an order for droplet isolation for COVID-19 with all activities to take place in her room. Review of the progress note dated 01/20/25 at 2:54 P.M. revealed Resident #44 complained of cold-like symptoms, and was COVID-19 tested with positive results. Resident #44 placed on isolation precautions. Review of the care plan dated 03/06/24 revealed Resident #44 did not have a care plan in place for infection control, droplet precautions, or COVID-19. Review of the facility document provided by the DON titled Isolation Residents undated, revealed Resident #44 was positive for COVID-19 as of 01/20/25. Interview on 01/21/25 at 8:25 A.M. with the Director of Nursing (DON) revealed the facility had one positive case of COVID-19 and that was for Resident #44. The DON revealed Resident #44 tested positive for COVID-19 on 01/20/25. Follow-up interview and review of Resident #44's medical record on 01/22/25 at 1:23 P.M. with the DON confirmed Resident #44 did not have a care plan related to infection control, COVID-19, or isolation and/or droplet precautions in place. The DON instructed the state surveyor to click on multiple areas within the Electronic Medical Record (EMR) and was unable to produce results. The DON confirmed and verified the findings at the time of the interview. 2. Review of the medical record for Resident #9 revealed a re-admission date of 10/05/23. Diagnoses included but were not limited to epilepsy, type II diabetes mellitus, and morbid obesity. Review of 01/14/25 quarterly Minimum Data Set (MDS) 3.0 revealed a Brief Interview of Mental Status (BIMS) score of 12 which indicated mild cognitive impairment. Review of activities of daily living (ADLs) revealed Resident #9 was dependent upon staff for toileting, dressing, transfers and mobility. Review of the care plan review section in the electronic medical record for Resident #9 revealed the last fully completed care plan quarterly review was on 05/03/23. Interview on 02/03/25 at 2:30 P.M. with MDS Nurse #848 stated care plans are to be reviewed quarterly and confirmed Resident #9's care plan review page indicated Resident #9's care plan had not been fully reviewed since 05/03/23. 3. Review of the medical record for Resident #26 revealed an admission date of 02/11/23. Diagnoses included but were not limited to hemiplegia and hemiparesis, morbid obesity, unilateral osteoarthritis. Review of 01/11/25 annual Minimum Data Set (MDS) 3.0 for Resident #26 revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Review of activities of daily living (ADLs) revealed Resident #26 required supervision for meals. Review of Resident #26's care plan which was last updated on 11/01/24 revealed Resident #26 had a self-care deficit related to limited mobility and hemiplegia/hemiparesis related to stroke. Interventions dated 02/13/23 was for supervised eating assistance. Resident #26's care plan dated 07/16/24 for demonstrated extrapyramidal symptoms (EPS) (involuntary movements and tremors) revealed an intervention for a speech therapy referral for speech and eating difficulty dated 07/16/24. Resident #26 was noted to have potential for altered nutrition and hydration related to hemiplegia and morbid obesity. Intervention last revised on 01/26/24 was for nursing to assist with meals as needed. Interview on 02/03/25 at 2:30 P.M. with MDS Nurse #848 stated care plans are to be reviewed quarterly and confirmed Resident #54's care plan for feeding assistance had not been updated since 01/06/24. MDS Nurse #848 also confirmed on the care plan review page in the electronic medical record there were no completed quarterly care plan review dates listed. 4. Review of the medical record for Resident #54 revealed an admission date of 10/20/23. Diagnoses included but were not limited to acute and chronic respiratory failure, chronic obstructive pulmonary disease, type II diabetes mellitus, morbid obesity, mild protein-calorie malnutrition, and bipolar disorder. Review of 12/29/24 significant change Minimum Data Set (MDS) 3.0 for Resident #54 revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. Resident #54 uses a wheelchair. Review of activities of daily living (ADLs) revealed Resident #54 requires set up for meals, supervision to wheel 50 feet and moderate assistance to wheel 150 feet. Review of Resident #54's care plan revealed it was initiated on 10/23/23 and latest revisions to any section were 05/29/24. Interview on 02/03/25 at 2:30 P.M. with MDS Nurse #848 stated care plans are to be reviewed quarterly and confirmed there was no indicated completed care plan review since 05/29/24. Review of the policy Care Plan - Advanced Care Plan Process revised December 2022 revealed the Interdisciplinary Team (IDT) will coordinate with the resident and/or their responsible party, an appropriate plan of care for the resident's needs or wishes specific to person-centered care based on the assessment and reassessment process within the required time frames. The IDT, in collaboration with the resident, will meet and review the care plan upon admission, quarterly, and annually. This deficiency represents non-compliance investigated under Complaint Number OH00161142 and OH00161136.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #17 revealed she was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, and COVID-19. Review of the MDS annual assessment dated [DATE], revealed Resident #17 had a Staff Assessment for Mental Status (SAMS) that indicated she had a short and long-term memory problem and was severely impaired regarding task of daily life. Review of the MDS assessment revealed Resident #17 was impaired on one side, upper and lower extremities, and was dependent on staff for Activities of Daily Living (ADLs). Review of the care plan dated 07/05/23 revealed Resident #17 required staff assistance with ADLs with interventions that included one-person assist for transfers and resident care per facility protocol. Review of the physician orders dated 04/19/22 revealed Resident #17 had an order for a one-person assist for transfers. Observation on 01/21/25 at 7:49 A.M. revealed Resident #17 call light was activated. Interview on 01/21/25 at 7:50 A.M. with Resident #17 revealed she wanted to get out of bed. Observation and interview on 01/21/25 at 8:07 A.M. revealed Licensed Practical Nurse (LPN) #854 entered Resident #17 call light, turned it off, and exited the room as she told Resident #17 she would get someone to assist her. LPN #854 confirmed and verified she turned off Resident #17 call light and was going to get staff to assist her. Observation and interview on 01/21/25 at 8:30 A.M. revealed Resident #17 was still in bed. Resident #17 revealed she still wanted to get out of bed. Observation on 01/21/25 at 8:52 A.M. revealed Resident #17 was still in bed needing staff assistance. Observation and interview on 01/21/25 at 9:45 A.M. revealed Certified Nursing Assistant (CNA) #885 passing the morning breakfast trays. CNA #885 revealed if another staff member turned off a call light without telling her the care needs required, she would not know if residents needed assistance, and they would go without care. CNA #885 revealed Resident #17 still required assistance at the time of the interview. CNA #885 confirmed and verified Resident #17 call light was off but she still required help. CNA #885 revealed everyone on her assignment still needed care due to her arriving late for her shift. Observation, during tour with the Director of Nursing (DON), and interview on 01/21/25 at 10:37 A.M. revealed Resident #17 call light was on. Resident #17 revealed she needed to be toileted and staff still had not assisted her. DON confirmed and verified Resident #17 still needed assistance. 3. Review of the medical record for Resident #25 revealed she was admitted to the facility on [DATE] with diagnoses that included pressure ulcer of the sacral region, type 2 diabetes, and hypertension. Review of the MDS quarterly assessment dated [DATE], revealed Resident #25 had Brief Interview for Mental Status (BIMS) score of 14, that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #25 required assistance from staff for ADLs. Review of the care plan dated 07/04/23 revealed Resident #25 had a self-care deficit with interventions that included assist of one staff member and resident care per facility policy. Observation on 01/21/25 at 10:43 A.M. revealed Resident #25 call light activated. Admissions Director (AD) #825 was observed walking past Resident #25 call light without providing assistance. 4. Review of the medical record for Resident #44 revealed she was admitted to the facility on [DATE], with diagnoses that included bilateral primary osteoarthritis of knee, hypertensive heart disease without heart failure, and major depressive disorder. Review of the MDS quarterly assessment dated [DATE] revealed Resident #44 had a BIMS score of 13 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #44 required assistance from staff for ADLs. Review of the care plan dated 03/07/25, for Resident #44 revealed she had a self-care deficit and was bed bound with interventions that included assistance of one staff. Observation on 01/21/25 at 10:06 A.M. revealed Resident #44 call light was activated. Observation on 01/21/25 at 10:12 A.M. revealed RN #880 walked past Resident #44 call light without providing assistance. Observation on 01/21/25 at 10:13 A.M. revealed CNA #889 approached Resident #44 room, grabbed a surgical mask from the personal protective equipment (PPE) bin outside of her room and continued to walk down the hall, without providing assistance. Observation on 01/21/25 at 10:14 A.M. revealed CNAs #826 and #885 walking past Resident #44 room without answering her call light. 5. Review of the medical record for Resident #26 revealed she was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, morbid obesity, and depression. Review of the MDS annual assessment dated [DATE], revealed Resident #26 had a BIMS score of 13 that indicated she was alert and oriented. Review of the MDS assessment revealed Resident #26 was dependent on staff for ADLs. Review of the care plan dated 06/20/23 for Resident #26 revealed she had a self-care deficit related to limited mobility with interventions that included staff assistance and care per facility protocol. Observation and interview on 01/21/25 at 7:47 A.M. revealed Resident #26 call light was activated. Resident #26 revealed she required assistance from staff for incontinence care and hadn't been assisted since 11:00 P.M. the night before, 01/20/25. Resident #26 revealed she was on Lasix and required care more frequently. Observation and interview on 01/21/25 at 8:31 A.M. revealed Resident #26 call light was activated. Resident #26 revealed she activated her call light because she still needed assistance with incontinence care, due to staff turning off her call light, but not assisting. Observation on 01/21/25 at 8:50 A.M. revealed Resident #26 call light was activated again and she was heard from the hallway yelling out Hello. Observation on 01/21/25 at 8:53 A.M. revealed Registered Nurse (RN) #848 was observed entering Resident #26 room, turned off the call light, did not provide any care and exited the room. Resident #26 reactivated her call light after RN #848 exited her room. Observation and interview on 01/21/25 at 9:00 A.M. revealed RN #848 enter Resident #26 room, turned off her call light and did not provide care. RN #848 revealed Resident #26 required assistance with incontinence care and reported she had not been changed since 10:00 P.M. the night prior, 01/20/25. RN #848 revealed he informed Resident #26 he would get the CNA assigned to her. RN #848 confirmed and verified he turned off Resident #26 call light without providing assistance. Interview on 01/21/25 at 11:09 A.M. with the DON revealed all staff were responsible to answer call lights to attempt to provide care to residents, however, if the staff assisting could not provide care, the call light were to remain on until a staff member that could provide care, did so. Review of the resident council meeting minutes dated 10/29/24 revealed residents voiced concerns regarding call light response. Review of the meeting minutes revealed the DON informed attendees that call lights were to be answered by all staff members and if assistance could not be provided, the call light should remain on until the appropriate staff could assist. Review of the resident council meeting minutes dated 12/27/24 revealed residents voiced concerns regarding call light responses. Review if the meeting minutes revealed the Administrator informed attendees that all staff were responsible for answering call lights and management and nursing management completed ambassador rounds. Review of the facility document titled Resident Call System revised March 2023, revealed the facility had a policy in place to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Review of policy revealed facility staff would respond to call lights in a timely manner and would not turn off the call light if needs were unable to be met. This deficiency represents non-compliance investigated under Master Complaint Number OH00162102 and Complaint Number OH00161556. Based on observation, interview, medical record review, review of hospital records, and facility policy review, the facility failed to timely implement a physician-ordered treatment to a vascular wound upon admission. This affected one (Resident #77) of three residents reviewed for wound care management. Additionally, the facility failed to ensure resident call lights were answered and care provided in a timely manner. This affected four (Residents #17, #25, #26, and #44) of four residents reviewed for call lights. The facility census was 100. Findings include: 1. Review of Resident #77's medical records revealed an admission date of 01/18/25. Diagnoses included diabetes, muscle weakness, and difficulty walking. Review of Resident #77's pre-admission hospital records, dated 01/07/25 through 01/18/25 revealed the resident was hospitalized for care and treatment of a left foot arterial (vascular wound) ulcer to the top of the left foot and ankle. The records noted the resident had significant pain to the left lower extremity. The hospital initiated a betadine-soaked gauze dressing to the left lower extremity. Review of Resident #77's care plan dated 01/20/25 revealed the resident had an activity of daily living (ADL) deficit related to weakness. Interventions included observing skin for redness and open areas and reporting any changes to the nurse. Review of Resident #77's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Resident #77 required maximum assistance with toileting, and moderate assistance with bathing and personal hygiene. Review of Resident #77's medical record revealed no evidence that an admission nursing assessment had been completed, including a comprehensive skin assessment to identify any areas of skin impairment present upon admission. Review of Resident #77's physician's orders revealed an order dated 01/23/25 for a wound dressing to a vascular wound on the resident's left lower extremity. The order stated to cleanse the left foot, toe, and ankle with normal saline, apply betadine-soaked gauze, apply an absorbent dressing, and wrap with kerlix (gauze roll) and secure with tape daily. Observation on 01/21/25 at 8:02 A.M. revealed Resident #77 was yelling out in pain that was heard from the hallway outside of a closed door to Resident #77's room. Upon entering Resident #77's room, Registered Nurse (RN) #844, and Licensed Practical Nurses (LPN) #803 and LPN #852 were observed in Resident #77's room. Resident #77 was observed with a tattered gauze dressing to her left foot that was soiled with yellow drainage and was not intact. Interviews with RN #844 and LPN #852 revealed they were not aware of what type of wound the dressing was covering, and had not removed the dressing since the resident was admitted . RN #844 and LPN #852 stated Resident #77 had come from the hospital with that dressing. Resident #77 was observed to have been yelling out in pain and was not able to state what was under the dressing to her left foot. Observation on 01/22/25 at 10:54 A.M. of Resident #77 with LPN #847 revealed the resident's left lower extremity dressing was the same tattered and soiled dressing, unchanged from the observation on 01/21/25. LPN #847 stated she was unaware of Resident #77 having a wound to the left foot, and confirmed the bandage appeared to be tattered and soiled. LPN #847 had proceeded to remove Resident #77's dressing and observation revealed a wound to the top of Resident #77's left foot that was approximately 2 inches long and 1 inch wide, with necrotic (black-colored areas indicating areas of dead tissue) areas, with the area surrounding the necrotic area appearing reddened. LPN #847 stated she would inform the wound nurse. During the observation, the DON entered Resident #77's room and DON stated she was unaware of the area. Observation on 01/22/25 at 11:04 A.M. revealed LPN #903 had entered Resident #77's room with the DON and the Administrator. LPN #903 stated she had been unaware of the wound to Resident #77's foot. LPN #903 stated she would gather supplies to cleanse the wound and had exited the room. At 11:04 A.M., LPN #903 returned to Resident #77's room and cleansed the area with normal saline, applied an absorbent dressing, and wrapped the resident's leg with a kerlix gauze roll. LPN #903 stated the edges of the wound appeared to be necrotic and confirmed the edges appeared reddened. LPN #903 stated the wound physician performed wound rounds on Thursdays and would be in the facility on 01/23/25 to see the resident's wound. Review of Resident #77's hard chart on 01/22/25 at 12:10 P.M. with the DON revealed the pre-admission hospital records noted the resident had been treated for a vascular wound and pain control prior to coming to the facility. Resident #77's hard chart was reviewed with the DON who confirmed the paperwork had included an ulcer to the left foot and pain control. The DON thanked the state surveyor for letting her know. Review of facility policy titled Pressure Ulcer Prevention and Risk Identification revised 01/23 revealed if a new skin area was identified the licensed nurse will initiate a skin grid flow record and update every seven days until area is resolved, the physician and responsible parties were to be notified and treatment will be initiated according to physician orders.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, facility policy review, the facility failed to adequately monitor resident nutritional status by not obtaining consistent weights per physician orders. This affected four residents (Resident #26, #54, #66, and #101) of eight residents reviewed for weights. This had the potential to affect all 100 residents residing in the facility. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 02/11/23. Diagnoses included but were not limited to hemiplegia and hemiparesis, morbid obesity, unilateral osteoarthritis. Review of Resident #26's Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Review of activities of daily living (ADLs) revealed Resident #26 required supervision for meals. Review of physician orders for Resident #26 revealed no active order for weight monitoring. Review of the electronic medical record for Resident #26 revealed no recorded weights for August 2024 and October 2024. Review of Resident #26's nutrition care plan revealed potential for altered nutrition and hydration related to hemiplegia, and morbid obesity. Intervention dated 01/27/23 stated to monitor and record weights as ordered. Interview on 01/29/25 at 12:05 P.M. with Registered Dietitian #915 confirmed there was no active physician order for monthly weights for Resident #26 and no recorded weight for August 2024 and October 2024. 2. Review of the medical record for Resident #54 revealed an admission date of 10/20/23. Diagnoses included but were not limited to acute and chronic respiratory failure, chronic obstructive pulmonary disease, type II diabetes mellitus, morbid obesity, mild protein-calorie malnutrition, and bipolar disorder. Review of Resident #54's MDS 3.0 significant change in status assessment dated [DATE] revealed a BIMS score of 13 which indicated intact cognition. Review of activities of daily living (ADLs) revealed Resident #54 required set up assistance for meals. Review of Resident #54's physician orders revealed an order dated 02/01/24 for monthly weights to be obtained every day shift starting on the first and ending on the second of every month. Review of the weights recorded in the electronic medical for Resident #54 revealed no weights were recorded for January 2025 or February 2025 (through 02/05/25). Review of the nursing progress notes dated 01/01/25 for Resident #54 revealed no nursing progress notes indicating reason the resident's weights had not been obtained as ordered. Review of Resident #54's Medication Administration Record (MAR) for February 2024 revealed on 02/01/25 and 02/02/25 to see nurses note related to why weight was not obtained. Review of nursing progress note dated 02/01/25 timed at 4:49 P.M. revealed monthly weight was unable to be obtained due to limited staffing. No progress note was found for 02/02/25 related to the reason the resident's weight had not been obtained. Interview on 02/04/25 at 11:05 A.M. with Assistant Director of Nursing (ADON) #898 confirmed weights were not completed as ordered for Resident #54 for January 2025 or February 2025. 3. Review of the medical record for Resident #66 revealed an admission date of 01/09/25. Diagnoses included but were not limited to alcohol abuse with intoxication, type II diabetes with hyperglycemia, and unspecified protein-calorie malnutrition. Review of Resident #66's MDS 3.0 admission assessment dated [DATE] revealed a BIMS score of 14 which indicated the resident was cognitively intact. Review of activities of daily living (ADLs) revealed Resident #66 required supervision for meals. Review of physician order for Resident #66 dated 01/10/25 revealed an order for a weight to be obtained on admission and weekly for three additional weeks. Review of Resident #66's recorded weights under the weight section in the electronic medical record revealed a weight of 123 pounds (#) upon admission and no additional weights recorded. Review of Resident #66's Medication Administration Record (MAR) for January 2025 revealed weight was recorded as refused on 01/17/25 and no response was recorded for 01/23/25. Review of Resident #66's nursing progress notes revealed no progress noted dated 01/17/25 indicating a weight refusal or indication of reattempts made to obtain Resident #66's weight. No progress note was found dated 01/23/25 indicating why weight for Resident #66 was not obtained. Interview on 01/29/25 at 12:05 P.M. with Registered Dietitian #915 confirmed weights upon admission are to be completed weekly for four weeks. RD #915 also confirmed no weight was recorded for 01/23/25 for Resident #66 and should have been per physician orders. 4. Review of the closed medical record for Resident #101 revealed an admission date of 12/06/24 and a discharge date of 01/06/25. Diagnoses included but were not limited to malignant neoplasm of brain, cerebral edema, altered mental status, and unilateral primary osteoarthritis. Review of Resident #101's MDS 3.0 assessment dated [DATE] revealed the resident had a BIMS score of 15 which indicated intact cognition. Review of activities of daily living (ADLs) revealed Resident #101 required set up for meals, used a walker, and required moderate assistance for walking 10 feet. Review of Resident #101's physician order dated 12/09/24 revealed weights were to be obtained on admission and weekly for three additional weeks. Review of Resident #101's recorded weights under the weight section in the electronic medical record for revealed two weights were recorded: a weight recorded on 12/07/24 of 134# and a weight recorded on 12/24/24 of 136.1#. Review of Resident #101's MAR for December 2024 revealed the weight was checked off as being completed by the nurse on 12/09/24, 12/16/24, and 12/23/24, but no weight was recorded. Interview on 01/29/25 at 12:05 P.M. with Registered Dietitian #915 revealed weights are recorded under the weights tab in the electronic medical record. Upon admission, residents are to be weighed weekly for four weeks and then monthly unless otherwise indicated. RD #915 confirmed there were no recorded weekly weights for 12/14/24 as physician ordered. Interview on 02/024/25 at 11:05 A.M. with Assistant Director of Nursing (ADON) #898 confirmed weights were indicated as completed on 01/09/24, 01/16/24, and 01/23/24 on the MAR but was unable to provide evidence of weights obtained and stated if the weight was recorded it would have populated under the weight section and was unsure why weights were indicated as complete. Review of the policy Weight Policy and Procedure revised December 2022 revealed all new admissions will be weighed weekly for the first four weeks after admission. Weights will be recorded in the resident's medical record. If a resident refuses to be weighed, staff will educate on the risks, encourage the resident to reconsider and document in the medical record. This deficiency represents an incidental finding identified while investigating Master Complaint Number OH00162102 and Complaint Numbers OH00161890, OH00161859, OH00161556, OH00161410, OH00161144, OH00161142, and OH00161136.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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Based on record review, staff interview, and review of facility policy, the facility failed to ensure residents' were timely administered medications and were free from significant medication errors. This affected five (Residents #26, #27, #61, #77, and #115) of five resident records reviewed for medication administration. The facility census was 100. Findings include: 1. Review of Resident #26's medical record revealed an admission date of 02/11/23. Medical diagnoses included hemiplegia and hemiparesis, morbid obesity, and osteoarthritis. Review of Resident #26's Medication Administration Record (MAR) for January 2025 revealed the resident had orders for the following morning medications daily at 8:00 A.M.: a. Sennosides 8.6 milligram (mg) two tablets for bowel maintenance b. Gabapentin 300 mg one capsule for neuropathy c. Losartan potassium 25 mg one tablet for hypertension d. Levetiracetam 500 mg one tablet for convulsions e. Potassium chloride extended release (ER) 10 milliequivalents (mEq) one tablet f. Apixaban (blood thinner) 5 mg one tablet for atrial fibrillation g. Oxybutynin ER 5 mg one tablet for overactive bladder h. Docusate sodium 100 mg one tablet for bowel maintenance i. Fluocinonide external cream 0.05% topically to affected areas for psoriasis j. Furosemide (diuretic) 40 mg one tablet for edema k. Amlodipine besylate 2.5 mg one tablet for hypertensive heart disease without heart failure l. Austedo extended release (XR) 48 mg one tablet for subacute dyskinesia (involuntary movements) Review of Resident #26's time-stamped MAR for January 2025 revealed on 01/04/25, all 8:00 A.M. medications were recorded as administered between 11:36 A.M. and 11:37 A.M. (Three hours and 36 minutes after they were due). On 01/15/25, the 8:00 A.M. medications were recorded as administered at 11:11 A.M. (three hours and 11 minutes after they were due). On 01/16/25, the above 8:00 A.M. medications were recorded as administered at 11:49 A.M. (three hours and 45 minutes after they were due). On 01/21/25, all 8:00 A.M. medications were recorded as administered between 1:49 P.M. and 1:59 P.M. (five hours and 45 minutes after they were due). 2. Review of Resident #27's medical record revealed an admission date of 05/02/24. Medical diagnoses included coronary artery disease, gastroesophageal reflux disease (GERD), and hypertensive heart disease. Review of Resident #27's MAR for January 2025 revealed the resident had orders for the following medications daily at 8:00 A.M.: a. Apixaban 5 mg one tablet for history of deep vein thrombosis DVT) b. Amlodipine 5 mg one tablet for hypertension c. Atenolol 25 mg one tablet for hypertension d. Clopidogrel 75 mg one tablet for coronary artery disease (CAD) e. Furosemide 20 mg one tablet once daily for hypertension f. Isosorbide Mononitrate ER 120 mg one tablet for CAD/angina (chest pain) g. Pantoprazole 50 mg one tablet for GERD h. Sodium chloride 1 gram (gm) one tablet Review of Resident #27's time-stamped MAR for January 2025 revealed on 01/04/25, 8:00 A.M. medications were recorded as administered at 11:35 A.M. (three hours and 35 minutes after they were due). On 01/15/25, 8:00 A.M. medications were recorded as administered at 11:29 A.M. (three hours and 29 minutes after they were due). On 01/16/25, 8:00 A.M. medications were recorded as administered at 12:02 P.M. (four hours and two minutes after they were due). On 01/21/25, 8:00 A.M. medications were recorded as administered at 3:39 P.M. (seven hours and 39 minutes after they were due). 3. Review of Resident 61's medical record revealed an admission date of 08/21/24. Medical diagnoses included falls, chronic heart failure and chronic obstructive pulmonary disease (COPD). Review of Resident #27's MAR for January 2025 revealed the resident had orders for the following medications daily at 8:00 A.M.: a. Aspirin 81 mg one tablet for anticoagulant b. Isosorbide dinitrate 30 mg two tablets once daily for hypertension c. Phenytoin sodium extended one capsule for anti-seizure d. Torsemide (diuretic) 10 mg one tablet every other day for edema (only administered on even days) e. Zoloft 25 mg two tablets for anxiety Review of Resident #61's time-stamped MAR for January 2025 revealed on 01/03/25, 8:00 A.M. medications (with the exception of Torsemide) were recorded as administered at 10:42 A.M. (four hours and 42 minutes after they were due). On 01/04/25, 8:00 A.M. medications were recorded as administered at 11:27 A.M. (five hours and 27 minutes after they were due). On 01/06/25, 8:00 A.M. medications were recorded as administered at 11:46 A.M. (five hours and 46 minutes after they were due). On 01/12/25, 8:00 A.M. medications were recorded as administered at 4:00 P.M. (eight hours after they were due). On 01/13/25, 8:00 A.M. medications (with the exception of Torsemide) were recorded as administered at 11:19 A.M. (three hours after they were due). On 01/14/25, 8:00 A.M. medications were recorded as administered at 1:53 P.M. (five hours and 53 minutes after they were due). On 01/21/25, 8:00 A.M. medications (with the exception of Torsemide) were recorded as administered at 3:01 P.M. (seven hours and one minute after they were due). 4. Review of Resident #77's medical record revealed an admission date of 01/18/25. Medical diagnoses included type II diabetes mellitus, peripheral vascular disease, protein-calorie malnutrition, anxiety, and acute pain. Review of Resident #77's MAR for January 2025 revealed the resident had orders for the following medications daily at 8:00 P.M.: a. Atorvastatin Calcium 80 mg one tablet for statin (elevated cholesterol) b. Latanoprost Ophthalmic Solution 0.005% one drop in both eyes for eye pressure c. Heparin sodium 5000 units/milliliter (ml), one ml subcutaneously for prevention d. Isosorbide Mononitrate ER 30 mg one tablet for blood pressure e. Ranolazine ER 500 mg one tablet for angina f. Gabapentin 100 mg one capsule for nerve pain Review of Resident #77's time-stamped MAR for January 2025 revealed on 01/20/25, 8:00 P.M. medications were recorded as administered at 11:06 P.M. (three hours and six minutes after they were due). On 01/23/25, 8:00 P.M. medications were recorded as administered on 01/24/25 at 5:11 A.M. (nine hours and 11 minutes after they were due). On 01/24/25, 8:00 P.M. medications were recorded as administered on 01/26/25 at 2:19 A.M. (six hours and 19 minutes after they were due). On 01/26/25, 8:00 P.M. medications were recorded as administered on 01/27/25 at 2:30 A.M. (six hours and 30 minutes after they were due). 5. Review of Resident #115's medical record revealed an admission date of 01/21/25. Medical diagnoses included hypertension, COPD, osteoarthritis, and depression. Review of Resident #115's MAR for January 2025 revealed the resident had orders for the following medications daily at 8:00 A.M.: a. Bupropion HCl ER 150 mg one tablet for antidepressant b. Cetirizine 10 mg one half tablet for itching c. Lidocaine External Patch 4% topically applied to affected area for pain d. Loratadine 10 mg one tablet for antihistamine e. Vitamin D3 2000 unit one tablet for health maintenance f. Diclofenac sodium external gel 1% topical gel to affected area for analgesic Review of Resident #115's time-stamped MAR for January 2025 revealed on 01/26/25, 8:00 A.M. medications were recorded at 11:25 A.M. (three hours and 25 minutes after they were due). On 01/27/25, 8:00 A.M. medications were recorded as administered at 12:09 P.M. (four hours and nine minutes after they were due). Interview on 01/22/25 at 8:55 A.M. with LPN #847 revealed her medications had been late on occasion and at times medications were not available. Interview on 01/22/25 at 1:34 P.M. with a family member of Resident #27 revealed there had been days she had seen residents get their medications late. The family member reported on 01/21/25, a neighboring resident's morning and afternoon medications had been administered at the same time. The family member reported she had taken a picture of the two medications cups that were left in a nearby resident's room on 01/21/25 at 3:16 P.M. Interview on 02/04/25 at 3:30 P.M. with the Director of Nursing (DON) confirmed the above residents had medications recorded as administered late. The DON revealed she had been aware of resident complaints regarding late medications. The DON stated she had educated the nurse regarding timely medication pass, and stated she planned to further discuss the issue at an upcoming facility quality assurance meeting. Review of the policy Medication Administration - General Guidelines revised August 2014 revealed medications are administered as prescribed in accordance with good nursing principles and practices. The five rights - right resident, right drug, right dose, right route, and right time - are applied for each medication being administered. The Medication Administration Record (MAR) is always employed during medication administration. Medications are administered within 60 minutes of scheduled time unless otherwise specified by the provider. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. This deficiency represents non-compliance investigated under Complaint Numbers OH00161859, OH00161142, and OH00161136.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident record review, staff interview, and facility policy review, the facility failed to ensure resident dietary preferences were maintained. This affected five residents (#25, #26, #28, #33, and #82) of five reviewed for dietary preferences. The facility census was 100. Findings include: 1. Review of the medical record for Resident #28 revealed she was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, cerebral infarction, and atrial fibrillation. Review of the quarterly, Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 12 that indicated she was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #28 was dependent on staff for Activities of Daily Living (ADLs). Review of the care plan dated 07/03/23 revealed Resident #28 had potential for altered nutrition related to hemiplegia, dementia, and morbid obesity with interventions that included assessing food preferences, and to provide and serve prescribed diet as ordered by the physician. Review of the physician orders dated 10/12/23 revealed Resident #28 had an order for a No Added Salt (NAS), Low-Calorie Sweetener diet with regular texture, and thin liquids consistency. Observation and interview on 01/23/25 at 8:51 A.M. during the breakfast meal tray pass, revealed Certified Nurse Assistant (CNA) #889 picked up Resident #28 breakfast tray from the delivery car and stated She's not going to eat this. She only likes bacon for breakfast. CNA #889 revealed Resident #28 only liked to eat bacon for breakfast. CNA #889 revealed floor staff were aware of Resident #28 meal preferences. CNA #889 revealed Resident #28 breakfast meal ticket only consisted of preferences related to chicken tenders. Observation and interview on 01/23/25 at 8:55 A.M. revealed CNA #889 returning from Resident #28 room with her breakfast meal tray in hand. CNA #889 revealed Resident #28 declined her breakfast meal tray due to her preferences not being followed. CNA #889 revealed Resident #28 breakfast meal tray consisted of scrambled eggs and a bagel. CNA #889 revealed Resident #28 did not eat scrambled eggs, sausage, or bagels. CNA #889 confirmed and verified the findings at the time of the observation. Interview on 01/28/25 at 2:20 P.M. with the Director of Nursing (DON) revealed the facility currently did not have a kitchen manager and was in the process of interviewing and hiring someone. DON revealed there was no staff available at this time to individualize meal requests. Observation and interview on 01/29/25 at 8:40 A.M. revealed Central Supply Clerk (CSC) #814 entered and exited Resident #28 room with her breakfast meal tray in hand. CSC #814 revealed Resident #28 declined her breakfast meal tray due to her not liking to eat breakfast. Interview on 01/29/25 at 8:42 A.M. with Resident #28 revealed she declined her breakfast meal tray because there was no bacon on it. Resident #28 revealed her breakfast meal consisted of waffles and sausage. Resident #28 revealed she did not eat sausage. Observation of Resident #28 breakfast meal ticket dated 01/29/25 revealed no breakfast meal preferences. 2. Review of the medical record for Resident #82 revealed he was admitted to the facility on [DATE] with diagnoses that included schizophrenia, syncope and collapse, and hypertensive heart disease. Review of the care plan dated 01/17/24 revealed Resident #82 had potential for altered nutrition with interventions that included to acknowledge changing food preferences. Observation and interview on 01/21/25 at 9:22 A.M. revealed Resident #82 breakfast tray consisted of an English muffin, scrambled eggs, and no bacon. Resident #82 revealed he preferred bacon. Interview on 01/28/25 at 2:20 P.M. with the DON revealed the facility currently did not have a kitchen manager and was in the process of interviewing and hiring someone. DON revealed there was no staff available at this time to individualize meal requests. 3. Review of the medical record for Resident #26 revealed she was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, morbid obesity and depression. Review of the care plan dated 06/20/23 revealed Resident #26 had potential for altered nutrition with interventions that included acknowledging changing food preferences. Review of the menu dated 01/21/25 revealed the breakfast meal consisted of a cheesy Amish breakfast casserole, English muffin, hot cereal juice of choice, choice of hot coffee or tea, and milk of choice. Observation and interview on 01/21/25 at 9:10 A.M. revealed Resident #26 breakfast tray consisted of an English muffin, bacon, and no eggs. Resident #26 revealed she liked eggs and would have preferred them to be on her breakfast tray. Resident #26 revealed she was not sure why she did not have eggs for breakfast. Interview on 01/28/25 at 2:20 P.M. with the DON revealed the facility currently did not have a kitchen manager and was in the process of interviewing and hiring someone. DON revealed there was no staff available at this time to individualize meal requests. 4. Review of the medical record for Resident #25 revealed she was admitted to the facility on [DATE] with diagnoses that included pressure ulcer of sacral region, type 2 diabetes, and hypertension. Review of the care plan dated 07/04/23 revealed Resident #25 had potential for altered nutrition with interventions that included acknowledging changing food preferences. Observation and interview on 01/21/25 at 9:30 A.M. revealed Resident #25 breakfast tray consisted of an English muffin, eggs, and no bacon. Resident #25 revealed there were many times when she did not get breakfast meat with her breakfast meal. Interview on 01/28/25 at 2:20 P.M. with the DON revealed the facility currently did not have a kitchen manager and was in the process of interviewing and hiring someone. DON revealed there was no staff available at this time to individualize meal requests. 5. Review of the medical record for Resident #33 revealed she was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, and chronic kidney disease. Review of the care plan dated 02/13/24 revealed Resident #33 had a right to make lifestyle choices and had potential for altered nutrition with interventions that included acknowledging changing food preferences. Review of Resident #33 meal ticket for the lunch meal on 01/28/25 revealed she was to receive mashed potatoes with every meal, whole milk and a magic cup. Observation and interview on 01/28/25 at 1:25 P.M. revealed Resident #33 seated in the main dining room with a lunch meal tray that consisted of chicken tenders and French fries. Business Office Manager (BOM) #822, present during the observation, revealed Resident #33 had three cups of juice, no milk, and acknowledged no residents had received any magic cups. BOM #822 confirmed and verified Resident #33 meal ticket, and the lack of preferences followed. Interview on 01/23/25 at 7:20 A.M. with Dietary Manager (DM) #908 revealed all residents received meal tickets to ensure meals were accurate and preferences were honored. DM #908 revealed residents were not served breakfast meat daily, however, if they requested it or it was a preference, they would receive it with their breakfast meal. Review of the facility document titled Selective Menus (Always Available Menu and Room Service Menu) undated, revealed the facility had a policy in place that residents would be able to choose foods they wish to have. Review of the document revealed the facility did not implement the policy. This deficiency represents an incidental finding identified while investigating Master Complaint Number OH00162102 and Complaint Numbers OH00161890, OH00161859, OH00161556, OH00161410, OH00161144, OH00161142, and OH00161136.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure resident records were maintained in an accurate manner and contained the assessments and services provided. This affected seven residents (#6, #9, #49, #54, #77, #82, #83) of seven reviewed for accurate medical records. The facility census was 100. Findings include: 1. Review of the medical record for Resident #6 revealed she admitted to the facility on [DATE] with diagnoses that included sepsis, Alzheimer's disease, and muscle weakness. Review of the physician orders dated 12/18/24 revealed Resident #6 required two-person assist for transfers. Review of the care plan dated 12/19/24 revealed Resident #6 had a self-care deficit with interventions that included assistance of one for bathing. Review of the medical record for Resident #83 revealed he was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, dementia, and epilepsy. Review of the care plan dated 07/03/23 revealed Resident #83 had a self-care deficit with interventions that included bathing assistance as needed and resident care per facility protocol. Review of the medical record for Resident #49 revealed he was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, traumatic subarachnoid hemorrhage, and legal blindness. Review of the physician orders dated 11/05/23 revealed Resident #49 had an order for transfer via hoyer lift. Review of the care plan dated 11/19/24 revealed Resident #49 had a self-care deficit with interventions that included bathing of one assist and resident care per facility protocol. Review of the medical record for Resident #82 revealed he was admitted to the facility on [DATE] with diagnoses that included schizophrenia, syncope and collapse, and hypertensive heart disease. Review of the care plan dated 01/17/24 revealed Resident #82 was at risk for Activities of Daily Living (ADLs) ADL decline with interventions included bathing assist of one and resident care per facility protocol. Review of the medical record for Resident #77 revealed she was admitted to the facility on [DATE] with diagnoses of cerebral infarction and type 2 diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was alert and oriented to person, place, and time with cognition impairment and required staff assistance for showers. Review of the medical record for Resident #54 revealed she was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, chronic obstructive pulmonary disease, and diastolic heart failure. Review of the MDS assessment revealed Resident #54 had impairment on both sides of her lower extremities and required assistance from staff for ADLs. Review of the care plan dated 02/19/24 revealed Resident #54 had a self-care deficit with interventions that included extensive total assistance with all ADLs. Interview on 01/21/25 at 9:07 A.M. with Resident #54 revealed she had not received any showers for a couple weeks. Interview on 01/21/25 at 1:50 P.M. with Resident #97 Power of Attorney (POA) revealed residents went without showers or bed baths. Resident #97 POA revealed Resident #97 went without a shower or bed bath due to staffing levels. Review of the shower sheet dated 01/20/25 for Resident #77 revealed she did not receive a shower due to the water being cold. Review of the shower sheets dated for the week of 01/12/25 through 01/18/25, for Residents #6, #49, #54, #77, #82, #83, identified to be affected by cold water temperatures, revealed documented showers. However, interviews with the Maintenance Director (MD) #853 on 01/21/25 at 3:12 P.M. and the Administrator on 01/22 25 at 2:30 P.M. revealed the unit in which residents #6, #49, #54, #77, #82, #83 resided on, did not have hot water at the time documented. The above findings were confirmed and verified by the Administrator on 02/05/25 at 3:04 P.M.2. Review of Resident #9's medical records revealed an admission date of 10/06/22. Diagnoses included obesity, muscle weakness and diabetes. Resident #9's Minimum Data Set (MDS) assessment revealed Resident #9 had intact cognition and required maximum assistance with bathing. Review of physician orders for January 2025 revealed Resident #9 was ordered Permethrin (cream used to treat scabies infection) 60 grams one time applied all over the body from the neck down and wash off skin within 8-14 hours. Orders were active from 01/20/25-01/27/25 and review of the Medication Administration Report (MAR) for January 2025 revealed Permethrin cream was administered on 01/22/25, 01/23/25, 01/25/25, 01/26/25 and 01/27/25. Physician orders for January-February 2025 had another order for Permethrin from 01/29/25-02/04/25. Review of MAR revealed cream was administered on 01/31/25, 02/01/25, 02/02/25 and 02/03/25. Interview on 02/04/25 at 10:06 A.M. with Licensed Practical Nurse (LPN) #928 revealed he had applied Resident #9's cream on 01/31/25 and 02/03/25. Telephone interview on 02/04/25 at 12:05 P.M. with pharmacy revealed one tube of Resident #9's Permethrin cream was sent on 01/10/25 and 01/12/25. Interview on 02/04/25 at 2:53 P.M. with Director of Nursing (DON) confirmed Resident #9's Permethrin cream was a one time dose and stated a second dose had been ordered on 01/12/25. DON stated the nursing staff should not have documented the extra doses as being administered. 3. Review of Resident #77's medical records revealed an admission date of 01/18/25. Diagnoses included falls, difficulty walking and muscle weakness. Review of Resident #77's medical records revealed no admission assessment had been completed by nursing. Interview on 02/04/25 at 3:30 P.M. with DON revealed she had been aware assessments had not been completed upon admission and recorded in the resident's medical record as required. DON stated she had educated the staff on documenting admission assessments and stated the facility was going to discuss the issue during their quality assurance and performance improvement meeting. This deficiency represents non-compliance investigated under Complaint Number OH00161142.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

