How many inspection deficiencies does FRANCISCAN CARE CTR SYLVANIA have?

FRANCISCAN CARE CTR SYLVANIA has 68 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at FRANCISCAN CARE CTR SYLVANIA?

FRANCISCAN CARE CTR SYLVANIA has a one-star staffing rating from CMS with 0.63 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 FRANCISCAN CARE CTR SYLVANIA located?

FRANCISCAN CARE CTR SYLVANIA is located in TOLEDO, OH. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does FRANCISCAN CARE CTR SYLVANIA have?

FRANCISCAN CARE CTR SYLVANIA has 96 certified beds.

Who owns FRANCISCAN CARE CTR SYLVANIA?

FRANCISCAN CARE CTR SYLVANIA is a for profit - corporation facility and is part of the COMMONSPIRIT HEALTH chain.

How does FRANCISCAN CARE CTR SYLVANIA compare to other nursing homes?

FRANCISCAN CARE CTR SYLVANIA 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.

FRANCISCAN CARE CTR SYLVANIA

Name: FRANCISCAN CARE CTR SYLVANIA
Address: 4111 HOLLAND SYLVANIA RD, TOLEDO, OH, 43623, US
Telephone: (419) 882-6582
Rating: 1.0

4111 HOLLAND SYLVANIA RD, TOLEDO, OH 43623 · (419) 882-6582

For profit - Corporation 96 Beds COMMONSPIRIT HEALTH Data: November 2025

Trust Grade

35/100

#862 of 913 in OH

Share this report:

FRANCISCAN CARE CTR SYLVANIA nursing home in TOLEDO, OH - Photo 1 of 2

FRANCISCAN CARE CTR SYLVANIA nursing home in TOLEDO, OH - Photo 2 of 2

Photo by Franciscan Care Center

Last Inspection: June 2024

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

Overview

Franciscan Care Center Sylvania has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #862 of 913 facilities in Ohio places it in the bottom half, and #31 of 33 in Lucas County means there are only two local options rated higher. While the facility is showing improvement, with the number of issues decreasing from 26 to 11 over the past year, it still reported a total of 68 issues, including serious concerns about skin assessments and care for pressure ulcers, which resulted in actual harm to a resident. Staffing has a 0% turnover rate, which is positive, but the overall staffing rating is poor, and the RN coverage is only average. Fortunately, the facility has not incurred any fines, which is a good sign, but families should be aware of the serious incidents related to care deficiencies. Overall, while there are strengths like stable staffing and no fines, the significant issues found during inspections raise important concerns for prospective residents and their families.

Trust Score: F
In Ohio: #862/913
Safety Record: Moderate
Inspections: Getting Better
Staff Stability: Turnover data not reported for this facility.
Penalties: No fines on record. Clean compliance history, better than most Ohio facilities.
Skilled Nurses: Each resident gets 37 minutes of Registered Nurse (RN) attention daily — about average for Ohio. RNs are the most trained staff who monitor for health changes.
Violations: 68 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★★★☆☆

3.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 26 issues

2025: 11 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Ohio average (3.2)

Significant quality concerns identified by CMS

Chain: COMMONSPIRIT HEALTH

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 68 deficiencies on record

1 actual harm

Apr 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 F0624 (Tag F0624)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure discharge instructions were provided at the time of discharge from the facility. This affected one (#3) of five residents reviewed for discharge. The facility census was 68. Findings include: Review of Resident #3's medical record revealed an admission date of 08/16/24. Diagnoses included acute cystitis, Type II diabetes mellitus with foot ulcer, cerebral infarction, dementia, paranoid schizophrenia, hypertension, depression, chronic ischemic heart disease, and non-pressure chronic ulcer to the right heel. Review of the most current Minimum Data Set (MDS) assessment, dated 08/22/24, revealed Resident #3 was assessed with severe cognitive impairment, required partial to moderate assistance with activities of daily living (ADLs), utilized a wheelchair for mobility and was propelled by staff, was incontinent of bowel and bladder, and was at risk for pressure ulcer development with no skin breakdown. Review of a social services progress note dated 10/09/24 at 7:44 A.M. revealed Resident #3 was discharged home on [DATE]. See discharge instructions for further information. Additional review of the medical record revealed no evidence Resident #3 or the resident's representative/family received discharge instructions. Interview on 04/03/25 at 12:55 P.M. with the Director of Nursing (DON) verified there was no evidence Resident #3 or her representative/family received discharge instructions. Review of the facility policy titled Discharge Planning Process, dated 02/27/23, revealed if discharge to the community was a goal, an active discharge care plan would be implemented and involve the interdisciplinary team, including the resident and/or resident representative. The plan shall be documented on the electronic health record (EHR) discharge assessment. An active individualized discharge care plan would address, at a minimum: discharge destination, with assurances the destination meets the resident's health/safety needs and preferences; identified needs, such as medical, nursing, equipment, educational, or psychosocial needs; caregiver/support person availability and the resident's or caregiver's/support persons capacity to perform required care; and residents goals of care and treatment preferences. Educational needs, as identified in the discharge plan, will be provided to the resident and/or family member prior to discharge. All relevant information would be provided in a discharge summary to avoid unnecessary delays in the resident's discharge or transfer, and to assist the resident in adjustment to his or her new living environment. This deficiency represents non-compliance investigated under Complaint Number OH00162848.