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Based on observations, resident interviews, staff interviews, and facility policy review, the facility failed to ensure the resident environment was kept in a clean and sanitary manner. This had the potential to affect all 100 residents residing in the facility. Findings include: Observation on 01/21/25 at 7:52 A.M. revealed multiple old, dirty dinner trays sitting on the ledge of the common area on the 200-Hall Unit, adjacent to Resident #80 room. Observation on 01/21/25 at 7:53 A.M. revealed multiple open and used staff drinks situated at the nurses station located on the 200-Hall Unit. Observation and interview on 01/22/25 at 5:45 A.M. revealed dirty dinner dishes sitting on the ledge of the common area on the 200-Hall Unit, adjacent to Resident #62 room. Certified Nurse Assistant (CNA) #883 revealed she wasn't aware of who placed the dishes there. CNA #883 revealed staff should have taken them away after the dinner meal. CNA #883 confirmed and verified the dirty dinner trays and dishes located on the 200-Hall Unit at the time of the observations. Observation and interview on 01/22/25 at 6:20 A.M. revealed multiple drink cups at the nurse's station on the 200-Hall Unit. Business Office Manager (BOM) #822 revealed staff beverages and cups should not be kept at the nurses station. BOM #822 confirmed and verified the findings at the time of the observation. Observation and interview on 01/27/25 at 6:44 A.M. revealed dirty dinner dishes sitting on a ledge adjacent to Resident #94 room. Licensed Practical Nurse (LPN) #868 confirmed and verified the observation. Observation and interview on 01/30/25 at 10:52 A.M. revealed nine drinks were observed at the nurses station on the 300-Hall Unit. Observation revealed a sign located at the nurses station that read NO DRINKS AT THE NURSES STATION. Interview with LPN #826 revealed she was unaware that staff drinks were not allowed at the nurses station. However, LPN #826 acknowledged the sign posted and verified the findings at the time of the observation. This deficiency represents non-compliance investigated under Master Complaint Number OH00162102 and Complaint Numbers OH00161410, OH00161136, OH00161142.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected most or all residents

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Based on observation and interview the facility failed to ensure chart room that contained residents private information were secured. This had the potential to affect all residents residing in facility. The facility census was 100. Findings include: Tour on 01/21/25 at 10:42 A.M. with Director of Nursing (DON) revealed 3 out of 4 doors to the facility's chart rooms had tape over the locks and the rooms were not secured. Each room contained the resident's hard chart with access to various components of the medical record. The DON confirmed the tape on the door and stated chart rooms were to be locked at all times, and removed the tape during tour. Observation on 01/27/25 at 6:52 A.M. revealed a chart room located on the 300 hall that had a wheelchair leg placed in the doorway leaving the door propped open. Interview with Licensed Practical Nurse (LPN) #834 at the time of observation confirmed the door was propped open when she arrived to start her shift on 01/26/25 at 7:00 P.M. LPN #834 stated the doors to the chart rooms were to remain secured at all times. This deficiency represents non-compliance investigated under Complaint Numbers OH00161142 and OH00161136.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, staff interviews, review of time punch details, daily staffing sheets and schedules, review of the facility assessment, and facility policy review, the facility failed to ensure adequate staffing levels to meet the needs of the residents. This affected all residents residing in the facility. The facility census was 100. Finding include: 1. Review of the daily staffing sheet dated 01/21/25 revealed the facility had 7 Certified Nurses Assistants (CNAs) scheduled for the 1st shift. Review of the daily staffing sheet revealed each CNA had designated rooms to provide care for. Review of the daily staffing sheet revealed CNA #838 was assigned to fifteen residents (#7, #11, #13, #20, #24, #29, #32, #35, #36, #38, #50, #66, #70, #77, #98), CNA #824 was assigned sixteen residents (#15, #18, #26, #27, #28, #49, #61, #67, #71, #72, #80, #82, #89, #91, #94, #100), CNA #885 was fourteen residents (#1, #6, #9, #17, #25, #30, #42, #44, #45, #54, #62, #78, #83, #92), CNA #878 was assigned fourteen residents (#2, #21, #31, #37, #39, #40, #43, #58, #60, #63, #69, #75, #87, #99), CNA #835 was assigned sixteen residents (#3, #10, #16, #22, #33, #48, #52, #57, #59, #65, #73, #76, #79, #81, #84, #97), and CNAs #855 and #889 was assigned the premium side, twenty-one residents (#4, #5, #8, #12, #19, #23, #34, #46, #47, #51, #53, #55, #56, #64, #68, #74, #86, #88, #93, #95, #96). Observation on 01/21/25 during tour of the facility from 7:30 A.M. to 9:00 A.M. revealed no staff providing care for fourteen residents (#1, #6, #9, #17, #25, #30, #42, #44, #45, #54, #62, #78, #83, #92) assigned to CNA #885. Observation and interview on 01/21/25 at 7:47 A.M. revealed Resident #26 call light was activated. Resident #26 revealed she required assistance from staff for incontinence care and hadn't been assisted since 11:00 P.M. the night before, 01/20/25. Resident #26 revealed she was on Lasix and required care more frequently. Observation and interview on 01/21/25 at 7:49 A.M. revealed Resident #17 call light was activated, and she wanted to get out of bed and needed incontinence care. Interview on 01/21/25 at 7:51 A.M. with Resident #52 revealed there were not enough staff in the building to assist with the residents and call light response times were over 30 minutes. Interview on 01/21/25 at 8:10 A.M. with CNA #824 revealed the facility could use more staff. Observation and interview on 01/21/25 at 8:31 A.M. revealed Resident #26 call light was activated. Resident #26 revealed she activated her call light because she still needed assistance with incontinence care, due to staff turning off her call light, but not assisting. Interview on 01/21/25 at 8:57 A.M. with CNAs #824 and #838 revealed they were unaware of what CNA was assigned to the rooms for residents #1, #6, #9, #17, #25, #30, #42, #44, #45, #54, #62, #78, #83, #92. Interview with CNAs #824 and #838 revealed CNA #885 was assigned to residents #1, #6, #9, #17, #25, #30, #42, #44, #45, #54, #62, #78, #83, #92 according to the daily staffing sheet, and had not arrived yet. Interview on 01/21/25 at 9:07 A.M. with Resident #54 revealed there were not enough staff and you could never find anyone. Resident #54 revealed no one answered her call light, she barely received care including showers and incontinence care. Observation and interview on 01/21/25 at 9:15 A.M. revealed CNA #885 had arrived for her shift. CNA #885 revealed she was assigned to work the 1st shift, which started at 7:00 A.M. CNA #885 confirmed and verified she had arrived approximately 2.5 hours late and residents assigned to her went without care. Interview on 01/21/25 at 9:30 A.M with Resident #25 revealed she had not got out of bed for two days, 01/17/25 and 01/28/25, due to no staff available. Interview on 01/21/25 at 9:41 A.M. with Licensed Practical Nurse (LPN) #832 revealed staffing could be better. Observation and interview on 01/21/25 at 9:45 A.M. revealed CNA #885 passing the morning breakfast trays. CNA #885 revealed if another staff member turned off a call light without telling her the care needs required, she would not know if residents needed assistance, and they would go without care. CNA #885 revealed Resident #17 still required assistance at the time of the interview. CNA #885 confirmed and verified Resident #17 call light was off, but she still required help. CNA #885 revealed everyone on her assignment still needed care due to her arriving late for her shift. Observation and interview on 01/21/25 at 9:49 A.M. revealed CNA #824 being called to assist on another unit. CNA #824 revealed she was going to help another unit, but did not know where the other assigned staff were. CNA #824 confirmed and verified some staff had not arrived for their shift. Observation, during tour with the Director of Nursing (DON), and interview on 01/21/25 at 10:37 A.M. revealed Resident #17 call light was on. Resident #17 revealed she needed to be toileted, and staff still had not assisted her. DON confirmed and verified Resident #17 still needed assistance. Interview on 01/21/25 at 11:26 A.M. with Resident #73 family member revealed Resident #73 had a camera in her room and staff were not checking on her for several hours. Resident #73 family member revealed she would call the nurse's station to get someone to check on Resident #73, but no one would answer the phone. Interview on 01/21/25 at 1:50 P.M. with Resident #97 Power of Attorney (POA) revealed facility staff never provide timely assistance. Resident #97 POA revealed staff would turn off call light but never return to provide care requested. Review of the punch detail report dated 01/21/25 revealed CNA #885 did not punch-in for her 1st shift assignment until 9:08 A.M. Review of the time punch dated 01/07/25 through 01/26/25 and 01/28/25, revealed CNA #885 was scheduled to work the 1st shift, 7:00 A.M.-7:00 P.M., however, she clocked-in 4 hours late (11:00 A.M.) on 01/08/25, approximately 3.5 hours late (10:22 A.M.) on 01/14/25, 2.5 hours late (9:30 A.M.) on 01/16/25, approximately 2.5 hours late (9:28 A.M.) on 01/18/25, and approximately 2 hours late (9:08 A.M.) on 01/21/25. Review of the time punch dated 01/28/25 revealed CNA #885 clocked-in approximately 2.5 hours late (9:23 A.M.) on 01/28/25. Review of the time punches for CNA #885 had a history of arriving late for her shift. Interview on 01/27/25 at 3:15 P.M. with CNA #838 revealed there were technically always only 5 CNAs to care for the residents on the A and B Units (Rooms 201-323) which housed 79 residents (#1, #2, #3, #6, #7, #9, #10, #11, #13, #15, #16, #17, #18, #20, #21, #22, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #35, #36, #37, #38, #39, #40, #42, #43, #44, #45, #48, #49, #50, #52, #54, #57, #58, #59, #60, #61, #62, #63, #65, #66, #67, #69, #70, #71, #72, #73, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #87, #89, #91, #92, #94, #97, #98, #99, #100). CNA #838 revealed 21 residents (#4, #5, #8, #12, #19, #23, #34, #46, #47, #51, #53, #55, #56, #64, #68, #74, #86, #88, #93, #95, #96) residing on the Premium Suites Unit had their own (2 CNAs) dedicated staff that were not allowed to assist throughout the building. Interview on 01/29/25 at 2:01 P.M. with LPN #846 revealed staffing the facility was an issue and the facility failed to be fully staffed to meet the needs of the residents. LPN #846 revealed she was unable to complete her expected daily tasks, such as medication passes, due to staffing levels. 2. Review of the Facility assessment dated [DATE] revealed staffing was based on the resident population and acuity and direct care staff (nurses and aides) worked 12-hour shifts from 7:00 A.M.-7:00 P.M. and 7:00 P.M.-7:00 A.M. Review of the facility assessment revealed the facility required 7 full-time CNAs and 1 part-time CNA designated for the 1st shift and 7 CNAs for the 2nd shift to meet the needs of the residents in the facility for an average daily census of 90 residents. The current facility census was 100 residents. Review of the resident council meeting minutes dated 12/27/24 revealed residents voiced concerns regarding short staffed daily. The Administrator informed attendees that they were staffed to state guidelines. Review of staffing reports and time punch details for December 2024 and January 2025 were reviewed with Human Resources Director (HRD) #871 and Staff Scheduler (SS) #841 revealed the following concerns: Review of the time punch detail dated 12/24/24 revealed the facility had 2 CNAs working the 3rd shift. Review of the time punch detail dated 12/25/24 revealed the facility had 3 CNAs working the 1st shift and 5 CNAs working 3rd shift. Review of the time punch detail dated 12/31/24 revealed the facility had 6 CNAs working the 1st shift and 3 CNAs working the 3rd shift. Review of the time punch detail dated 01/28/25 revealed the facility had 6 CNAs working the 1st shift. Review of the time punch detail dated 01/31/25 revealed the facility had 5 CNAs working the 3rd shift. Interview on 01/28/25 at 8:39 A.M. with HRD #871 and SS #841 revealed they were responsible for staffing the facility. Interview revealed the facility did not utilize agency and staffing was based on census, acuity, and per patient day (PPD). HRD #871 revealed she scheduled between 7 and 8 aides per shift depending on the census with 2 aides on the premium unit and 5 to 6 aides on the other units. HRD #871 provided state survey staffing schedules and time-punches dated for the month of December 2024 through February 2025. HRD #871 confirmed and verified staffing schedules and time-punches were accurate at the time of review and reflected the facility was staffed under their planned ratios on the above dates and shifts. Reconciliation with the staff schedules, the daily staffing sheets, observed floor staff, and census and acuity levels, revealed the facility did not accurately staff the facility to meet the needs of the residents residing in the facility. Review of the facility document titled Resident Call System revised March 2023, revealed the facility had a policy in place to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Review of policy revealed facility staff would respond to call lights in a timely manner and would not turn off the call light if needs were unable to be met. Review of the document revealed the facility did not implement the policy. This deficiency represents non-compliance investigated under Master Complaint Number OH00162102 and Complaint Numbers OH00161890, and OH00161136.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected most or all residents