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

Read full inspector narrative →

Based on observation, medical record review, and staff interview, the facility failed to ensure timely repositioning and offloading was provided to dependent residents to assist in the prevention of pressure ulcers. This affected three (#1, #4, #10) of three residents reviewed for pressure ulcers. The facility census was 68. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 12/19/24. Diagnoses included congestive heart failure, stage III chronic kidney disease, osteoarthritis, muscle weakness, chronic obstructive pulmonary disease (COPD), hypothyroidism, anemia, hypertension, and chronic embolism and thrombosis deep veins of lower extremity. Review of the most current Minimum Data Set (MDS) assessment, dated 03/19/25, revealed Resident #1 was assessed with intact cognition and was dependent on staff for the completion of activities of daily living (ADLs), including transfer and bed mobility. Resident #1 was incontinent of bowel and bladder, received scheduled pain medication, and was at risk for pressure ulcer development with no current skin breakdown. Review of the plan of care, dated 12/21/24, revealed Resident #1 was at risk for skin breakdown due to immobility. Interventions included to encourage turning side to side when in bed to decrease pressure on her back. Additionally, Resident #1 had an ADLs self-care deficit with interventions including to reposition and turn in bed. Review of the scale for predicting pressure sore risk, dated 03/18/25, revealed Resident #1 scored 16, indicating the resident was assessed to be at risk for pressure ulcer development. Review of the Certified Nursing Assistant (CNA) task documentation revealed turning and repositioning was to occur at least every two hours. Further review of the documentation from 03/02/25 to 04/02/25 revealed evidence Resident #1 was only turned and repositioned five times during that timeframe. Observation on 04/02/25 at 5:56 A.M. revealed Resident #1 was in bed, positioned on her back. CNA #301 and CNA #215 entered the room and provided Resident #1 with incontinence care and proceeded to reposition the resident; however, the resident remained on her back. Observation on 04/02/25 at 9:19 A.M. revealed Resident #1 remained in bed, positioned on her back. Concurrent interview with CNA #276 revealed she assumed care of Resident #1 at 7:00 A.M. CNA #276 verified she had made no attempts to reposition Resident #1 since the beginning of her shift (approximately two hours and 20 minutes prior and approximately three hours and 25 minutes since the resident was last known to receive care). CNA #276 further confirmed she was unaware of the last time Resident #1 was repositioned and stated she did not receive that information from the previous shift. 2. Review of Resident #4's medical record revealed an admission date of 10/25/24. Diagnoses included fracture of the left pubis initial encounter (10/26/24), fracture of sacrum initial encounter (10/26/25), adult failure to thrive, repeated falls, Type II diabetes, osteoarthritis, major depressive disorder, anxiety disorder and scoliosis. Review of the MDS assessment, dated 03/25/25, revealed Resident #4 was cognitively intact. Further review revealed Resident #4 was dependent on staff for toilet use, bathing, dressing, and transfers. Review of the plan of care, dated 11/01/24, revealed Resident #4 had an ADLs self-care deficit due to fatigue and limited mobility. Interventions included two staff to reposition and turn in bed. Review of the CNA task documentation revealed turning and repositioning was to occur at least every two hours. Further review of the documentation from 03/02/25 to 04/02/25 revealed only seven entries indicating Resident #4 was repositioned in bed. Interview on 04/02/25 at 5:50 A.M. with CNA #301 revealed she had checked Resident #4 and provided incontinence care with repositioning at 5:20 A.M. Observation on 04/02/25 at 5:54 A.M. revealed Resident #4 was positioned on her back in bed. Observation on 04/02/25 at 9:12 A.M. of Resident #4, with CNA #276, revealed the resident was positioned on her back in bed. Resident #4 was soiled, with a moderate amount of urine and a small formed bowel movement in her adult incontinence brief. Concurrent interview with CNA #276 verified this contact was the first care she provided to Resident #4 since assuming her care at 7:00 A.M. (approximately two hours and 15 minutes prior and approximately three hours and 50 minutes since the resident last received care). CNA #276 stated she was unaware of the last time Resident #4 was last repositioned or checked for incontinence. 3. Review of Resident #10's medical record revealed an admission date of 01/30/25. Diagnoses included metabolic encephalopathy, hypertension, irritable bowel syndrome, cerebral infarction, Type II diabetes mellitus, and protein calorie malnutrition. Review of the most current MDS assessment, dated 02/25/25, revealed Resident #10 had intact cognition, had a range of motion deficit to one side upper and lower extremities, was dependent on staff for the completion of ADLs, utilized a wheelchair propelled by staff for mobility, was incontinent of bowel and bladder, and was at risk for pressure ulcer development with no current skin breakdown. Review of the plan of care, dated 01/02/25, revealed Resident #10 had a self-care performance deficit due limited mobility. Interventions included staff to reposition and turn in bed. Review of a physician order dated 03/15/25 revealed Resident #10 was to be repositioned every two hours while awake every shift. Interview on 04/02/25 at 5:45 A.M. with CNA #272 revealed Resident #10 was last checked for incontinence and repositioned in bed, on her right side, at 5:15 A.M. Observation on 04/02/25 at 5:50 A.M. revealed Resident #10 was in bed, positioned on her right side. Observation on 04/02/25 at 8:15 A.M. revealed Resident #10 remained in bed, positioned on the right side. Concurrent interview with Resident #10 revealed she had not been checked on or repositioned since the night shift. Interview on 04/02/25 at 8:27 A.M. with CNA #275 verified she had not provided care for Resident #10 since assuming responsibility for her care at 7:00 A.M. (approximately one and on-half hours prior). CNA #275 confirmed she was unaware the last time Resident #10 was checked on or repositioned. Observation on 04/02/25 at 9:09 A.M. revealed Resident #10 remained in bed, in the same position on the right side. Concurrent interview with Resident #10 revealed she was experiencing left buttock prickly pain. Resident #10 stated many times that turning and repositioning did not occur every two hours and during an eight hour day shift, she was frequently only repositioned once. Observation on 04/02/25 at 9:30 A.M. revealed CNA #275 providing care to Resident #10, who was heavily soiled with urine. Concurrent interview with CNA #275 verified this was the first care she provided Resident #10 since assuming her care at 7:00 A.M. (approximately two and one-half hours prior and approximately four hours and 15 minutes since the last known time the resident received care). This deficiency represents non-compliance investigated under Complaint Numbers OH00161775 and OH00163320.

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

Read full inspector narrative →

Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure timely incontinence care was provided. This affected three (#1, #4, and #10) of three residents reviewed for incontinence care. Additionally, the facility failed to ensure sufficient catheter care or physician orders regarding the maintenance of an indwelling urinary catheter for Resident #1. This affected one (#1) of one resident reviewed for catheter care. The facility identified six residents with indwelling catheters. The facility census was 68. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 12/19/24. Diagnoses included congestive heart failure, stage III chronic kidney disease, osteoarthritis, muscle weakness, chronic obstructive pulmonary disease (COPD), hypothyroidism, anemia, hypertension, and chronic embolism and thrombosis deep veins of lower extremity. Review of the most current Minimum Data Set (MDS) assessment, dated 03/19/25, revealed Resident #1 was cognitively intact, was dependent on staff for the completion of activities of daily living (ADLs), was incontinent of bowel and bladder, received scheduled pain medication, and was at risk for pressure ulcer development with no current skin breakdown. Review of the plan of care, initiated 12/21/24, revealed Resident #1 had an ADLs self-care performance deficit related to impaired balance. Interventions included assistance with personal hygiene care. Review of a physician order dated 03/18/25 revealed an order was initiated indicating a Foley catheter (indwelling urinary catheter) may be inserted if no significant output every three hours. Further review of the medical record revealed no additional physician orders related to catheter care or maintenance, diagnosis for the use of a catheter and no evidence of routine catheter care. Observation on 04/02/25 at 5:56 A.M. revealed Resident #1 in bed, positioned on her back, with an indwelling urinary catheter in place. Certified Nursing Assistant (CNA) #301 and CNA #215 entered the room and observed Resident #1 to be incontinent of a moderate amount of liquid stool. CNA #301 obtained wash cloths and a towels, applied soap and water to the wash cloths, and proceeded to Resident #1's bedside. CNA #301 cleansed the resident's anterior perineum and removed black/brown stool with the wash cloth; however, no attempts to cleanse the indwelling catheter tubing occurred. Interview with CNA #301, following the observation, verified she did not sufficiently cleanse Resident #1's catheter tubing. Review of the facility policy titled, Catheter Care, revised 05/10/23, revealed catheter care would be performed every shift and as needed by nursing personnel. For female residents, gently separate labia to expose urinary meatus, wipe from front to back with a clean cloth moistened with water and perineal cleaner (soap), and use a new part of the cloth or different cloth for each side. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter. Dry area with towel. Additional observation on 04/02/25 at 9:19 A.M. with CNA #276 revealed Resident #1 was incontinent of liquid stool and had red excoriation to the anterior peridium. Concurrent interview with CNA #276 revealed she assumed care for Resident #1 at the beginning of her shift at 7:00 A.M. and verified she had not provided the resident with care since the beginning of her shift (approximately two hours and 20 minutes prior). CNA #276 confirmed she was unaware of the last time Resident #1 was checked on and received care as she did not receive that information from the previous shift. 2. Review of Resident #4's medical record revealed an admission date of 10/25/24. Diagnoses included fracture of the left pubis initial encounter (10/26/24), fracture of sacrum initial encounter (10/26/25), adult failure to thrive, repeated falls, Type II diabetes, osteoarthritis, major depressive disorder, anxiety disorder and scoliosis. Review of the MDS assessment, dated 03/25/25, revealed Resident #4 was cognitively intact. Additionally, Resident #4 was dependent on staff for toilet use, bathing, dressing, and transfers. Review of the plan of care, dated 11/01/24, revealed Resident #4 had urinary/bowel incontinence due to impaired mobility and physical limitations. Interventions included check for incontinence, change as needed (PRN), apply disposable briefs, and establish voiding patterns. Interview on 04/02/25 at 5:50 A.M. with CNA #301 revealed she had checked Resident #4 and provided incontinence care with repositioning at 5:20 A.M. Observation on 04/02/25 at 9:12 A.M. of Resident #4, with CNA #276, revealed the resident was soiled with a moderate amount of urine and a small formed bowel movement contained in an adult incontinence brief. CNA #276 confirmed her shift began at 7:00 A.M., approximately two hours and 15 minutes prior, and this was the first care she had provided to Resident #4. Further interview with CNA #276 revealed she was unaware of when Resident #4 had been last checked for incontinence. 3. Review of Resident #10's medical record revealed an admission date of 01/30/25. Diagnoses included metabolic encephalopathy, hypertension, irritable bowel syndrome, cerebral infarction, Type II diabetes mellitus, and protein calorie malnutrition. Review of the MDS assessment, dated 02/25/25, revealed Resident #10 was cognitively intact. Resident #10 had a range of motion deficit to one side upper and lower extremities, was dependent on staff for the completion of ADLs, utilized a wheelchair propelled by staff for mobility, was incontinent of bowel and bladder, and was at risk for pressure ulcer development with no current skin breakdown. Review of the plan of care, dated 01/02/25, revealed Resident #10 was at risk for urinary and bowel incontinence due to impaired mobility. Interventions included check for incontinence and apply disposable briefs. Interview on 04/02/25 at 5:45 A.M. with CNA #272 revealed Resident #10 was last checked for incontinence and repositioned in bed at 5:15 A.M. Interview on 04/02/25 at 8:15 A.M. with Resident #10 revealed she was soiled and no staff had been in her room to check on her since the night shift. Interview on 04/02/25 at 8:27 A.M. with CNA #275 verified she had not checked on Resident #10 since the beginning of her shift at 7:00 A.M. and further confirmed she was unaware of the last time Resident #10 was checked for incontinence. Observation on 04/02/25 at 9:30 A.M. of Resident #10, with CNA #275, revealed the resident was heavily soiled with urine. Concurrent interview with CNA #275 verified this was the first time she had checked Resident #10 since the beginning of her shift at 7:00 A.M., approximately two and one-half hours prior. Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, revised March 2018, revealed appropriate care and services would be provided for residents who were unable to carry out ADLs independently, including hygiene and elimination (toileting). This deficiency represents non-compliance investigated under Complaint Numbers OH00161775, OH00162056, OH00162035, OH00162173, OH00162668, and OH00163320.