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Based on observation, resident interviews, staff interviews, facility policy review, and return demonstration of a test tray, the facility failed to serve hot, palatable meals. This affected all 100 residents as the facility did not identify any residents that were solely not receiving food by mouth (NPO). Findings include: Interview on 01/21/25 at 7:51 A.M. with Resident #52 revealed the food needed to be improved and was often cold. Interview on 01/21/25 at 9:07 A.M. with Resident #54 revealed she often did not want her breakfast because it was cold and always needed rewarmed. Interview on 01/21/25 at 9:38 A.M. with Resident #3 revealed the facility food was bad. Interview and observation at 9:44 A.M. revealed Resident #54 call light was activated. Resident #54 revealed her food was cold and needed warmed up. Resident #54 revealed she did not like eating cold food. Interview on 01/21/25 at 10:06 A.M. with Resident #62 revealed the facility food was a joke. Observation on 01/23/25 at 7:20 A.M. of the kitchen breakfast meal preparation with Dietary Manager (DM) #908 revealed the steam table consisted of scrambled eggs with a temperature reading of 155 degrees fahreneheit, oatmeal 206 degrees fahrenheit, grits 204 degrees fahreneheit, bagel 144 degrees fahrenheit, and sausage patties 202 degrees fahrenheit. Observation on 01/21/25 at 8:20 A.M. revealed the breakfast meal cart arrived to the 200-Hall Unit. A return demonstration of the test tray with DM #908 at 8:47 A.M., approximately 25 minutes later, revealed the scrambled eggs were 107.1 degrees fahreneheit, the bagel was 110.4 degrees fahreneheit, and the tray was absent of oatmeal, grits, and sausage patties. DM #908 confirmed and verified the eggs were not hot and the meal was absent of other items. This deficiency represents non-compliance investigated under Complaint Numbers OH00161142 and OH00161136.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected most or all residents

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Based on observation, resident interviews, staff interviews, and review of facility mealtimes, revealed the facility failed to ensure meals were served in a timely manner. This affected all 100 residents as the facility did not identify any residents that were solely not receiving food by mouth (NPO). The facility census was 100. Findings include: Interview on 01/21/25 at 7:51 A.M. with Resident #52 revealed the facility food could be improved. Resident #52 revealed the food was always served late and cold. Interview on 01/21/25 at 9:07 A.M. with Resident #54 revealed she had not received her breakfast yet. Resident #54 revealed the food was always cold and needed to be warmed up. Observation on 01/21/25 at 9:10 A.M. revealed the breakfast cart arrived to the 200-Hall unit. Observation and interview on 01/22/25 at 9:31 A.M. revealed Resident #77 did not have a breakfast tray. Certified Nurse Assistant (CNA) #862 confirmed and verified Resident #77 was still without a breakfast tray. Observation and interview on 01/22/25 at 9:34 A.M. revealed Resident #115 was seated in her wheelchair outside of her room visibly upset. Resident #115 revealed she was upset because her breakfast meal had not arrived. No meal cart or staff passing meal trays were observed at the time of the observation. Observation on 01/22/25 at 9:58 A.M. revealed residents on the 300-Hall unit were receiving their breakfast trays. Review of the meal service times revealed the facility served breakfast between 7:00 A.M. and 8:45 A.M. Observation and interview on 01/23/25 at 7:20 A.M. of the breakfast meal preparation with Dietary Manager (DM) #908 revealed the kitchen served the front hall rooms (201-230) first, then the middle hall rooms (231-256), followed by the back hall room (301-323). DM #908 revealed the kitchen staff delivered the meal carts to the units and the floor staff were responsible for delivering them to residents. Observation revealed the breakfast meals arrived to the first unit at 8:20 A.M., and the last tray for first unit was served at 8:46 A.M. Observation revealed the time in which the last tray was served on the first unit, was when the entire facility should have already been served according to the listed mealtimes. Observation revealed other units had not been served yet and the meals were late. DM #908 confirmed and verified the above findings at the time of the observations. This deficiency represents an incidental finding identified while investigating Master Complaint Number OH00162102 and Complaint Numbers OH00161890, OH00161859, OH00161556, OH00161410, OH00161144, OH00161142, and OH00161136.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Administration (Tag F0835)

Could have caused harm · This affected most or all residents

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Based on observation and interview the facility failed to ensure adequate amounts of supplies were available to provide resident care. This had the potential to affect all residents residing in the facility. The facility census was 100. Findings include: Observation of clean linen closet on the 200 hall on 01/21/25 at 9:45 A.M. revealed no towels or washcloths and 1 package of disposable incontinence briefs. Observation was confirmed by Certified Nursing Assistant (CNA) #824 and CNA #824 stated she often had to go to other units to look for items and stated there had been times she had not had linens for a few hours after the start of her shift at 7:00 A.M. Interview on 01/22/25 at 8:38 A.M. with CNA #861 revealed there had been many times she did not have supplies to provide incontinence care. Interview on 01/27/25 at 12:59 P.M. with Resident #27's daughter revealed on 01/26/25 at 1:16 P.M. she had sent a text message to the Director of Nursing (DON) to inform her of the lack of incontinence briefs for Resident #27. Resident #27's daughter stated the DON had not responded to her text message and stated she had informed the Activities Director (AD) #813 about the lack of briefs and he was able to locate one package. Resident #27's daughter stated she had also shared some of the briefs with other residents due to she was worried they would not have any and might not be provided with incontinence care. Interview on 02/05/25 at 3:01 P.M. with Administrator and DON revealed the facility would not confirm or deny the lack of supplies. This deficiency represents non-compliance investigated under Complaint Number OH00161142.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Staffing Data (Tag F0851)

Could have caused harm · This affected most or all residents

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Based on record review and interview, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all residents. Findings include: Review of the STNA assignments dated 01/07/25 through 02/05/25 revealed one nurse was assigned to the SNF (Skilled Nursing Facility) premium nursing unit and one to two Certified Nursing Assistant's (CNA)'s were assigned to the SNF premium nursing unit. The schedule did not specify which nurse and aide were assigned to care for residents in the attached Assisted Living (AL) area. Interview on 02/04/25 at 2:40 P.M. of the Administrator revealed the Skilled Nursing Facility (SNF) and the Assisted Living (AL) area did not have separate schedules for staff assignments. The Administrator stated the SNF and AL used the same schedule. The Administrator stated the nurse and aides assigned to the SNF premium nursing unit were the same nurse and aides who cared for residents in the AL area. The Administrator confirmed the schedule did not reflect that the nurse and aide assigned to the premium nursing unit were also assigned to care for the residents residing in the AL. The Administrator stated there was one resident (Resident #1) residing in the AL area. The Administrator stated she called the corporate office about not having a separate schedule for the SNF and AL and the auditor said the AL was not a separate building, it was part of someone's unit, Resident #1 needed minimal care, he did not have dressing changes, he was independent and the staff hours calculated for the Skilled Nursing Facility did not include hours needed to care for Resident #1 in the AL. This deficiency represents an incidental finding identified while investigating Master Complaint Number OH00162102 and Complaint Numbers OH00161890, OH00161859, OH00161556, OH00161410, OH00161144, OH00161142, and OH00161136.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0940 (Tag F0940)

Could have caused harm · This affected most or all residents

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Based on employee file review and interview, the facility failed to ensure staff were trained as required. This had the potential to affect all 100 residents residing at the facility. Findings include: Review of the employee file for Certified Nursing Assistant (CNA) #823 on 01/29/25 at 10:30 A.M. with Human Resource Director #871 revealed an employee start date of 10/10/24. Review of the general orientation check list dated 10/10/24 for CNA #824 revealed it was incomplete with numerous sections not indicated as checked off as complete. The orientation checklist revealed various admissions/marketing, dietary, social services, administration, therapy, and nursing areas were not indicated as being checked off. Areas which were not checked off as complete included but were not limited to infection control, dementia and memory care training, wound care, incident/accident reporting, restorative nursing, transfer techniques, Hoyer procedures and enhanced barrier precautions. Review of the employee file for CNA #885 on 01/29/25 at 10:35 A.M. with Human Resource Director #871 revealed a start date of 07/03/24. Review of the general orientation checklist dated 07/03/24 for CNA #885 was incomplete with numerous sections not indicated as being checked off. The orientation checklist revealed various maintenance, housekeeping, admissions, activities, dietary, social services, administration, therapy, and nursing were not indicated as being checked off as completed. Some of the Identified areas that did not indicate completion included but was not limited to infection control, dementia training, wounds, incident/accident reporting, transfer techniques, Hoyer procedures and enhanced barrier precautions. Interview following the completion of employee files on 01/29/25 at 10:53 A.M. with Human Resource Director #871 confirmed orientation checklists for CNA #823 and #885 were partially filled out and not complete as required. Interview on 02/04/25 at 7:18 A.M. with LPN #832 stated did not feel proper orientation was given upon hire, was given an orientation packet to read and no staff went over the information, stated was supposed to have two-day orientation but only got one due to staffing shortage. This deficiency represents non-compliance investigated under Master Complaint Number OH00162102 and Complaint Numbers OH00161142 and OH00161142.

Jul 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure wound care was ordered and documented according to nurse practitioner orders. This affected one resident (#15) of three residents reviewed for wound care. The facility census was 83. Findings include: Record review of Resident #15 revealed she was admitted [DATE] with diagnoses including a stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) and diabetes. She had an as-needed order dated 07/19/24 for wound care, but no scheduled time or days when wound care was to be done. Review of her treatment administration record (TAR) revealed no wound care procedures were documented as completed in 07/2024. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had mild or no cognitive impairment and had a stage III pressure sore present on admission. Record review of Resident #15's wound nurse practitioner notes revealed an assessment on 07/05/24 identified the resident as having a stage III pressure sore to her sacrum measuring 2.1 centimeters (cm) by 0.9 cm with a depth of 0.1 cm. The orders called for daily application of calcium alginate and a clean dry dressing. Their assessment on 07/25/24 noted the wound was improving and measured 1.8 cm by 0.7 cm by 0.2 cm and called for a silver alginate dressing to be applied daily. Interview with Resident #15 on 07/29/24 at 10:02 A.M. revealed she received daily wound care, had the wound prior to admission, and was seen weekly by the wound nurse practitioner. She had no concerns with her wound care. Interview with Wound Nurse Practitioner #501 on 07/29/24 at 4:08 P.M. revealed Resident #15 was to receive daily wound care of silver alginate with a dry dressing. She knew of no concerns with wound care not being done. Interview with the Director of Nursing (DON) on 07/29/24 at 4:20 P.M. confirmed the above findings, including that wound care was to be done daily and was not documented through 07/2024. She said that due to the location on the sacrum the wound became easily soiled with incontinence care, so staff regularly changed the dressing despite the lack of scheduled orders. Observation of wound care for Resident #15 on 07/30/24 at 9:18 A.M. revealed her previous dressing was dated 07/29/24. The wound appeared clean and without clear evidence of negligence or infection. The nurse performed wound care according to the nurse practitioner orders. This deficiency represents noncompliance investigated under Complaint Number OH00154883.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure residents were regularly screened for risk of falls. This affected three residents (#15, #57, and #61) of four residents reviewed for falls. The facility census was 83. Findings include: 1. Record review of Resident #15 on 07/30/24 revealed she was admitted on [DATE] with diagnoses including diabetes, muscle weakness, and venous insufficiency. Review of her assessments revealed her last fall risk assessment was done 01/28/24 and identified her to not be at risk for falls. She had no documented falls in the last three months. 2. Record review of Resident #57 on 07/30/24 revealed she was admitted on [DATE] with diagnoses including Alzheimer's dementia, diabetes, obesity, and unspecific difficulty walking. Review of her assessments revealed her last fall risk assessment was done 11/05/23 and identified her to be at risk for falls. She had no documented falls in the last three months. 3. Record review of Resident #61 on 07/30/24 revealed he was admitted on [DATE] with diagnoses including prostate cancer, asthma, and chronic kidney disease. Review of his assessments revealed his last fall risk assessment was done 03/19/24 and identified him to be at risk for falls. He had no documented falls in the last three months. Record review of the facility's fall management policy dated 12/2022 revealed all residents were to be assessed for fall risk on admission, quarterly, and with significant change. Interview with the Director of Nursing on 07/30/24 at 8:47 A.M. confirmed the above findings. This deficiency represents noncompliance investigated under Complaint Number OH00154883.

Jun 2024 1 deficiency

MINOR (C) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Minor Issue - procedural, no safety impact

Deficiency F0806 (Tag F0806)

Minor procedural issue · This affected most or all residents

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Based on observation, interview, and record review the facility failed to provide condiments or an alternative for breakfast on 06/03/24. This had the potential to affect all residents who receive food from the kitchen, other than Residents #9 and #40 who the facility identified as receiving nothing by mouth. The facility census was 78. Findings include: Observation on 06/03/24 at 9:15 A.M. revealed residents in the special care dining room requesting syrup for their waffles. Interview on 06/03/24 at 9:15 A.M. with State Tested Nursing Assistant (STNA) #532 confirmed the kitchen reported to them that they were out of syrup and offered no alternatives. Interview on 06/03/24 at 9:16 A.M. with Resident #66 and Resident #68 revealed they had no syrup for their waffle or sausage patty and really wanted syrup. They confirmed they only had butter on their trays for their waffle. Interview on 06/03/24 at 9:18 A.M. with Resident #59 revealed he wanted syrup for his waffle, but the kitchen did not have any and did not offer him anything else. Interview on 06/03/24 at 9:20 A.M. with Resident #62 confirmed he had no syrup for his breakfast from the kitchen, but he had an extra stash in his room where he had some. Interview on 06/03/24 at 9:30 A.M. with Resident #33 revealed he had no syrup only butter for his waffle that day. Interview on 06/03/24 at 9:32 A.M. with STNA #555 confirmed she had no syrup or alternatives to offer her residents for breakfast that morning. Observation on 06/03/24 at 9:35 A.M. of the menu for the day in the main hallway revealed breakfast for 06/03/24 was choice of juice, hot or cold cereal, waffles, sausage, and choice of milk. Observation of the kitchen storage on 06/03/24 at 9:45 A.M. revealed no concerns. Dry storage revealed no syrup was available. Interview during the observation on 06/03/24 at 9:45 A.M. with Dietary Manager #549 confirmed she received a phone call this morning that the facility was out of syrup. She reported that the facility had jelly and sugar free syrup that needed pre poured as an alternative. She confirmed she was not on tray line this morning but when she did get to the facility, she ordered more syrup, and it will be delivered hopefully that day. Interview on 06/03/24 at 9:50 A.M. with Dietary Aide #506 confirmed he was on tray line for breakfast that morning. He reported only one nursing aide called the kitchen requesting sugar free syrup for one resident, but he was not sure who it was and who it was for. He confirmed no alternatives were communicated to the staff. Review of the facility invoices from 05/08/24 to 06/03/24 revealed the facility had 200 packets of syrup delivered on 05/08/24 and 05/22/24. This deficiency was an incidental finding identified during the complaint investigation.

Mar 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0624 (Tag F0624)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of court documents, review of the Statement of Expert Evaluation, review of a police report, and facility policy review, the facility failed to prevent an unauthorized leave of absence (LOA) and subsequent discharge of Resident #78 who had a Protection Service Order (PSO) in place from a case brought by Adult Protective Services (APS). This affected one resident (#78) of three residents who were reviewed for discharge. The facility census was 76. Findings Include: Review of the medical records for Resident #78 revealed an admission date of 01/29/24 and a discharge date of 02/12/24 with diagnoses including hypertension and Alzheimer's dementia. Review of a sworn affidavit in Resident #78 medical records dated 01/09/24 completed by an APS social worker revealed Resident #78 suffers from dementia and is frail and unsteady on her feet. It also revealed Resident #78 was unable to state what to do in an emergency. Impairments of short- and long-term memory were noted. The home was cluttered with severe bug infestation. There was no food in the refrigerator or freezer. Resident #78 stated that daughters are emotionally and verbally abusive. Money has been used by others without permission and bills have not been paid. There was an electric bill notice of shut off. Review of the court document titled Cuyahoga County Division of Senior and Adult Services (CCDSAS) case number 2024 ADV dated 01/17/24 stated upon petition of the CCDSAS, for an order authorizing the provision of Protective Services pursuant to Ohio Revised Code (O.R.C.) 5101.68 for [Resident #78]. The court finds by clear and convincing evidence that Resident #78 is in need of protective services, is incapacitated and that there is no person authorized by law or court order to give consent or is willing to consent to said protective services. Therefore, it is ordered that the Director of CCDSAS or his/her designee, shall be authorized to give consent for said adult for protective services. It is further ordered that the Director of CCDSAS, Adult Senior Protective Services or his/her designee shall have authority to consent to an evaluation and/or medical treatment as may be ordered by the adult's physician, and nursing home admission and authority is given for purposed of completing/assisting with any and all forms of associated with obtaining Medicare and/or Medicaid. It is further ordered that all persons be restrained from interfering with this order and the provision of protective services of the adult. It is further ordered that the adult be transported and admitted to the nearest hospital from her residence for a complete medical and geriatric-psychiatric examination to determine is she has capacity and to determine her care needs and for care and treatment as prescribed by his/her attending physician and for placement to other appropriate placement as determined by CCDSAS, APS. The adult is to be discharged to an appropriate care facility. This judgement will be effective from 01/17/24 and for six-month period unless otherwise ordered by this court. Review of the hospital referral dated 01/19/24 at 10:24 A.M. revealed the post-acute discharge plan: [Resident #78] was brought to the Emergency Department (ED) by APS social worker. Per ED note, the resident was financially exploited by her daughters, one of who she lives with. There is a PSO in the physical chart; stating that the resident is incapacitated; however, requesting a psychiatric exam to determine capacity. The resident is pending state guardianship. Courts would like for the resident to be placed in a skilled nursing facility (SNF). APS is the temporary decision maker moving forward in this case until a guardian is appointed. Resident #78 will need SNF placement pending evaluations as she cannot return to recent livening environment. Review of the Statement of Expert Evaluation dated 01/19/24 to 01/22/24 Resident #78 was physically impaired, unable to ambulate independently, reports of exploitation from APS, possible exploitation from caregivers, and is cognitively impaired and cannot adequately assess or make decisions about housing or care. The resident is not capable of managing finances and property due to impaired cognition and memory. Guardianship should be established/continued. Review of the physician's order dated 01/30/24 included Resident #78 may leave the facility for field trips. A review of Resident #78's face sheet listed an APS worker as first contact. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating Resident #78 was moderately cognitively impaired. Review of the Nurse Practitioner progress note dated 02/06/24 revealed Resident #78 recently admitted to the facility from the hospital after being admitted for psychiatric/geriatric evaluation due to an APS consult. Resident #78 was being financially exploited by family and a pastor. She is currently pending guardianship. The impression and plan stated guardianship pending. A progress note dated 02/13/24 revealed that the charge nurse advised the Director of Nursing (DON) that Resident #78 had signed out of the facility at 6:00 P.M. on 02/12/24 with her daughter. Resident #78 stated she was going to dinner. Attempts were made to contact daughter in order to locate Resident #78, but the calls were unanswered and there was no voicemail box available. The progress note also revealed that Resident #78 had an APS case worker. The DON and Social Service Director (SSD) #214 contacted the APS supervisor on file. The DON spoke with local police officer as well and provided legal documents regarding court order. Police officer stated resident is alert and oriented and has a BIMS of 12. Police officer states resident was able to leave with daughter and is not considered missing therefore, their involvement is not needed at this time. Police will update facility if any new information becomes available. A police report, incident number 202400826, dated 02/13/24 revealed the police were called at 12:31 P.M. The DON stated to them Resident #78 had a court order to be at facility. Stated daughter checked her out last night. Police were advised by the APS supervisor that he was the only one able to check resident out of facility. Family was called and not aware the resident was not allowed to leave facility. The resident was picked up from home and transported back to the facility. The police were informed by the DON that they could not accept Resident #78 due to there being no payment information for her since she was discharged on 02/12/24. APS was contacted. Resident #78 was to be transported to the hospital. Resident #78 was transported back to the police station where she was checked by Emergency Medical Services (EMS). She was then transported by EMS to the local hospital. On 03/04/24 at 9:25 A.M., an interview with the DON revealed Resident #78 left the faciity on [DATE] with family to go out to dinner and did not return. The DON tried multiple times to contact family but there were no return calls nor was a voicemail box available. The DON then contacted APS and they advised her to call the police. The DON stated there was nothing in protective order that stated Resident #78 could not leave the facility. The DON stated she was not aware until after four days of Resident #78 being admitted that a PSO was in place. The DON also stated Resident #78 was not permitted back in building when returned by the police because resident had been gone over 24 hours and there was no medical need. At 2:00 P.M. the DON stated Resident #78 was not able to return to building due to no listed payer source. On 03/04/24 at 12:33 P.M. an interview with the Admissions and Marketing Assistant #222 revealed that she took the referral from the hospital for Resident #78 via a computerized system and verified that APS involvement was on the referral. On 03/04/24 at 12:55 an interview with Regional Nurse Consultant revealed Resident #78 did not have APS listed as guardian, and Resident #78 was only going out to dinner. Stated Resident #78 was not re-admitted as she was gone over 24 hours. On 03/04/24 at 1:45 P.M. an interview with APS revealed a PSO grants APS temporary decision making. APS follows and does not close case until a guardian is appointed. The APS worker stated she was notified that skilled days were up, and the facility was going to work with them until Medicaid could be obtained. At that point the PSO was provided to facility. Resident #78 is currently in another SNF, and a guardianship court date is set for 03/12/24. A review of the facility policy titled, Admission, Transfer and Discharge, dated November 2022, revealed a resident can be transferred or discharged : • If the transfer or discharge is necessary for the resident's welfare and his/her needs cannot be met in the healthcare facility. • If the resident's health has sufficiently improved so that the resident no longer needs the services of the health care facility. • If the safety and health of other residents within the health care facility is endangered. • If the resident has failed, after reasonable and appropriate notice, to pay for a stay in the health care facility. • The facility will assure that sufficient preparation and orientation is provided to the resident for a safe and orderly transfer or discharge. This deficiency represents non-compliance investigated under Master Complaint Number OH00151203.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Transfer (Tag F0626)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of hospital records, review of a police report, and facility policy review, the facility failed to permit Resident #78, who had a Protection Service Order (PSO) in place from a case brought by Adult Protective Services (APS), to return to the facility after an unauthorized leave of absence (LOA) with family. This affected one resident (#78) of three residents reviewed for discharge. The facility census was 76. Findings Include: A review of medical records for Resident #78 revealed an admission date of 01/29/24 and a discharge date of 02/12/24 with diagnoses including hypertension and Alzheimer's dementia. Review of hospital record reviews revealed an emergency room record dated 01/19/24 revealed Resident #78 was there for evaluation and guardianship. There were social and financial concerns. A psychiatry evaluation dated 01/22/24 while Resident #78 was in the hospital revealed Resident #78 lacked capacity to make own medical decisions, had moderate cognitive and memory impairment, poor understanding of domestic and financial situation. An Expert Evaluation dated 01/22/24 while Resident #78 was hospitalized revealed the resident was physically impaired, there were allegations of exploitation made by APS, exploitation by caregivers, cognitive impaired, and cannot adequately assess or make decisions about care and that guardianship should be established. APS was temporary decision maker until a guardian can be appointed. Review of the physician's order dated 01/30/24 included Resident #78 may leave the facility for field trips. A review of Resident #78's face sheet listed an APS worker as first contact. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating Resident #78 was moderately cognitively impaired. Review of the Nurse Practitioner progress note dated 02/06/24 revealed Resident #78 recently admitted to the facility from the hospital after being admitted for psychiatric/geriatric evaluation due to an APS consult. Resident #78 was being financially exploited by family and a pastor. She is currently pending guardianship. The impression and plan stated guardianship pending. A progress note dated 02/13/24 revealed that the charge nurse advised the Director of Nursing (DON) that Resident #78 had signed out of the facility at 6:00 P.M. on 02/12/24 with her daughter. Resident #78 stated she was going to dinner. Attempts were made to contact daughter in order to locate Resident #78, but the calls were unanswered and there was no voicemail box available. The progress note also revealed that Resident #78 had an APS case worker. The DON and Social Service Director (SSD) #214 contacted the APS supervisor on file. The DON spoke with Lyndhurst police officer as well and provided legal documents regarding court order. Police officer stated resident is alert and oriented and has a BIMS of 12. Police officer states resident was able to leave with daughter and is not considered missing therefore, their involvement is not needed at this time. Police will update facility if any new information becomes available. A police report, incident number 202400826, dated 02/13/24 revealed the police were called at 12:31 P.M. The DON stated Resident #78 had a court order to be at the facility, and the resident's daughter checked her out last night. Police were advised by the APS supervisor that he was the only one able to check resident out of facility. Family was called and stated they were not aware that the resident was not allowed to leave the facility. The resident was picked up from home and transported back to the facility. Upon arrival, the police were informed by the DON that they could not accept Resident #78 due to there being no payment information for her since she was discharged . APS was contacted. Resident #78 was to be transported to the hospital. Resident #78 was transported back to the police station where she was checked by Emergency Medical Services (EMS) and then transported by EMS to the local hospital. On 03/04/24 at 9:25 A.M., an interview with the DON revealed Resident #78 left the faciity on [DATE] with family to go out to dinner and did not return. The DON tried multiple times to contact family but there were no return calls nor was a voicemail box available. The DON then contacted APS and they advised her to call the police. The DON stated there was nothing in protective order that stated Resident #78 could not leave the facility. The DON stated she was not aware until after four days of Resident #78 being admitted that a PSO was in place. The DON also stated Resident #78 was not permitted back in building when returned by the police because resident had been gone over 24 hours and there was no medical need. At 2:00 P.M. the DON stated Resident #78 was not able to return to building due to no listed payor source. On 03/04/24 at 12:33 P.M. an interview with the Admissions and Marketing Assistant #222 revealed that she took the referral from the hospital for Resident #78 via a computerized system and verified that APS involvement was on the referral. On 03/04/24 at 12:55 an interview with Regional Nurse Consultant revealed Resident #78 did not have APS listed as guardian, and Resident #78 was only going out to dinner. Stated Resident #78 was not re-admitted as she was gone over 24 hours. On 03/04/24 at 1:45 P.M. an interview with APS revealed a PSO grants APS temporary decision making. APS follows and does not close case until a guardian is appointed. The APS worker stated she was notified that skilled days were up, and the facility was going to work with them until Medicaid could be obtained. At that point the PSO was provided to facility. Resident #78 is currently in another SNF, and a guardianship court date is set for 03/12/24. A review of the facility policy titled, Leave of Absence, dated October 2022, revealed a Physician order will be obtained for a resident requesting LOA from the facility regardless of length. If the physician objects to the resident leaving the facility, then resident will be leaving against medical advice. Nothing in the policy stated if a resident is out after midnight they are discharged . This deficiency represents non-compliance investigated under Master Complaint Number OH00151203.