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, resident interview, medical record review and staff interview, the facility failed to ensure medications were available for administration per physician order. This affected one (#1) of seven residents reviewed for medication administration. The facility census was 68. Findings include: Review of Resident #1's medical record revealed an admission date of 12/19/24. Diagnoses included congestive heart failure, stage III chronic kidney disease, osteoarthritis, muscle weakness, chronic obstructive pulmonary disease (COPD), hypothyroidism, anemia, hypertension, and chronic embolism and thrombosis deep veins of lower extremity. Review of the Minimum Data Set (MDS) assessment, dated 03/19/25, revealed Resident #1 was cognitively intact. Resident #1 was dependent on staff for the completion of activities of daily living (ADLs), was incontinent of bowel and bladder, received scheduled pain medication, and was at risk for pressure ulcer development with no current skin breakdown. Review of the plan of care, dated 12/21/24, revealed Resident #1 had chronic pain related to fibromyalgia. Interventions included encourage to ask for medication, encourage to tell staff what increased or alleviated pain, and monitor effectiveness of pain medication. Review of physician orders dated 03/18/25 revealed Resident #1 was ordered acetaminophen oral tablet, two tablets to equal 1000 milligrams (mg) every eight hours as needed (PRN) for pain or Roxicodone oral tablet 5 mg, one tablet by mouth every six hours as needed for pain. Review of the Medication Administration Record (MAR) for March 2025 revealed on 03/28/25 at 9:42 P.M., Resident #1 received Roxicodone for pain level of 5 on a scale from one to ten. Further review revealed no evidence Resident #1 was administered Roxicodone after 03/28/25. Observation on 04/03/25 at 5:54 A.M. revealed Resident #1 was awake and in bed. Concurrent interview with Resident #1 revealed she was experiencing level 8 to 9 pain and had received pain medication at approximately 5:00 A.M. Resident #1 stated she had been without her preferred pain medication, Roxicodone, for several days and was told it was unavailable. Resident #1 confirmed the facility had administered Tylenol (acetaminophen) for pain for a few days, but she would have preferred the Roxicodone as it was more effective. Interview on 04/03/25 at 5:57 A.M. with Licensed Practical Nurse (LPN) #211 confirmed Resident #1's Roxicodone had been unavailable for administration for several days. Concurrent observation of medications available for Resident #1 in the medication cart revealed a medication card containing Roxicodone 5 mg with an order/fill date of 04/02/25. LPN #211 confirmed Resident #1's Roxicodone had not been available for administration for several days and was not received until this morning from the pharmacy. Interview on 04/03/25 at 6:04 A.M. with Unit Manger Registered Nurse (UMRN) #318 verified Resident #1's Roxicodone was not reordered timely, resulting in the medication not being available for administration for approximately five days. This deficiency represents non-compliance investigated under Complaint Number OH00162668 and OH00164016.

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 F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the pharmacy delivery manifest, the facility failed to ensure medications were obtained and administered as ordered by the prescribing physician, resulting in a significant medication error. This affected one (#7) of seven residents reviewed for medication administration. The facility census was 68. Findings include: Review of Resident #7's medical record revealed an admission date of 12/20/24. Diagnoses included anemia, cirrhosis, hepatic encephalopathy, chronic kidney disease, Type II diabetes mellitus, major depressive disorder, gastrointestinal hemorrhage, chronic viral hepatitis C, facial weakness, and vitamin d deficiency. Review of the Minimum Data Set (MDS) assessment, dated 01/23/25, revealed Resident #7 was cognitively intact, utilized a wheelchair for mobility, required partial to moderate staff assistance with activities of daily living (ADLs), was incontinent of bowel and bladder, had no fall history, no known weight loss, received a therapeutic diet, and was at risk for pressure ulcer development with no skin breakdown. Review of a physician order, dated 12/20/24, revealed Resident #7 was ordered Rifaximin (used to treat gastrointestinal and liver-related conditions) oral tablet 550 milligrams (mg) two times a day for hepatic (relating to the liver). Review of the Medication Administration Record (MAR) from 12/23/24 to 12/27/24 revealed Rifaximin was documented at unavailable for administration. Further review revealed the medication was not administered again until 01/01/25 at 8:00 P.M. Review of the nursing progress notes from 12/23/24 through 12/27/24 revealed Rifaximin was documented as unavailable for administration on 12/23/24, 12/24/24, and 12/25/24. Review of a social services progress note dated 12/27/24 revealed Resident #7's daughter learned the resident had not been receiving a medication (Rifaximin) that she was supposed to be getting and a Registered Nurse (RN) was working on resolving this. Further review of the medical record from 12/23/24 through 12/27/24 revealed no evidence the physician was notified Rifaximin was unavailable for administration to Resident #7. Review of the facility pharmacy manifest, dated 12/31/24, revealed Rifaximin 550 mg was delivered to the facility for Resident #7. Interview on 04/03/25 at 12:50 P.M. with the Director of Nursing (DON) verified Rifaximin was not available for administration to Resident #7 from 12/23/24 through 12/27/24, when the resident was transferred to the hospital. The DON stated the resident brought a partial bottle of the medication to the facility upon admission on [DATE]; however, the medication ran out on 12/23/24 and was unavailable for administration until it was delivered on 12/31/24. This deficiency represents non-compliance investigated under Complaint Number OH00161775 and OH00164016.