Jan 2024 9 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to ensure a urinary catheter bag had a privacy cover over it to maintain privacy and dignity for Resident #49. This affected one Resident (#49) of two residents (#49 and #64) who had urinary catheters. The census was 69. Findings include: On 01/17/24 at 12:25 P.M. observation of Resident #49 in the facility dining room eating lunch revealed his urinary catheter bag collecting urine was not in a privacy cover. Interview on 01/17/24 at 12:26 P.M. with Assistant Director of Nursing (ADON) #811 verified Resident #49 was eating lunch in the dining room and the urinary catheter bag did not have a privacy covering over it.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a baseline nursing care plan for Resident #75 according to the regulation requirement. This affected one Resident (#75) of 20 residents reviewed for care plans. The facility census was 69. Findings include: Record review revealed Resident #75 was admitted to the facility on [DATE] and discharged on 10/18/23 with diagnoses including malignant neoplasm of oropharynx, drug induced pancytopenia, anemia due to antineoplastic chemotherapy, elevated white blood cell count, localized swelling, mass and lump of the neck and head, malignant neoplasm of prostate cancer, chronic kidney disease stage three, peripheral vascular disease and acute respiratory failure. Review of the admission assessment dated [DATE] revealed Resident #75's functional assessment was one person assist. He was partial weight bearing. He was oriented to time, place and person. Further review of the medical record revealed no evidence a baseline care plan involving Resident #75's needs for care and services had been developed within the first 48 hours of admission nor was there a comprehensive care plan developed in lieu of the baseline care plan within 48 hours after admission. Interview on 01/17/24 at 4:38 P.M. with the Director of Nursing (DON) confirmed Resident #75's medical record did not have a baseline care plan with interventions within 48 hours of admission nor had a comprehensive care plan been developed within 48 hours of admission in lieu of the baseline care plan.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident, family and staff interviews, and review of facility policy, the facility failed to ensure nail care was provided for Resident #23 and timely incontinence care was provided for Resident #35. This affected two residents (#23 and #35) of three residents reviewed for activities of daily livings (ADL). The facility census was 69. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 06/17/22 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness, spinal stenosis, and dependence on wheelchair. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 that indicated Resident #23 was alert and oriented to person, place, and time. Review of the MDS assessment revealed Resident #23 utilized a wheelchair and was dependent for ADLs. Review of the care plan dated 09/12/23 revealed Resident #23 required extensive assistance for ADL functioning related to cerebral infarction affecting right dominant side that included personal hygiene, bathing, dressing and/or grooming. Observation and interview on 01/16/24 at 11:14 A.M. revealed Resident #23 laying in bed with her right hand laying across her chest. Resident #23's right hand was contracted with the middle and ring fingernails brown in color, thick, brittle, and approximately 1.5 inches in length. Resident #23's thumb, index and pinkie fingernails were yellow in color, thick, and approximately one inch in length. Resident #23's left hand fingernails were well manicured. Resident #23 revealed her nails on her right hand were always long despite asking staff to trim them. Resident #23 revealed staff clipped her nails on her left hand, but did not trim the right hand. Interview on 01/16/24 at 2:59 P.M. with State Tested Nurse Assistant (STNA) #241 revealed staff aides were responsible for trimming resident nails. STNA #241 confirmed staff did not trim Resident #23 nails. Interview on 01/17/24 at 8:03 A.M. with Licensed Practical Nurse (LPN) #215 revealed staff did not trim Resident #23 nails. LPN #215 revealed Resident #23's nails were trimmed by her family, friends, and/or her church members. Interview on 01/17/24 at 8:21 A.M. with STNA #200 revealed she never trimmed Resident #23 nails. Interview on 01/17/24 at 12:21 P.M. with the Director of Nursing (DON) revealed STNA's were responsible for trimming fingernails. DON revealed Resident #23 fingernails were too thick for nail clippers utilized by the facility, therefore staff did not trim them. Follow-up interview on 01/17/24 at 12:40 P.M. with the DON revealed Resident #23's nails were now trimmed as she sat in the dining room. The DON revealed STNA #200 trimmed her nails and was not aware if facility staff had ever attempted to do it before. The DON revealed Resident #23's nails were trimmed with the nail clippers utilized by the facility. Review of the facility document titled Activities of Daily Living (ADL), dated March 2023, revealed the facility had a policy in place to ensure all staff understood the principles of quality of life and honor and support these principles for each resident and that the care and services provided were person-centered and honor and support each resident preferences, choices, values, and beliefs. Further review of the policy revealed the facility would provide hygiene care that included bathing, dressing, grooming, and oral care. Review of the document revealed the facility did not implement the policy. 2. Review of medical record revealed Resident #35 had an admission date of 10/25/23. Diagnoses included Parkinson's disease without dyskinesia, chronic obstructive pulmonary disease, unspecified protein-calorie malnutrition, and incontinence of bowel and bladder. Review of the comprehensive MDS assessment, dated 11/01/23, revealed the resident had impaired cognition. The resident was dependent for toileting. The resident was identified to be always incontinent of bowel and bladder. Review of the plan of care dated 10/25/23 revealed the resident had functional incontinence related to impaired mobility, weakness, and debilitation. Interventions included to check and change during care rounds (every two hours), wash/rinse, dry perineum, and apply adult brief. Review of the plan of care dated 10/25/23 revealed the resident was at risk for altered skin integrity. Interventions included to apply barrier cream as ordered, pressure reducing devices on chair and bed, and turn every two hours and as needed. Review of the plan of care dated 11/07/23 revealed the resident had altered skin integrity. Interventions included to turn and reposition during care rounds and as needed. Review of pressure ulcer assessments dated 10/26/23 to 11/25/23 revealed the resident was at mild to high risk for pressure ulcers. Review of the incontinence care log for Resident #35 revealed limited information regarding if staff completed incontinence care every two hours. Observations on 01/17/24 from 10:39 A.M. to 2:05 P.M. revealed a delay in incontinence care for Resident #35. At 10:39 A.M. Resident #35 was sleeping while seated in her wheelchair. Observations on 01/17/24 at 11:35 A.M. revealed STNA #200 entered Resident #35's room to assist Resident #35 with taking in fluids. Resident #35 remained asleep. Observations on 01/17/24 at 12:53 P.M. revealed staff brought a lunch tray to Resident #35. Resident #35 remained in her wheelchair having no incontinence care provided. Observations at 01/17/24 1:00 P.M. revealed Resident #35's granddaughter was in to visit. Observation and interview on 01/17/24 at 1:30 P.M. with LPN #235 revealed staff had not completed incontinence care or repositioned Resident #35. LPN #235 stated all residents who were incontinent should be checked/changed and repositioned every two hours. Interview on 01/17/24 at 1:48 P.M. with STNA #200 and #244 revealed incontinence care should be completed every two hours with care rounds but the family didn't want Resident #35 checked and changed every two hours because Resident #35 was tired during the day. Interview on 01/17/23 at 1:51 P.M., with a family member of Resident#35 revealed the family member stated she spoke with the Administrator and DON about not providing care for Resident #35 during the overnight shift due to excessive sleepiness during the day. The family member stated they wanted incontinence care provided during the day hours. Observations on 01/17/23 at 2:05 P.M. revealed STNA #200 and #244 provided incontinence care for Resident #35. Resident #35 had two round areas of skin impairment on her bottom covered with a thick layer of paste. Interview on 01/18/23 at 11:03 A.M., the DON stated incontinence care should be provided during care rounds as needed. Interview on 01/18/23 at 4:00 P.M., with the Assistant Director of Nursing (ADON) #217 verified the incontinence care logs for Resident #35 had limited information regarding if staff completed incontinence care every two hours. Review of facility policy titled AM/PM Resident Care, dated 2022, revealed staff should complete incontinence care during care rounds as needed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure adequate supervision of Resident #46 to prevent a fall. This affected one resident (46) of two residents reviewed for falls. The facility census was 69. Finding include: Record review was conducted for Resident #46 who was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, visual loss both eyes, visual hallucination, vascular dementia, hypertension, peripheral vascular disease, localized edema, and glaucoma. Review of the quarterly Minimum Data Set ( MDS) 3.0 assessment, dated 10/12/23, revealed the resident had clear speech and made self-understood, was cognitively intact, had no known displays of physical or verbal behavior symptoms, exhibited no rejection of care, and her functional range of motion for upper and lower extremities was impaired. Resident #46 required a wheelchair for mobility, maximal assistance for bathing and site to stand, dependent on staff for personal hygiene, substantial assistance was needed for eating and moderate assistance to roll left and right in bed. Resident #46 did not walk 10 feet and had no falls since the prior MDS assessment. A review of Resident #46's care plan,date revised 12/14/23, revealed at risk for falls. Fall prevention intervention included the door will remain open one quarter, encourage use of call light, encourage use of nonskid socks, instruct resident on safety measures, keep call bell in reach. A review of Resident #46 care plan, date revised 12/12/23, revealed a self-care deficit related to hemiplegia and hemiparesis due to cerebral infarction and activities of daily living (ADL) needs including ambulation and transfer assist of one, bathing and hygiene assist of one, dressing and grooming assist of one, toileting assist of one. A review of Resident #46's Fall Risk assessment dated [DATE] revealed the resident was at high risk for falls with a score of 14. Most recent fall was 01/04/24. Resident #46 had severely impaired sight, ambulated with problems, and needed devices. Resident #46 was at risk for falls due to health conditions and medications. A review of Resident #46's progress note written on 01/04/24 revealed the nurse was notified by an aid resident had fallen on the floor in the bathroom. Resident #46 was sitting on the floor in front of the sink on her bottom. Resident denied pain and injury. Nurse assessed resident, vital signs were assessed by the nurse and range of motion was done. Resident #46's son, the doctor and nurse manager were notified. A review of a physician note dated 01/04/24 for an acute visit revealed Resident #46 had an unwitnessed fall. Resident #46 stated she hit her head and denied headaches. Neurology checks were unremarkable. The physician discussed options with resident and family. The facility was to follow unwitnessed fall protocol. Review of a witness statement dated 01/04/24 by State Tested Nursing Assistant (STNA) #283 revealed STNA #283 was helping Resident #46 brush her teeth, turned around to set up the wheelchair and Resident #46 fell onto her butt to the floor after her knee got weak and buckled. Interview on 01/18/24 at 9:25 A.M. with the Director of Nursing ( DON) revealed the STNA #283 had set Resident #46 up in the bathroom to brush her teeth, then the STNA left the resident alone to go make the resident's bed. The DON verified Resident #46 was left alone in the bathroom and fell, and Resident #46 was a standby assist for care. The DON stated the STNA was terminated due to leaving Resident #46 alone in the bathroom. An interview was conducted on 01/18/24 at 10:02 A.M. with Resident #46 who revealed she fell because she could not find the grab bar by the sink. Resident #46 stated no staff was in the bathroom with her so she fell. Interview on 01/18/24 at 10:06 A.M. with STNA # 260 revealed Resident #46 was a transfer assist of one-person, one-person assistance needed for oral hygiene and resident was not to stand alone. Interview on 01/18/24 at 10:11 A.M. with Licensed Practical Nurse (LPN) # 302 revealed Resident # 46 was a one-person assistance with transfers and if the resident was at the sink in the bathroom she would need to sit in her wheelchair for safety. LPN #302 stated Resident #46 should not be left alone while standing. Review of facility policy titled Activities of Daily Living ,revision date March 2023, revealed resident care was based on the comprehensive assessment of the resident and consistent with the resident's needs and choices, the facility would provide the necessary care and services. Review of the facility policy titled Fall Management, revision date of December 2022, revealed the facility would identify each resident who was at risk for falls and would develop a plan of care and implement interventions to manage falls.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview the facility failed to date insulin pens when opened. This affected four (Resident #4, #5, #36, and Resident #51) of five residents reviewed for medication storage. The facility census was 69. Findings include: 1. Review of the medical record for Resident #4 revealed an admission date of [DATE]. Diagnoses included type two diabetes mellitus. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed the resident had intact cognition. Review of physician orders revealed an order for lispro injection solution dated [DATE]. Review of the Medication Administration Record (MAR) revealed Resident #4 received lispro injection of four units on [DATE]. 2. Review of the medical record for Resident #5 revealed an admission date of [DATE]. Diagnoses included diabetes mellitus. Review of the comprehensive MDS 3.0 assessment, dated [DATE], revealed the resident had intact cognition. Review of physician orders revealed an order for Humalog solution dated [DATE]. Review of the MAR revealed Resident #5 received five units of Humalog on [DATE]. 3. Review of the medical record for Resident #36 revealed an admission date of [DATE]. Diagnoses included diabetes mellitus. Review of the comprehensive MDS 3.0 assessment, dated [DATE], revealed the resident had impaired cognition. Review of physician orders revealed an order for Humalog solution dated [DATE]. Review of the MAR revealed Resident #36 received two units of Humalog on [DATE]. 4. Review of the medical record for Resident #51 revealed an admission date of [DATE]. Diagnoses included diabetes mellitus. Review of the comprehensive MDS 3.0 assessment, dated [DATE], revealed the resident had intact cognition. Review of physician orders revealed an order for Lispro solution dated [DATE]. Review of the MAR revealed Resident #51 received five units of Lispro on [DATE]. Observation was conducted on [DATE] at 2:15 P.M. of the insulin pens for Resident #4, #5, #36 and #51 and revealed the pens were opened but not dated with the open date. Interview was conducted on [DATE] at 2:15 P.M. with Licensed Practical Nurse (LPN) #235 during the observation of the insulin pens. LPN #235 verified the insulin pens were not dated to indicate the first day the insulin was used for Resident #4, #5, #36 and #51. Review of facility policy titled Vials and Ampules of Injection Medications, dated 2023, revealed staff must record date opened and date expired on all multidose vials.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to ensure staff removed gloves after emptying a catheter and before proceeding to touch Resident #49's personal items. This affected one resident (#49) of 20 residents reviewed for infection control. The census was 69. Findings include: Observation was conducted on 01/17/24 at 2:36 P.M. of State Tested Nursing Assistant (STNA) #237 emptying Resident $49's urinary catheter bag. STNA #237 emptied the urine from the catheter bag and did not remove her gloves after completing the task. STNA #237 came back out of Resident #49's bathroom with the same gloves on and adjusted his bedside table closer to him, straightened his personal belongings on top of the table and pushed his newly opened bottle of water closer to him to be in his reach. Interview on 01/17/24 at 2:38 P.M. with STNA #237 confirmed she completed emptying Resident #49's catheter bag and did not remove her gloves or wash her hands after the task and before handling Resident #49's personal items.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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Based on observation, staff interview, and facility policy review, the facility failed to ensure temperatures in the main dining room were kept at a comfortable level. This had the potential to affect seventeen residents (#5, #7, #15, #18, #19, #22, #23, #24, #27, #31, #33, #37, #39, #41, #47, #48, #377) the facility identified as residents who ate meals in the main dining room. The facility census was 69. Findings include: Observation on 01/17/24 at 4:36 P.M. in the main dining room, during the dinner meal, revealed a thermostat located on the wall adjacent to the windows. The thermostat was set to 68 degrees Fahrenheit (F) with a current temperature reading of 66 degrees F. Interviews on 01/17/24 at 4:38 P.M. with Residents #18, #23 and #31 revealed it was cold and sometimes uncomfortable while eating due to the the dining room not being warm. Observation and interview on 01/17/24 at 4:39 P.M. revealed Bookkeeper (BKR) #287 standing in front of the thermostat. BKR #287 revealed the thermostat was locked on a degree setting of 68 degrees F and had a current temperature of 66 degrees F. BKR #287 confirmed and verified the above findings at the time of the observation. Interview on 01/17/24 at 4:44 P.M. with Maintenance Director (MD) #804 and #805 revealed depending on the resident's preference, temperatures in common areas usually were set between 72 and 74 degrees F and usually set higher than 68 degrees F. MD #804 and #805 revealed temperatures in the facility should be set between 71 and 81 degrees F. According to the national and local weather forecast via www.weather.com, dated 01/17/24, the temperature for the facility's location revealed a high of 21 degrees F and a low of 18 degrees F. Review of the facility document titled Extreme Heat/Cold, revised January 2023, revealed the facility had a policy in place to provide a comfortable living environment for residents. Review of the policy revealed the temperatures within the facility and the resident areas would be maintained between 71 degrees F and 81 degrees F. Review of the document revealed the facility did not implement the policy.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected multiple residents