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

Read full inspector narrative →

Based on observation, resident interview, medical record review, and staff interview, the facility failed to ensure physician ordered meal textures were served to residents. This affected one (#5) of four residents reviewed for meal textures. The facility census was 68. Findings include: Review of Resident #5's medical record revealed an admission date of 05/18/21. Diagnoses included psychosis, chronic obstructive pulmonary diseases (COPD), major depressive disorder, generalized anxiety disorder, hallucinations, morbid obesity, and osteoporosis. Review of the Minimum Data Set (MDS) assessment, dated 03/02/25, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Resident #5 was dependent on staff for dressing and transfers, required set up assistance for eating and received a mechanically altered therapeutic diet. Review of the care plan, revised 03/04/25, revealed Resident #5 had a self-care deficit, had impaired cognitive function, was at risk for pain, and was at nutrition and hydration risk. Interventions for nutritional risk included monitor for signs and symptoms of dysphagia, provide and serve diet as ordered, and monitor intakes. Review of Resident #5's physician orders revealed an order dated 04/21/22 for a regular diet, mechanical soft texture, thin consistency, and no straws. Review of the Nutritional Assessment, dated 06/24/24, revealed Resident #5 was to receive a mechanical soft diet with no straws. Resident #5's meal intakes varied, and she frequently consumed snacks in her room. Observation on 03/31/25 at 12:41 P.M. revealed Resident #5 had been provided her lunch meal of a chicken patty on a bun with tomato and lettuce. Resident #5 was observed taking the bun apart and asked how she was expected to eat it. Resident #5's meal ticket was observed on the tray and indicated Resident #5 was to have a mechanical soft textured diet. Coinciding interview with Resident #5 verified she was to have ground meat. Resident #5 stated her food texture was not baby food, but also was not whole like she had been served. Interview on 03/31/25 at 12:43 P.M. with Licensed Practical Nurse (LPN) #305 verified Resident #5 was provided the wrong textured diet and did not receive ground meat as she required. This deficiency represent non-compliance investigated under Complaint Number OH00162035.

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

Read full inspector narrative →

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure staff applied personal protective equipment (PPE) when providing high contact care to residents on enhanced barrier precautions (EBP). This affected one (#1) of one resident reviewed for EBP. The facility census was 68. Findings include: Review of Resident #1's medical record revealed an admission date of 12/19/24. Diagnoses included congestive heart failure, stage III chronic kidney disease, osteoarthritis, muscle weakness, chronic obstructive pulmonary disease (COPD), hypothyroidism, anemia, hypertension, and chronic embolism and thrombosis deep veins of lower extremity. Review of the Minimum Data Set (MDS) assessment, dated 03/19/25, revealed Resident #1 was cognitively intact, was dependent on staff for the completion of activities of daily living (ADLs), was incontinent of bowel and bladder, received scheduled pain medication, and was at risk for pressure ulcer development with no current skin breakdown. Review of a physician order dated 03/18/25 revealed a Foley catheter (indwelling urinary catheter) may be inserted if no significant output every three hours. Further review revealed no further physician orders related to catheter care, maintenance, or instructions regarding EBP. Observation on 04/02/25 at 5:56 A.M. revealed Resident #1 was in bed, positioned on her back, with an indwelling urinary catheter in place. Further observation revealed at the room entry there was an isolation cart containing disposable gloves and gowns. No signage was observed indicating PPE was needed when providing care for Resident #1. Continued observation revealed Certified Nursing Assistant (CNA) #301 and CNA #215 entered Resident #1's room and applied disposable gloves. However, no gown or additional PPE were applied. Resident #1 was found to be incontinent of a moderate amount of liquid stool. CNA #301 obtained wash cloths and a towels, applied soap and water to the wash cloths, and proceeded to Resident #1's bedside. CNA #301 cleansed the resident's anterior perineum and removed black/brown stool with the wash cloth. CNA #301 and CNA #215 left the room and disposed of the soiled items. Concurrent interview with CNA #301 and CNA #215 revealed they were unaware Resident #1 was on EBP due to having an indwelling urinary catheter and verified they did not don a gown prior to providing high contact care for the resident. CNA #301 and CNA #215 further confirmed there was no signage posted at the room entry to instruct them on applying PPE. Observation on 04/02/25 at 6:20 A.M., with Unit Manager Registered Nurse (UMRN) #318 verified Resident #1 had an indwelling catheter in place and no signage was posted to instruct staff to apply PPE for EBP. Additional observation on 04/02/25 at 9:19 A.M. revealed CNA #276 applied disposable gloves and entered Resident #1's room. CNA #276 proceeded to provide incontinence and catheter care for the resident. Following care, CNA #276 exited the room and discarded the soiled items. Concurrent interview with CNA #276 verified Resident #1 was on EBP due to having an indwelling catheter and further confirmed she did not wear a gown while providing high contact care for the resident. Review of the facility policy titled, Enhanced Barrier Precautions, revised 2/13/25, revealed EBP were implemented for the prevention of transmission of multi-drug-resistant organisms. Clear signage would be posted on the door or wall outside of the resident's room indicating the type of precautions, required PPE, and the high-contact resident care activities that required the use of gown and gloves. An order for EBP would be obtained for residents with wounds or indwelling medical devices even if the resident was not known to be infected. Indwelling medical devices included urinary catheters. Make gowns and gloves available immediately outside of the resident's room. High contact resident care activities included: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (urinary catheters).