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Based on observation, staff interview, and policy review, the facility failed to ensure mechanically altered diets were prepared to a proper consistency to ensure safe consumption. This had the potential to affect eleven Residents (#3, #9, #19, #30, #33, #34, #35, #37, #49, #327, #379) who were identified by the facility to have a minced and moist mechanically altered diet order. The facility census was 69. Findings include: Observation and interview during the mechanical altered food preparation on 01/16/24 at 11:46 A.M. revealed Dietary [NAME] (DC) #249 being informed to prepare the mechanical soft honey garlic chicken by Dietary Manager (DM) #814. DC #249 was observed grabbing five pieces of chicken and placing it on a white cutting board. DC #249 was observed using a handheld knife to hand chop up the chicken and place it in a serving dish for the steam table. Observation revealed the chicken pieces were chopped by hand and were approximately one inch by one inch in size. DC #249 revealed she was allowed to prepare all mechanically altered diets by hand, except the pureed diets. DC #249 revealed the knife utilized was sharp enough to chop the chicken up small enough for consumption and the food processor was not needed. DC #249 confirmed and verified there were multiple forms of mechanically altered diets and the facility had a food processor in place to assist with meal preparation, but all mechanically altered meals, after being hand chopped, had gravy added. Interview on 01/17/24 at 9:47 A.M. with Registered Dietician (RD) #818 revealed a food processor was to be used for all mechanically altered diets, including pureed, mechanical soft, and minced and moist. Interview with the Director of Nursing (DON) on 01/18/24 at 12:39 P.M. revealed if a resident had a mechanically altered diet, including minced and moist, the facility just added gravy and there was no policy followed for specific sizes. Review of the International Dysphagia Diet Standardization Initiative (IDDSI) dated 2018, revealed mechanically altered, ground, pureed, and/or minced and moist diets had different consistencies to decrease difficulty in swallowing. Review of the IDDSI revealed pureed diets required no chewing, could be eaten with a spoon, could not be drank from a cup or straw; minced and moist was to be 4 millimeters (mm) in size, fit between a fork prong, moist with thick gravy, and could be eaten with a fork. Review of the facility document titled Dietary Policy and Procedure Manual: Keeping Food Safe undated, revealed the facility had a policy in place that food should be provided in a consistency the resident can tolerate safely. Further review of the policy revealed some residents had dysphasia that affected their ability to swallow, and certain consistencies could place the individual at risk for aspiration and food and beverage restrictions should be checked. Review of the document revealed the facility did not implement the policy.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, staff interview, and facility policy review, the facility failed to ensure food was served in a sanitary manner and food was stored and dated properly. This had the potential to affect 67 of 69 residents receiving food from the kitchen. The facility identified Residents #63 and #73 as not receiving food from the kitchen. The facility census was 69. Findings include: An initial tour of the kitchen was conducted on 01/16/24 between 9:30 A.M. and 10:35 A.M. with Dietary Manager (DM) #814. The following was observed and verified at the time of observation. In the dry storage area, one bag of hot cocoa, one bag of brown sugar, and one bag of biscuit mix was undated, and one bag of food thickener was open to air, unsealed. In the walk-in fridge, a container of cooked rice was open to air. In the walk-in freezer, one bag of hash browns, one box of frozen chicken, one bag of celery, and one bag of green peppers were open to air and undated. During the follow-up tour of the kitchen on 01/16/24 at 11:29 A.M. at the time of tray line, DM #814 was observed checking the temperature of food items located on the steam table. DM #814 was observed using a handheld thermometer to obtain temperature of the parsley noodles and honey garlic chicken. DM #814 used a white napkin to clean the thermometer after each temp check. No alcohol preparation pad or sanitation cloth was used. DM #814 confirmed and verified the findings at the time of the observation. Observation and interview on 01/16/24 at 11:41 A.M. revealed Dietary [NAME] (DC) #249 touching and adjusting her black surgical mask then reached down and gathered multiple hot plates to prepare to serve food. DC #249 confirmed and verified the findings at the time of the observation. Observation and interview on 01/16/24 at 11:56 A.M. revealed Dietary Aide (DA) #250 had uncovered and noticeable facial hair exposed while assisting with tray line. DA #250 confirmed and verified the findings at the time of the observation. Review of the facility document titled Food Handling undated, the facility had a policy in place that food items that were open to air, not labeled or dated, would not be served. Review of the policy revealed the facility did not implement the policy.

Sept 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interview the facility failed to allow residents to have personal items in their rooms. This affected one (Resident #65) of three residents reviewed for access to personal items. The census was 65. Findings included: Review of the medical record for Resident #65 revealed an admission date of 03/30/22. Diagnoses included multiple sclerosis (MS), Alzheimer's disease, and dementia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 07/19/23, revealed Resident #65 had intact cognition. Review of plans of care care dated 01/17/23 revealed Resident #65 had behaviors of including calling emergency services and daughter several times a day. No behaviors were documented related to threatening staff, recording staff or other residents. Review of the nurse progress notes for the past three months revealed no entries regarding Resident #65 having unsafe behaviors. Interview on 08/31/23 at 7:49 A.M. with Resident #65 revealed she had MS and it was difficult to use her hands. Resident #65 stated her daughter gave her an Echo Show (a physical device that is used to interact with [NAME] [artificial intelligence service] to listen to music, watch movies and speak to family through facetime. Resident #65 stated the device did not have the capability to video record staff or other residents. Interview on 08/31/23 at 1:39 P.M. with the daughter of Resident #65 revealed the Echo Show device did not have the capability to video record and the device was used to listen to music, watch movies and call family. Resident #65 had a behavior of calling emergency services; however, the device was disabled to prevent Resident #65 from calling emergency medical services. The intent of the Echo Show device was not for recording purposes. The daughter stated the facility removed the Echo Show device from Resident #65's room in July 2023. Interview on 08/31/23 at 1:48 P.M. with the Administrator revealed Resident #65's Echo Show device was taken away to prevent video recording of staff and residents in the facility. The Administrator stated the facility policy stated any recording device must be secured/mounted to a wall to protect staff and residents. The Administrator confirmed they had no knowledge Resident #65 was using the device to record staff or residents. The Administrator indicated the family did not bring in the device so they could monitor Resident #65. The Administrator stated she had limited knowledge of the capabilities of the Echo Show device but staff told her the daughter told staff she was recording them at times. The Administrator spoke with the facility legal team who told her to remove the device. Observations on 08/31/23 at 2:35 P.M. confirmed Resident #65's Echo Show device was in the administrator office. Follow up interview and observation of the Echo Show with the Administrator on 08/31/23 at 2:40 P.M. revealed the applications included a streaming feature to view movies and ability to listen to music, make phone calls, and video chat. There were no applications that would allow the device to video record. The Administrator verified the applications and indicated the Echo Show would remain in her office until someone told her differently. This deficiency represents non-compliance investigated under Complaint Number OH00145775.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interview, the facility failed to ensure call lights and resident telephones were within reach. This affected four (Residents #25, #34, #45 and #54) of 10 residents observed for call light placement. The census was 65. Findings included: Review of the medical record for Resident #25 revealed an admission date of 08/23/23. Diagnoses included encephalopathy, unspecified, paraplegia, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had intact cognition and required extensive assistance for bed mobility. Review of the medical record for Resident #34 revealed an admission date of 07/24/23. Diagnoses included morbid obesity, altered mental status and Parkinson's disease. Review of the comprehensive MDS assessment dated [DATE] revealed Resident #34 had impaired cognition and required extensive assistance for bed mobility. Review of the medical record for Resident #45 revealed an admission date of 08/11/23. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting the left side of body, and chronic kidney disease. Review of the comprehensive MDS assessment dated [DATE], revealed Resident #45 had impaired cognition and required extensive assistance for bed mobility. Review of the medical record for Resident #54 revealed an admission date of 03/06/23. Diagnoses included hemiplegia affecting right dominant side and schizoaffective disorder, bi-polar type. Review of the quarterly MDS assessment dated [DATE], revealed Resident #54 had impaired cognition and required extensive assistance for bed mobility. Observation on 08/31/23 at 8:03 A.M. revealed Resident #34 lying in bed, the call light was located under the bed on the floor. Interview immediately after the observation with Licensed Practical Nurse (LPN) #200 verified the observation and LPN #200 placed the call light within Resident #34's reach. Observation on 08/31/23 at 8:08 A.M. revealed Resident #54 sitting in a Broda chair alongside her bed; the call light was located on the floor approximately four feet behind the resident. Interview immediately after observations with State Tested Nurse Assistant (STNA) #202 verified the observation and STNA #202 placed the call light within reach of Resident #54. Observation on 08/31/23 at 9:55 A.M. revealed Resident #25 lying in bed, the call light cord and the remote to operate the bed were tangled up together and lying over the edge of the mattress, out of reach of Resident #25. Interview immediately after the observation with the Assistant Director of Nursing (ADON) verified the observations. The ADON untangled the cords and placed the call light and bed remote control within Resident 25's reach. Observation on 09/05/23 at 11:21 A.M. revealed Resident #45 lying in bed with her body shifted to the left side of the bed. Resident #45's phone was ringing. Resident #45 could not answer the phone because the phone was located on the dresser next to the bed, approximately four feet from Resident #45. Resident #45 said she could not reach the phone. Interview immediately after observation with LPN #204 verified the observation. This deficiency represents non-compliance investigated under Complaint Number OH00145775.