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

Read full inspector narrative →

Based on observation, medical record review, resident interview, Power of Attorney (POA) interview, staff interview and review of facility policy, the facility failed to ensure dependent residents received feeding assistance and scheduled showers. This affected four (#1, #6, #10, and #9) of 14 residents reviewed for activities of daily living (ADLs). The facility census was 68. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 12/19/24. Diagnoses included congestive heart failure, stage III chronic kidney disease, osteoarthritis, muscle weakness, chronic obstructive pulmonary disease (COPD), hypothyroidism, anemia, hypertension, and chronic embolism and thrombosis deep veins of lower extremity. Review of the most current Minimum Data Set (MDS) assessment, dated 03/19/25, revealed Resident #1 was assessed with intact cognition and was dependent on staff for the completion of ADLs. Resident #1 was incontinent of bowel and bladder, received scheduled pain medication, and was at risk for pressure ulcer development with no current skin breakdown. Review of the plan of care, dated 12/21/24, revealed Resident #1 had a self-care deficit. Interventions included provide a sponge bath when a full bath or shower could not be tolerated. Review of the Certified Nursing Assistant (CNA) task documentation from 03/02/25 through 04/02/25 revealed documentation on 03/31/24 that a shower or bath was performed and Resident #1 required substantial or maximal staff assistance. Further review revealed no evidence of any additional baths or showers were provided between 03/02/25 and 04/02/25. Interview on 04/02/25 at 9:19 A.M. CNA #276 confirmed showers were not always completed as scheduled due to the extensive level of care required by residents and lack of sufficient staff to assist with transfer to and from the common shower/bath. 2. Review of Resident #6's medical record revealed an admission date of 06/28/24 and a discharge date of 03/10/25. Diagnoses included COPD, dementia, chronic respiratory failure, morbid obesity, osteoarthritis, delusional disorder, auditory hallucinations, visual hallucinations, anxiety disorder, suicidal ideation, major depressive disorder, and unsteadiness on her feet. Review of the MDS assessment, dated 03/02/25, revealed Resident #6 was severely cognitively impaired. Resident #6 utilized a wheelchair for mobility and required maximal staff assistance with toilet use, bed mobility, transfers and parts of dressing. Resident #6 was dependent on staff for bathing. Review of the plan of care, dated 07/14/24, revealed Resident #6 had an ADLs self-care deficit related to dementia and COPD. Interventions included resident required staff to provide a bath as necessary. Review of a physician order dated 09/22/24 revealed Resident #6 was to receive a shower or bed bath every evening shift on every Wednesday and Sunday. Review of the CNA task documentation from 03/02/25 through 04/02/25 revealed no documented evidence a shower or bed bath was provided to Resident #6 on 03/05/25 or 03/09/25. Interview on 04/02/25 at 7:35 A.M. with the Administrator verified there was no evidence Resident #6 received a shower or bed bath as scheduled on 03/05/25 or 03/09/25. 3. Review of Resident #10's medical record revealed an admission date of 01/30/25. Diagnoses included metabolic encephalopathy, hypertension, irritable bowel syndrome, cerebral infarction, Type II diabetes mellitus, and protein calorie malnutrition. Review of the most recent MDS assessment, dated 02/25/25, revealed Resident #10 had intact cognition, had a range of motion deficit to one side upper and lower extremities, was dependent on staff for the completion of ADLs, utilized a wheelchair propelled by staff for mobility, was incontinent of bowel and bladder, and was at risk for pressure ulcer development with no current skin breakdown. Review of a physician order dated 12/16/24 revealed Resident #10 was to receive a shower or bed bath every day shift on every Monday and Thursday. Review of the plan of care, dated 01/02/25, revealed Resident #10 had an ADLs self-care deficit related to limited mobility and hypertension. Interventions included resident required staff to provide a bath as necessary. Review of the CNA task documentation from 03/02/25 to 04/02/25 revealed nine opportunities for showers. Resident #10 received six bed baths, with no shower or bed bath documented on 03/27/25. Interview on 03/31/25 at 10:00 A.M. with Resident #10 revealed she was scheduled for a shower today and did not receive one prior to being assisted from her bed to a wheelchair. Resident #10 stated she did not receive showers and frequently received bed baths due to lack of staff. Interview on 03/31/25 at 12:27 P.M. with CNA # 275 confirmed she was assigned to provide care for Resident #10. CNA #275 verified she did not provide Resident #10 with a shower today, as scheduled. Further interview with CNA #275 revealed three of the four residents she was assigned to provide showers to today required a mechanical lift and extensive staff assistance and confirmed the residents would not receive their showers as scheduled due to the extensive workload and lack of staff assistance or availability. 4. Review of Resident #9's medical record revealed an admission date of 03/01/23. Diagnoses included fracture of lower end right humerus subsequent encounter (02/21/25), cerebral infarction, Type II diabetes, dysphagia, osteoarthritis, seizures, bipolar disorder, and anxiety disorder. Review of the MDS assessment, dated 03/18/25, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident was moderately cognitively impaired. Resident #9 was dependent on staff for toilet use, transfers, and bathing. Resident #9 received a mechanically altered therapeutic diet and required moderate assistance with eating. Review of the care plan, revised 03/04/25, revealed Resident #9 had an ADL self-care performance deficit. Interventions included staff to provide a bath as necessary, Resident #9 preferred showers, and the resident required staff assistance for feeding at mealtime. Review of Resident #9's bathing documentation for the last three months revealed the resident was to be bathed (either shower or bed bath based on her preference) every Tuesday and Saturday. Review of Resident #9's bathing tracking documentation revealed the resident was not bathed as scheduled 16 times in the last three months. The Tuesdays and Saturdays where there was no documentation of care provided were 01/04/25, 01/07/25, 01/18/25, 01/21/25, 01/25/25, 02/01/25, 02/04/25, 02/08/25, 02/11/25, 02/22/25, 03/01/25, 03/08/25, 03/15/25, 03/22/25, 03/25/25, and 03/29/25. Interview on 03/31/25 at 12:08 P.M. with Resident #9's POA revealed she came into the facility on a daily basis to feed the resident lunch. Resident #9's POA reported the resident had some declines and now required assistance with eating. Resident #9's POA reported there were not enough staff in the building to provide the necessary care to the resident, adding there were not enough staff to feed her or bath her as she needed and wanted. Observation on 03/31/25 at 12:15 P.M. of Resident #9 revealed the resident was seated in bed. Her hair appeared oily and uncombed. Resident #9 was unable to hold a spoon to move her lunch meal to her mouth. Resident #9's POA assisted Resident #9 with eating and Resident #9 ate 75% of her lunch meal. Coinciding interview with Resident #9 verified she needed assistance with eating and was not getting the showers she wanted. Interview on 03/31/25 at 12:52 P.M. with CNA #219 revealed residents were to be bathed twice a week and verified showers were not provided as they should due to there not being enough staff to get them done. Interview on 03/31/25 at 5:09 P.M. with CNA #314 revealed she was the only aide on the square (area within the facility) to provide care for approximately 58 residents. CNA #314 reported she worked from 7:00 A.M. to 6:30 P.M. There was another aide, CNA #219, who left at 5:00 P.M. CNA #314 reported there were times when there were no aides on the square from 6:00 P.M. to 11:00 P.M. CNA #314 stated there were three nurses in the building, but they had their own tasks to complete and did not typically assist with resident care. CNA #314 verified Resident #9 was to be bathed on second shift but often times only peri-care was completed and showers were not done because there was not enough staff to do them. CNA #314 reported Resident #9 was able to make her needs known, but she had to be asked what she needed, adding she would not use her call light or ask for help on her own. CNA #314 reported Resident #9 injured her wrist and now struggled at times with feeding herself. Observation on 03/31/25 at 5:48 P.M. revealed Resident #9 received her dinner tray. Resident #9 was served a mechanical soft textured diet and was set up with a fork in the ground meat and a straw in her chocolate milk carton. Resident #9 was not asked if she needed assistance. Interview on 03/31/25 at 5:52 P.M. with Resident #9 confirmed staff had not checked on her or offered assistance with eating. Resident #9 was unsure if she could feed herself. Observations on 03/31/25 at 6:01 P.M. and 6:10 P.M. revealed Resident #9 still had not eaten any of her dinner and no staff checked on her to see if she needed help. Further observation at 6:21 P.M. revealed the resident had not eaten any of her dinner and staff had not checked to see if she needed assistance. Interview on 03/31/25 at 6:26 P.M. with Registered Nurse (RN) #208 revealed Resident #9 used to feed herself but recently had been asking for staff to assist her. RN #208 reported she tried to help the aides with resident care but she had her own responsibilities she was required to do. RN #208 stated she would ask Resident #9 if she needed assistance with eating, but she needed to complete a dressing change for another resident first. Observation on 03/31/25 at 6:29 P.M. revealed CNA #314 was at the nurses' station completing documentation in the electronic record. Resident #9's dinner tray continued to be untouched and no staff checked on her to see if she needed assistance. Coinciding interview with CNA #314 revealed she helped those who were dependent on staff with eating but, since she was the only aide working on the square, she was not able to check on those who were not always dependent for eating as there was not enough time. CNA #314 verified Resident #9 had not been checked on or assisted with her dinner meal. Observation on 03/31/25 at 6:33 P.M. revealed CNA #314 covered Resident #9's untouched dinner plate and removed the tray from the room. Resident #9 was not asked if she wanted something else or if she needed assistance. Interview on 04/03/25 at 8:00 A.M. with the Director of Nursing (DON) verified Resident #9's showers were not completed as scheduled. The DON was unable to find any additional information for the 16 showers that were missed for Resident #9. Review of the facility's shower scheduled revealed all residents were scheduled to receive two showers a week. Review of the facility policy titled, Activities of Daily Living, revised March 2018, revealed residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. In addition, appropriate care and services would be provided for residents who were unable to carry out the activities of daily living in accordance with their plan of care including appropriate assistance with dining. This deficiency represents non-compliance investigated under Complaint Numbers OH00162035, OH00162668 and OH00163320.

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

Read full inspector narrative →

2. Review of Resident #1's medical record revealed an admission date of 12/19/24. Diagnoses included congestive heart failure, stage III chronic kidney disease, osteoarthritis, muscle weakness, chronic obstructive pulmonary disease (COPD), hypothyroidism, anemia, hypertension, and chronic embolism and thrombosis deep veins of lower extremity. Review of the most current Minimum Data Set (MDS) assessment, dated 03/19/25, revealed Resident #1 was assessed with intact cognition and was dependent on staff for the completion of activities of daily living (ADLs). Resident #1 was incontinent of bowel and bladder, received scheduled pain medication, and was at risk for pressure ulcer development with no current skin breakdown. Review of the plan of care, dated 12/21/24, revealed Resident #1 had a self-care deficit. Interventions included provide a sponge bath when a full bath or shower could not be tolerated. Review of the CNA task documentation from 03/02/25 through 04/02/25 revealed documentation on 03/31/24 that a shower or bath was performed and Resident #1 required substantial or maximal staff assistance. Further review revealed no evidence of any additional baths or showers provided between 03/02/25 and 04/02/25. Interview on 04/02/25 at 9:19 A.M. CNA #276 confirmed showers were not always completed as scheduled due to the extensive level of care required by residents and lack of sufficient staff to assist with transfer to and from the common shower/bath. 3. Review of Resident #4's medical record revealed an admission date of 10/25/24. Diagnoses included fracture of the left pubis initial encounter (10/26/24), fracture of sacrum initial encounter (10/26/25), adult failure to thrive, repeated falls, Type II diabetes, osteoarthritis, major depressive disorder, anxiety disorder and scoliosis. Review of the MDS assessment, dated 03/25/25, revealed Resident #4 was cognitively intact. Further review revealed Resident #4 was dependent on staff for toilet use, bathing, dressing, and transfers. Review of the plan of care, dated 11/01/24, revealed Resident #4 had an ADLs self-care deficit due to fatigue and limited mobility. Interventions included two staff to reposition and turn in bed. Review of the CNA task documentation revealed turning and repositioning was to occur at least every two hours. Further review of the documentation from 03/02/25 to 04/02/25 revealed only seven entries indicating Resident #4 was repositioned in bed. Interview on 04/02/25 at 5:50 A.M. with CNA #301 revealed she had checked Resident #4 and provided incontinence care with repositioning at 5:20 A.M. Observation on 04/02/25 at 5:54 A.M. revealed Resident #4 was positioned on her back in bed. Observation on 04/02/25 at 9:12 A.M. of Resident #4, with CNA #276, revealed the resident was positioned on her back in bed. Resident #4 was soiled, with a moderate amount of urine and a small, formed bowel movement in her adult incontinence brief. Concurrent interview with CNA #276 verified this contact was the first care she provided to Resident #4 since assuming her care at 7:00 A.M. (approximately two hours and 15 minutes prior and approximately three hours and 50 minutes since the resident last received care) due to inadequate staffing. CNA #276 stated she was unaware of the last time Resident #4 was last repositioned or checked for incontinence. 4. Review of Resident #10's medical record revealed an admission date of 01/30/25. Diagnoses included metabolic encephalopathy, hypertension, irritable bowel syndrome, cerebral infarction, Type II diabetes mellitus, and protein calorie malnutrition. Review of the most recent MDS assessment, dated 02/25/25, revealed Resident #10 had intact cognition, range of motion deficit to one side upper and lower extremities, was dependent on staff for the completion of ADLs, utilized a wheelchair propelled by staff for mobility, was incontinent of bowel and bladder, and was at risk for pressure ulcer development with no current skin breakdown. Review of a physician order dated 12/16/24 revealed Resident #10 was to receive a shower or bed bath every day shift on every Monday and Thursday. Review of the plan of care, dated 01/02/25, revealed Resident #10 had an ADLs self-care deficit related to limited mobility, and hypertension. Interventions included resident required staff to provide a bath as necessary. Review of the CNA task documentation from 03/02/25 to 04/02/25 revealed nine opportunities for showers. Resident #10 received six bed baths, with no shower or bed bath documented on 03/27/25. Interview on 03/31/25 at 10:00 A.M. with Resident #10 revealed she was scheduled for a shower today and did not receive one prior to being placed from her bed to a wheelchair. Resident #10 stated she did not receive showers and frequently received bed baths due to lack of staff. Interview on 03/31/25 at 12:27 P.M. with CNA # 275 confirmed she was assigned to provide care for Resident #10. CNA #275 verified she did not provide Resident #10 with a shower today, as scheduled. Further interview with CNA #275 revealed three of the four residents she was assigned to provide showers to today required a mechanical lift and extensive staff assistance and confirmed the residents would not receive their showers as scheduled due to the extensive workload and lack of staff assistance or availability. Interview on 04/02/25 at 7:20 A.M. with the Administrator verified there were a number of holes in the staffing schedule and the facility did not meet the state minimum staffing requirement of 2.5 hours of direct resident care per resident per day. The Administrator reported they had interviews set up but the hiring process took time and they were trying to get staff to fill in for call offs or no shows but the process was not efficient and the management staff were often required to come in and cover shifts. The Administrator further verified, even with management in the building trying to assist, there were still not enough staff to meet the needs of the residents. Review of the staffing schedules from 03/17/25 to 03/23/25 revealed the facility identified a total of nine licensed nurses and 22 CNAs were needed on each of the dates to cover all shifts. Further review revealed the following: on 03/17/25, there were only 7.1 licensed nurses schedule and 5.6 CNAs scheduled; on 03/18/25, there were only 6.8 licensed nurses scheduled and 9.8 CNAs scheduled; on 03/19/25, there were 10.7 licensed nurses (1.7 more than identified) but only 12.3 CNAs scheduled; on 03/20/25, there were 10.7 licensed nurses scheduled (1.7 more than identified) but only 10 CNAs scheduled; on 03/21/25, there were only 8.8 licensed nurses scheduled and 10.2 CNAs scheduled; on 03/22/25, there were nine nurses scheduled but only nine CNAs scheduled; and on 03/23/25, there were only 8.8 licensed nurses scheduled and 11.2 CNAs scheduled. On each of the dates, the facility had significantly lower staffing than the need identified on the staffing schedules. Review of the staffing schedules from 03/31/25 to 04/02/25 revealed the facility required 22 CNAs and nine licensed nurses on each of the days. Further review revealed the following: on 03/31/25, there were only seven licensed