Feb 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure staff washed and/or sanitized their hands to prevent possible cross contamination of germs during Resident #11's bath and Resident #17's incontinence care. This affected two out of four residents observed for incontinence care and one out of one resident observed for bathing. The facility census was 68. Findings include: 1. Review of Resident #11's record revealed the resident was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following a stroke with right sided paralysis, aphasia (Loss of ability to understand or express speech.), depression, anemia, left hand contracture, eye disease, osteoarthritis and hypertensive heart disease. Resident #11's Minimum Data Set (MDS) assessment dated [DATE] indicated she needed extensive assistance with bathing, toileting and personal hygiene. Resident #11's plan of care revised on 01/03/23 indicated Resident #11 needed extensive assistance with activities of daily living. Interventions included to have one staff member assist with dressing, bathing and personal hygiene. An observation on 02/14/23 at 8:43 A.M. of State Tested Nursing Assistant (STNA) #92 assist Resident #11 with her bath and personal hygiene revealed concerns with handwashing. STNA #92 entered Resident #11's room and donned a pair of disposable gloves without washing her hands prior to donning the gloves. STNA #92 assisted Resident #92 out of bed to her wheelchair and propelled Resident #11 to the bathroom and assisted her on the toilet. Upon entering the bathroom there was a soiled fitted bed sheet on the floor. STNA #92 picked up the bed sheet and placed the sheet on the floor in the shower. STNA #92 proceeded to assist Resident #11 with her bath. STNA #92 used a soapy washcloth to perform the task placing the soiled soapy washcloths in Resident #11's sink after washing her perineal area and applied moisture barrier cream. STNA #92 completed Resident #11's bath and used the same gloved hands to search in Resident #11's dresser, closet and gather additional clothing to assist Resident #11 with donning her clothes. STNA #92 proceeded to assist Resident #92 with positioning in front of the sink. STNA #92 removed the soiled washcloths from the sink that were used for Resident #11's bath and removed her gloves and did not wash or sanitize her hands. STNA #92 then assisted Resident #11 with applying toothpaste to her toothbrush and other grooming tasks. Upon completion of Resident #11's bathing needs, STNA #92 propelled Resident #11 out of the bathroom and assisted Resident #11 with setting up her breakfast tray. STNA #92 touched various food items on Resident #11's meal tray and placed her call light and television remote in reach. STNA #92 donned a second pair of disposable gloves and gathered the soiled bath and bed linens and placed them in a plastic bag. STNA #92 exited the room and discarded the soiled linen in the appropriate receptacle. Interview with STNA #92 immediately after the observation, verified the above findings and stated she had failed to wash her hands to prevent the possible cross contamination of germs during Resident #92's care. 2. Resident #17 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following a stroke with left sided paralysis, morbid obesity with lymphedema, high blood pressure, chronic pain, convulsions and amyloidosis (A rare disease that occurs when a protein called amyloid builds up in organs.) Resident #17's nursing admission assessment indicated she was dependent on staff for her incontinence needs. Resident #17's plan of care initiated upon admission to the facility indicated she had an activity of daily living deficit related to her functional impairment. Interventions on the plan of care included to provide one staff member to assist with bathing and hygiene care. An observation on 02/14/23 at 8:16 A.M. of STNA #88 and STNA #81 assist Resident #17 with her incontinence care revealed concerns with handwashing. STNA #88 obtained a bath basin and filled the basin with warm water. STNA #88 donned a pair of disposable gloves without washing her hands prior to performing the incontinence care. STNA #88 proceeded to wash Resident #17's front perineal area and placed the soiled soapy washcloth in the basin of water and proceeded to clean Resident #17's back portion of her perineal area. STNA #88 completed the incontinence care and placed the soiled incontinence brief and soiled linen in separate plastic bags. STNA #88 removed her gloves and did not wash her hands and donned a second pair of disposable gloves. STNA #88 touched various surfaces in the room including Resident #17's personal items, the call light button and bed adjustment remote. STNA #88 gathered the plastic bags with soiled linen and soiled incontinence brief and exited the room. STNA #88 verified the above findings on 02/14/23 at 8:30 A.M. and confirmed she did not follow handwashing practices to prevent the spread of germs. Review of the facility policy and procedure titled Handwashing (undated) indicated all employees should wash hands thoroughly with soap and water in the following circumstances: - Before and after physical contact with a resident. - Before preparing or serving meals. - Before and after contact with resident body fluids, soiled linen resident equipment and general cleaning. - Arriving on duty and prior to leaving the facility. - Coughing or blowing nose and using the restroom. - Before and after eating. The Centers for Disease Control handwashing guidance dated indicated healthcare personnel should use an alcohol based hand sanitizer or soap and water to sanitize their hands in the following clinical situations: - Immediately before touching a patient. - Before performing a aseptic technique. - Before moving from work on a soiled body site to a clean body site. - After touching a patient or patient's immediate environment. - After contact with blood, body fluids, or contaminated surfaces. - Immediately after glove removal.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to maintain an adequate supply of towels and linens to provide incontinence care and baths in a timely manner. This affected one (Resident #32) of three residents reviewed for activity of daily living care and had the potential to affect all the residents in the facility. Findings include: An observation on 02/13/23 between 8:15 A.M. and 9:00 A.M. of the linen storage closets on each of the three nursing units in the facility revealed there were less than ten towels and washcloths in each supply closet. The observation was verified with State Tested Nursing Assistant (STNA) #90 and STNA #83 at the time of the observation. Review of Resident #32's record revealed the resident was re-admitted to the facility on [DATE] with diagnoses including sepsis with septic shock, osteomyelitis (bone infection), acute respiratory/kidney failure, metabolic encephalopathy, paraplegia, acute [NAME] cord infarction, unstageable pressure ulcer of the right and left ischium and stage three pressure ulcer of the sacral region, neuromuscular bladder with an indwelling urinary catheter, urinary retention and major depressive disorder. A review of Resident #32's plan of care initiated on 10/19/22 indicated he needed assistance of one staff member for bathing and hygiene needs. An interview with Resident #32 on 02/13/23 at 3:10 P.M. indicated the facility did not have enough towels and washcloths to use for his bathing needs. Resident #32 stated he had bought his own disposable body wipes due to the lack of availability of washcloths and towels. Resident #32 stated he used the disposable wipes to clean himself. Resident #32 indicated he was not assisted with his bathing needs today and had worn the same clothes for two days. Resident #32 stated due to his paralysis from the waist down to his feet he was unable to properly wash himself independently. An interview with STNA #88 on 02/14/23 at 7:30 A.M. indicated the facility did not have clean washcloths and towels consistently to assist the residents with their bathing needs and incontinence care. STNA #88 stated on the weekends the facility usually ran out of towels, washcloths and bath blankets. An interview with STNA #83 on 02/14/23 at 7:43 A.M. indicated there was no linen available at the beginning of her shift to provide a bath or incontinence care. STNA #83 indicated the facility did not stock disposable body wipes in the facility and residents were not provided wipes routinely. STNA #83 indicated during the weekends the soiled linen was not washed and the direct care staff had to wash and dry the washcloths and towels to have them available to assist with the residents' bathing, hygiene and incontinence care. An interview with Housekeeper (HK) #91 on 02/13/23 at 9:24 A.M. indicated he was aware of the problem with having clean linen available for the staff to assist the residents with their care needs. HK #91 indicated there were enough towel and washcloths if the staff did not use them to perform incontinence care. HK #91 stated he had suggested to the Administrator the facility should provide disposable wipes to use for incontinence care. HK #91 stated the facility did not purchase enough disposable wipes for the staff to use for incontinence care. HK #91 stated there was one full time and one part time person assigned to wash the linens and resident clothing in the facility. The full time person was on leave and there was a problem with the delivery of the clean resident clothes back to them after laundered. HK #91 indicated he was often assigned to deliver the clean clothes back to the residents in addition to other duties including driving residents to their appointments, maintenance, housekeeping and filling in for staff when they reported off for their shift. HK #91 indicated the laundry and housekeeping department had excessive call-offs and often arrived late for their shift. When the staff failed to show up to work for their shift it created extra work for the other staff and the laundry department was behind in washing and drying the linens and resident clothing. HK #91 stated when the census was low in the facility the housekeeping and laundry assistant's hours were cut and the staff could not afford to stay due to the limited hours they were scheduled. HK #91 stated the facility needed to replace at least one of the housekeepers who had resigned. HK #91 stated some of the direct care staff would assist the laundry department with delivery of clothing to the residents and clean linens to the linen closet in addition to their other duties. An interview with Housekeeping Manager (HM) on 02/14/23 at 2:43 P.M. indicated he was in charge of the laundry, housekeeping and maintenance department. HM indicated one laundry assistant had resigned last weekend and approval to hire two additional staff for the laundry department. HM indicated he was aware the laundry piled up and was not washed and dried in a timely manner due to the lack of staff needed to perform the laundry duties. HM indicated some of the direct care staff would actually wash and dry some of the linens so they could provide care to the residents. HM indicated with the current staff he had available to perform housekeeping and laundry duties was not enough to keep up with the amount of work assigned to them. An interview with Administrator and Central Supply Manager (CSM) #89 on 02/14/23 at 3:00 P.M. indicated the facility purchased enough towels/washcloths and other linens for the staff to use to provide care to the residents. CSM #89 indicated the facility stocked disposable body wipes for the staff and residents. The disposable body wipes were stored in the central supply room and staff and/or residents must make a request for the wipes before the wipes were dispensed to the staff/residents. CSM #89 and Administrator indicated the residents were not given the disposable wipes upon admission to the facility but would be provided upon request. Administrator and CSM #89 stated the facility staff should be aware the disposable wipes were available in the central supply room and could request the wipes for their use for residents' care needs. Administrator and CSM #89 indicated the disposable body wipes were not stocked on the individual nursing units and staff must request the disposable body wipes from the central supply room. The Administrator indicated there was no reason the facility laundry department should fail to wash and dry the towels/washcloths and other linens in a timely manner for the staff to use when assisting the residents with their care needs. A review of the Resident Council Minutes dated 01/25/23 indicated the residents wanted to know how long they had to wait for clothing to be returned to them from laundry. The facility indicated there were 58 residents were were frequently or occasionally incontinent of bladder and 48 residents who were occasionally or frequently incontinent of bowel. There were 68 residents who needed assistance with their bathing needs. The facility census was 68. This deficiency represents non-compliance investigated under Complaint Number OH00139833, OH00138724, OH00138444, and OH00138400.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and staff and resident interview, the facility failed to maintain a staffing level to ensure call lights were answered in a timely manner to provide care and maintain enough staff to ensure bath and bed linens were available for use for the residents. This affected five (Residents #32, #15, #22, #39, and #5) of nine residents interviewed and had the potential to affect all the residents in the facility. The facility census was 68. Findings include: 1. Review of Resident #32's record revealed the resident was re-admitted on [DATE] with diagnoses including sepsis with septic shock, paraplegia, chronic pain, urinary retention, neuromuscular bladder with a indwelling urinary catheter, pressure ulcers of the right buttock and sacral region, and spinal cord infarction and depressions. Resident #32's plan of care initiated on 10/19/22 indicated interventions to promote healing and prevent worsening of his pressure ulcers. Interventions on the plan of care included to check for incontinence and provide incontinence care during care rounds and as needed. Resident #32's Minimum Data Set (MDS) assessment dated [DATE] indicated he needed two staff to assist with transfers using a mechanical lift and needed assistance with all activities of daily living. On 02/13/23 at 3:10 P.M. an interview with Resident #32 indicated the facility was not staffed well enough to provide care for the residents in a timely manner. Resident #32 stated he waited more than 30 minutes for staff to answer his call light routinely. When he was up in his wheelchair for an extended period of time he had increased pain and was worried about his pressure ulcers located on his backside. Resident #32 indicated he could not tolerate more than one to one and a half hours up in his wheelchair. Resident #32 indicated he had already been up in his wheelchair for two hours. Resident #32 stated he had to wait up to three hours for assistance with incontinence care and this affected his wound healing. Resident #32 stated he had been admitted to the hospital for sepsis in the past and did not want his wounds to become infected. Resident #32 stated he had complained to several nursing staff and administrative staff with no resolution to his complaint. Resident #32 stated the staff would often answer his call light after 30 minutes and never return for an extended period of time to assist him with his care needs. An interview with Resident #22 on 02/13/23 at 10:07 A.M. indicated the staff often took up to 30 minutes to answer her call light. Resident #22 indicated she did not receive the morning care she needed in a timely manner. Resident #22 stated she was still wearing the clothes she wore to bed last night and was unsatisfied with the timeliness of the care in the facility. An interview with Resident #39 on 12/13/23 at 10:16 A.M. indicated the call light response in the facility was poor. Resident #39 stated she was not routinely assisted out of bed and the staff took a long time to answer her call light. On 02/13/23 at 2:15 P.M. an interview with Resident #5 indicated the staff routinely took more than 30 minutes to respond to her call light due to a staffing problem in the facility. 2. Review of Resident #15's record revealed the resident was admitted on [DATE] with diagnoses including paraplegia, pressure of the sacrum and left buttock, malnutrition, asthma, urethral stricture, anxiety disorder and atherosclerotic heart disease. Resident #15's plan of care revised on 12/20/22 indicated he had bowel and bladder incontinence and was at risk for complications and skin breakdown. Resident #15 was admitted with an indwelling urinary catheter due to a urethral stricture and staff were to provide catheter care and incontinence care. Interventions on the plan of care included to check Resident #15 for incontinence during care rounds and as needed. Resident #15's plan of care revised on 01/24/23 indicated Resident #15 had an activity of living deficit related to his diagnosis of paraplegia. Interventions on the plan of care included to use a mechanical lift for transfers, provide assistance with bathing , hygiene and toileting needs. Resident #15's MDS assessment dated [DATE] indicated Resident #15 needed extensive assistance with dressing and was totally dependent on staff for his toileting needs and transfers. An observation and interview with Resident #15 on 02/13/23 from 3:10 P.M. to 3:40 P.M. revealed he had pushed his call light at 2:55 P.M. Resident #15 stated he was paralyzed from the waist down to his feet, had wounds on the right and left ischium and was unable to determine if he was incontinent of bowel unless he detected the odor of incontinence. Resident #15 stated the staff did not routinely check him for incontinence. Resident #15 indicated he needed transferred with a mechanical lift and two staff were needed to assist him with transferring from his bed to wheelchair and back to bed. Resident #15 stated the facility did not staff adequately to ensure the residents were provided care in a timely manner. At 3:40 P.M. STNA #81 responded to Resident #32's call light. At 4:00 P.M. STNA #81 was able to find two staff members (STNA #83, STNA #84) to assist with using the mechanical lift to transfer Resident #15 back to bed. An interview on 02/13/23 at 4:00 P.M. with STNA #81 indicated she had just returned from her 30 minute lunch break and another STNA (STNA #82) did not have a walkie talkie to alert her of Resident #32's call light being activated. STNA #81 stated the hall Resident #15 resided was very busy and they did not have enough staff to respond to the call lights in a timely manner. An interview with STNA #82 on 02/13/23 at 4:15 P.M. indicated she was covering STNA #81's resident while she was on her lunch break. STNA #82 stated she was busy with another resident and did not have a walkie talkie to alert her Resident #15's call light was on. STNA #81 stated she did not know Resident #15 needed assistance and had activated his call light for help. Interview with Licensed Practical Nurse (LPN) #85 on 02/14/23 at 6:35 A.M. indicated the staffing level did not allow the staff to routinely finish their job duties during her 12 hour shift. LPN #85 indicated she often had to stay over her shift to finish her work. LPN #85 indicated the work load was heavy and the facility needed to schedule additional staff to meet the needs of the residents in a timely manner. An interview with Registered Nurse (RN) #86 on 02/14/23 at 7:34 A.M. indicated the staffing level in the facility was not adequate to ensure the residents were cared for in a timely manner. RN #86 indicated the facility provided staff from a staffing agency which helped with providing the residents' care but she often had to stay after the end of her shift to ensure all her job duties were completed. An interview with STNA #87 on 02/14/23 at 7:40 A.M. indicated the staffing level in the facility was not adequate to provide care for the residents in a timely manner. STNA #87 stated the call light response was prolonged or not answered for a long time due to the staff were busy caring for other residents. STNA #87 indicated most of the staff worked 12 hour shifts. An interview with STNA #83 on 02/14/23 at 7:43 A.M. indicated the staffing level was not good in the facility. STNA #83 indicated she often stayed over her 12 hour shift to assist the next shift with providing care for the residents. STNA #83 stated some of problems with providing morning care was complicated by the lack of clean linen and/or disposable body wipes available to assist the residents with their incontinence/morning care. STNA #83 indicated three staff members had recently resigned due to the amount of work the facility expected staff to accomplish during their shift. 3. An observation on 02/13/23 between 8:15 A.M. and 9:00 A.M. of the linen storage closets on each of the three nursing units in the facility revealed there were less than ten towels and washcloths in each supply closet. The observation was verified with STNA #90 and STNA #83 at the time of the observation. An interview with Resident #32 on 02/13/23 at 3:10 P.M. indicated the facility did not have enough towels and washcloths to use for his bathing needs. Resident #32 stated he had bought his own disposable body wipes due to the lack of availability of washcloths and towels. Resident #32 stated he used the disposable wipes to clean himself. Resident #32 indicated he was not assisted with his bathing needs today and had worn the same clothes for two days. Resident #32 stated due to his paralysis from the waist down to his feet he was unable to properly wash himself independently. An interview with STNA #88 on 02/14/23 at 7:30 A.M. indicated the facility did not have clean washcloths and towels consistently to assist the residents with their bathing needs and incontinence care. STNA #88 stated on the weekends the facility usually ran out of towels, washcloths and bath blankets. An interview with STNA #83 on 02/14/23 at 7:43 A.M. indicated there was no linen available at the beginning of her shift to provide a bath or incontinence care. STNA #83 indicated the facility did not stock disposable body wipes in the facility and residents were not provided wipes routinely. STNA #83 indicated during the weekends the soiled linen was not washed and the direct care staff had to wash and dry the washcloths and towels to have them available to assist with the residents' bathing, hygiene and incontinence care. An interview with Housekeeper (HK) #91 on 02/13/23 at 9:24 A.M. indicated he was aware of the problem with having clean linen available for the staff to assist the residents with their care needs. HK #91 indicated the facility had a high turnover of staff. HK #91 stated one full time and one part time person assigned to wash the linens and resident clothing in the facility. The full time person was on leave and there was a problem with the delivery of the clean clothes back to the residents after being laundered. HK #91 indicated he was often assigned to deliver the clean clothes back to the residents in addition to other duties including driving residents to their appointments, maintenance, housekeeping and filling in for staff when they reported off for their shift. HK #91 indicated the facility had trouble keeping quality staff who wanted to work. The laundry and housekeeping department had excessive call-offs and staff often arrived late for their shift. When the staff failed to show up to work for their shift this created extra work for the other staff and the laundry department was behind in washing and drying the linens and resident clothing. HK #91 stated the facility needed to replace at least one of the housekeepers who had resigned. HK #91 stated some of the direct care staff would assist the laundry department with delivery of clothing to the residents and clean linens to the linen closet in addition to their other duties. An interview with Housekeeping Manager (HM) on 02/14/23 at 2:43 P.M. indicated he was in charge of the laundry, housekeeping and maintenance department. HM indicated one laundry assistant had resigned last weekend and approval to hire two additional staff for the laundry department. HM indicated he was aware the laundry piled up and was not washed and dried in a timely manner due to the lack of staff needed to perform the laundry duties. HM indicated some of the direct care staff would actually wash and dry some of the linens so they could provide care to the residents. HM indicated the current staff he had available to perform housekeeping and laundry duties was not enough to keep up with the amount of work assigned to them. An interview with Administrator on 02/14/23 at 3:00 P.M. indicated there was no reason the facility laundry department should fail to wash and dry the towels/washcloths and other linens in a timely manner for the staff to use when assisting the residents with their care needs. A review of the Resident Council Minutes dated 01/25/23 indicated the residents wanted to know how long they had to wait for clothing to be returned to them from laundry. The facility indicated there were 58 residents were were frequently or occasionally incontinent of bladder and 48 residents who were occasionally or frequently incontinent of bowel. There were 68 residents who needed assistance with their bathing needs. The facility census was 68. This deficiency represents non-compliance investigated under Complaint Number OH00139913, OH00139833, OH00138444, and OH00138400.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No fines on record. Clean compliance history, better than most Ohio facilities.

Concerns

• Multiple safety concerns identified: Special Focus Facility, 1 harm violation(s). Review inspection reports carefully.
• 59 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• Grade F (10/100). Below average facility with significant concerns.
• 69% turnover. Above average. Higher turnover means staff may not know residents' routines.

Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.

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About This Facility

What is Avenue At Lyndhurst's CMS Rating?

CMS assigns AVENUE AT LYNDHURST an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Ohio, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Avenue At Lyndhurst Staffed?

CMS rates AVENUE AT LYNDHURST's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 69%, which is 23 percentage points above the Ohio average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.

What Have Inspectors Found at Avenue At Lyndhurst?

State health inspectors documented 59 deficiencies at AVENUE AT LYNDHURST during 2023 to 2025. These included: 1 that caused actual resident harm, 57 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Avenue At Lyndhurst?

AVENUE AT LYNDHURST is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PROGRESSIVE QUALITY CARE, a chain that manages multiple nursing homes. With 80 certified beds and approximately 82 residents (about 102% occupancy), it is a smaller facility located in LYNDHURST, Ohio.

How Does Avenue At Lyndhurst Compare to Other Ohio Nursing Homes?

Compared to the 100 nursing homes in Ohio, AVENUE AT LYNDHURST's overall rating (1 stars) is below the state average of 3.2, staff turnover (69%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Avenue At Lyndhurst?

Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.

Is Avenue At Lyndhurst Safe?

Based on CMS inspection data, AVENUE AT LYNDHURST has documented safety concerns. The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Ohio. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Avenue At Lyndhurst Stick Around?

Staff turnover at AVENUE AT LYNDHURST is high. At 69%, the facility is 23 percentage points above the Ohio average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Avenue At Lyndhurst Ever Fined?

AVENUE AT LYNDHURST has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Avenue At Lyndhurst on Any Federal Watch List?

AVENUE AT LYNDHURST is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.

Facility Details

Beds: 80
Avg. Residents: 82
Occupancy: 103.0%
Ownership: For profit - Limited Liability company
Chain: PROGRESSIVE QUALITY CARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
1 Actual Harm citation: -5
59 Deficiencies: -10
Special Focus Facility: -20
Final Score: 10/100

Nearby Alternatives

ALTENHEIM 5-star O'NEILL HEALTHCARE BAY VILLAGE 5-star JOSHUA TREE CARE CENTER 5-star

View all in LYNDHURST →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 366488