nurses scheduled and 14.6 CNAs; on 04/01/25, there were 9.1 licensed nurses scheduled but only 10.4 CNAs; and on 04/02/25, there were 11.7 (2.7 more than the identified need) licensed nurses scheduled but only 12.7 CNAs. On each of the dates, the facility had significantly lower staffing than the need identified on the staffing schedules. Review of the staffing tool from 03/17/25 to 03/23/25 revealed the facility failed to meet the state minimum staffing requirement of 2.5 hours per resident per day on 03/17/25 at 2.0 hours, 03/18/25 at 2.37 hours, 03/21/25 at 2.23 hours, 03/22/25 at 2.01 hours, and 03/23/25 at 2.08 hours. Review of the PBJ Staffing Report for fiscal year 2024, quarter four (07/01/25 through 09/30/25) revealed the facility triggered for excessively low weekend staffing and had a one star staffing rating (indicating low staffing and/or high staff turnover). This deficiency represents non-compliance investigated under Complaint Numbers OH00162056, OH00162035, OH00162173, OH00162566, OH00162668, OH00163320, and OH00164016. Based on observation, resident interview, Power of Attorney (POA) interview, staff interview, medical record review, review of the Payroll Based Journal (PBJ) Staffing Report and review of the facility's staffing schedule, the facility failed to ensure adequate staffing to meet resident needs. This affected four (#9, #1, #4 and #10) of 14 residents reviewed for staffing and had the potential to affect all residents in the facility. The facility census was 68. Findings include: 1. Review of Resident #9's medical record revealed an admission date of 03/01/23. Diagnoses included fracture of lower end right humerus subsequent encounter (02/21/25), cerebral infarction, Type II diabetes, dysphagia, osteoarthritis, seizures, bipolar disorder, and anxiety disorder. Review of Resident #9's Minimum Data Set (MDS) assessment, dated 03/18/25, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #9 was moderately cognitively impaired. Resident #9 was dependent on staff for toilet use, transfers, and bathing. Resident #9 received a mechanically altered therapeutic diet and required moderate assistance with eating. Review of the care plan, revised 03/04/25, revealed Resident #9 had a self-care deficit. Interventions included staff to provide bath as necessary, the resident preferred showers, and staff assistance for feeding at mealtime. Review of Resident #9's bathing documentation for the last three months revealed the resident was to be bathed (either shower or bed bath based on her preference) every Tuesday and Saturday. Review of Resident #9's bathing tracking revealed the resident was not bathed as scheduled 16 times in the last three months. The Tuesdays and Saturdays missed were 01/04/25, 01/07/25, 01/18/25, 01/21/25, 01/25/25, 02/01/25, 02/04/25, 02/08/25, 02/11/25, 02/22/25, 03/01/25, 03/08/25, 03/15/25, 03/22/25, 03/25/25, and 03/29/25. Interview on 03/31/25 at 12:08 P.M. with Resident #9's POA revealed she came into the facility on a daily basis over lunch to feeding Resident #9. The POA reported the resident had some declines and now required assistance with eating. Resident #9's POA reported there was not enough staff in the building to provide the necessary care to the resident, including bathing and feeding assistance as needed and wanted. Observation on 03/31/25 at 12:15 P.M. of Resident #9 revealed the resident was seated in bed. Her hair appeared oily and uncombed. Resident #9 was unable to hold a spoon to move her lunch meal to her mouth. Resident #9's POA assisted Resident #9 with eating and the resident ate 75% of her lunch meal. Coinciding interview with Resident #9 verified she currently needed assistance with eating and was not getting the showers she wanted. Interview on 03/31/25 at 12:52 P.M. with Certified Nursing Assistant (CNA) #219 verified residents were to be bathed twice a week and showers were not done as they should due to there not being enough staff to do them. Observation on 03/31/25 at 5:07 P.M. revealed CNA #219 left for the day. Interview on 03/31/25 at 5:09 P.M. with CNA #314 verified she was the only aide on the square to provide care for approximately 58 residents. CNA #314 reported she worked from 7:00 A.M. to 6:30 P.M. and there was another aide, CNA #219, who left at 5:00 P.M. CNA #314 reported there were times when there were no aides on the square from 6:00 P.M. to 11:00 P.M. CNA #314 stated there were three nurses in the building currently but they had their own tasks to complete and did not typically assist with resident care. CNA #314 verified Resident #9 was to be bathed on second shift but often only received peri-care and showers were not provided because there were not enough staff to do them. CNA #314 reported Resident #9 was able to make her needs known, but she had to be asked what she needed because she would not use her call light or ask for help on her own. CNA #314 reported Resident #9 had injured her wrist and now struggled at times with feeding herself. Observation on 03/31/25 at 5:48 P.M. revealed Resident #9 received her dinner tray. Resident #9 received a mechanical soft textured diet and was set up with a fork in the ground meat and a straw in her chocolate milk carton. Resident #9 was not asked if she needed assistance. Interview on 03/31/25 at 5:52 P.M. with Resident #9 revealed no one checked on her to see if she needed help. Resident #9 stated she was not sure she could feed herself. Observation on 03/31/25 at 6:01 P.M. and 6:10 P.M. revealed Resident #9 still had not eaten any of her dinner and no staff checked on her to see if she needed help. Continued observation at 6:21 P.M. revealed Resident #9 still had not eaten any of her dinner and no staff checked on her to see if she needed help. Interview on 03/31/25 at 6:26 P.M. with Registered Nurse (RN) #208 verified Resident #9 used to be able to feed herself but recently had been asking for staff to assist her. RN #208 reported she would try and help the aides with resident care but had her own responsibilities she was required to do. RN #208 reported she would ask Resident #9 if she needed assistance with eating, but she needed to complete a dressing change for another resident first. Observation on 03/31/25 at 6:29 P.M. revealed CNA #314 at the nurses station completing documentation in the electronic record. Resident #9's dinner tray continued to be untouched and no staff checked on her to see if she needed assistance. Coinciding interview with CNA #314 revealed she had helped those who were dependent on staff with eating, but since she was the only aide working in the square she was not able to check on those who were not always dependent for eating as there was not enough time. CNA #314 verified Resident #9 had not been checked on or assisted. Observation on 03/31/25 at 6:33 P.M. revealed CNA #314 covered Resident #9's untouched dinner plate and removed the tray from the room. Resident #9 was not asked if she wanted something else or if she needed assistance. Observation on 03/31/25 at 6:35 P.M. revealed the Administrator, Director of Nursing (DON) and a corporate staff were still in the facility, but were seated in the front of the facility, away from resident care areas, in the Administrator's office and not providing assistance on the floor.

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

Read full inspector narrative →

Based on review of the Payroll-Based Journal (PBJ) Staffing Data Report, staff interview and review of the facility policy, the facility failed to submit required staffing information. This had the potential to affect all 68 residents who resided in the facility. The facility census was 68. Findings include: Review of the PBJ Staffing Data Report for Quarter Four of 2024 (July 1 - September 30) revealed the facility triggered for failure to submit data for the quarter. Interview on 04/03/25 at 11:48 A.M. with the Administrator verified the PBJ data was not submitted for Quarter Four of 2024 (July 1- September 30). The Administrator reported Human Resources (HR) was responsible for submitting the data and it was not done. The Administrator stated she did not know why the data was not submitted as required. The Administrator provided a copy of the updated policy and reported she submitted the data for the quarter including the months of October, November, and December 2024. Review of the facility policy titled, PBJ Protocol, revised 11/19/24, revealed staffing data was to be collected, and the facility would ensure data submission was completed monthly before the 15th of each month.

Jan 2025 1 deficiency

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure residents were prepared a safe and orderly discharge. This affected Residents #8 and #9 reviewed for discharge. The facility census was 76. Findings included: 1. Review of Former Resident (FR) #8's medical record revealed an admission date of 12/11/24 and was discharged to home on [DATE]. Diagnoses included left femur fracture, atrial fibrillation, and dementia. Review of FR #8's discharge Minimum Data Set (MDS) dated [DATE] revealed her cognition was intact. The resident required moderate assistance with toileting, shower/bathing, lower body dressing, chair to bed transfers, toilet transfer, and walking up to 50 feet. Review of FR #8's care plan revealed she required assistance with discharge planning for a home goal and to arrange outside services and equipment needs prior to discharge. Review of FR #8's Notice of Medicare Non-Coverage (NOMNC) revealed an end of service date of 12/29/24. The resident denied an appeal and chose to discharge to home. The form was signed on 12/27/24. Review of FR #8's medical record revealed a physician's note dated 12/29/24 to discharge home with home healthcare for skilled nursing, occupational therapy, physical therapy, and speech therapy. Review of FR #8's Social Service note dated 12/27/24 revealed Social Service Designee (SSD) #100 met with the resident and her daughter to discuss the discharge. The daughter informed SSD #100 that she would pick up FR #8 on 12/30/24 at 12:00 P.M. and SSD #100 was also informed the resident would need Home Health Care (HCC) and informed the SSD which companies they chose. Review of FR #8's assessment note dated 12/30/24 revealed the resident was discharged to home. Review of FR #8 Social Service note dated 12/31/24 revealed a HHC referral was sent to the HHC Company. Interview with HHC Employee #400 on 01/17/25 at 10:09 A.M. revealed the company received an email from SDD #100 on 12/31/24 requesting home care for FR #8. Due to the holiday the resident was failed to be contacted until 01/03/25. HHC Employee revealed the company required long term care facilities to complete referrals earlier to ensure medical durable equipment and care were scheduled for the day of discharge. Interview with SSD #100 on 01/17/25 at 9:05 A.M. revealed the referral to the HHC for FR #8 was sent on 12/31/24 but she didn't recall receiving a confirmation. 2. Review of FR #9's medical record revealed an admission date of 11/16/24. The resident was discharged to home on [DATE]. Diagnoses included breast cancer and chronic kidney disease. Review of Resident #9's discharge MDS dated [DATE] revealed the resident had an intact cognition. The resident required moderate assistance for showers/bathing and supervision for walking and toileting. Review of Resident #9's NOMNC revealed the resident was notified on 11/22/24 that the long-term care coverage would end on 11/24/24. The resident chose not to appeal. Review of FR #9's Social Service note dated 11/22/24 revealed FR #9's son agreed to a discharge day of 11/25/24 and the SSD informed the family she would send information to their HHC company of choice. Review of FR #9's medical record revealed she discharged to home on [DATE]. Review of FR #9's Social Service note dated 11/27/24 revealed the SSD placed the request for HHC services which included a wheeled walker (two days after discharge). There was a delay in placing the order for the needed equipment and care due to the Certified Nurse Practitioner being unavailable to sign the discharge paperwork. Interview with SSD #100 on 01/17/25 at 1:28 P.M. SSD #100 verified FR #9 was discharged to home the referral for HHC services was not completed until 11/27/24. The SSD stated she does not complete referrals until all therapy notes were in the medical record system which typically took one to two days after discharge. Review of the facility policy titled, Discharge Planning Process dated 02/27/23 revealed the facility will assist residents and their resident representative in choosing an appropriate post-acute care provider (HHA) that will meet the resident's needs, goals and preferences. This deficiency represents non-compliance investigated under Complaint Number OH00161252.

Aug 2024 1 deficiency

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on medical record review, staff interview, review of shower schedules, and review of a facility policy, the facility failed to ensure residents were provided with scheduled bathing. This affected three (#9, #50, and #68) of three residents reviewed for bathing. The facility census was 76. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 01/06/23. Diagnoses include chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, oral dysphagia, stage three chronic kidney disease, generalized muscle weakness, need for assistance with personal care, anorexia, anxiety disorder, dementia, and depression. Review of the annual Minimum Data Set (MDS) assessment, dated 07/05/24, revealed Resident #9 was severely cognitively impaired, was dependent for showering and bathing, and required substantial/maximal assistance with personal hygiene. Review of a facility shower schedule revealed Resident #9 was scheduled for showers every Wednesday and Saturday on second shift. Review of Resident #9's shower documentation for 07/10/24 through 08/08/24 revealed Resident #9 was scheduled to be bathed nine times during that time frame. Further review revealed Resident #9 only received bed baths on 07/17/24, 07/20/24, and 07/24/24, with a shower refusal documented on 07/10/24. 2. Review of the medical record for Resident #50 revealed an admission date of 07/15/24. Diagnoses include Alzheimer's disease, lumbar spinal stenosis, dizziness and giddiness, hyperlipidemia, and hypertension. Review of the admission MDS assessment, dated 07/22/24, revealed Resident #50 was moderately cognitively impaired and required setup or clean-up assistance for showering and bathing as well as all personal hygiene. Review of a facility shower schedule revealed Resident #50 was scheduled for showers every Monday and Thursday on first shift. Review of Resident #50's shower documentation for 07/15/24 through 08/08/24 revealed Resident #50 was scheduled to receive five showers during that time frame. Further review revealed Resident #50 only received showers on 07/17/24, 07/25/24, and 08/01/24. 3. Review of the medical record for Resident #68 revealed an admission date of 03/24/24. Diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysphagia, schizoaffective disorder, anxiety, hypertension, and atrial fibrillation. Review of the MDS assessment, dated 08/02/24, revealed Resident #68 was severely cognitively impaired and was dependent for showering/bathing as well as all personal hygiene. Review of a facility shower schedule revealed Resident #68 was scheduled for showers every Monday and Thursday on first shift. Review of Resident #68's shower documentation for 07/10/24 through 08/08/24 revealed Resident #68 was scheduled to be bathed nine times during that time frame. Further review revealed Resident #68 only received bed baths on 07/15/24, 07/18/24, and 07/22/24. Interview on 08/08/24 at approximately 11:00 A.M. with the Director of Nursing (DON) revealed the facility was in the process of converting their shower documentation from shower sheets to their electronic medical record (EMR). Interview on 08/08/24 at approximately 2:30 P.M. with the DON and the Administrator verified Resident #9, Resident #50, and Resident #68 were not bathed according to their scheduled bathing times. The DON and the Administrator verified Resident #9 was bathed on three of nine scheduled opportunities between 07/10/24 and 08/08/24, verified Resident #50 received three of the five scheduled showers between 07/15/24 through 08/08/24, and verified Resident #68 received three of the nine scheduled showers between 07/10/24 through 08/08/24. Review of facility policy titled, Resident Showers, dated 11/17, revealed residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. This deficiency represents non-compliance investigated under Complaint Number OH00156323 and represents continued non-compliance from the survey dated 06/13/24.

Jun 2024 20 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

Read full inspector narrative →

Based on facility medical record review, observation, resident and staff interview, and facility policy review, the facility failed to ensure residents were treated with dignity/respect when staff failed to cover the drainage bag of an indwelling urinary catheter. This affected one resident (Resident #13) of five residents reviewed for dignity. The facility census was 67. Findings include: Review of the medical record for Resident #13 revealed an admission date of 12/13/22. Diagnoses included chronic obstructive pulmonary disease (COPD), need for assistance with personal care, hypertension (HTN), obstructive and reflux uropathy, peripheral vascular disease, atrial fibrillation (a. fib), chronic kidney disease (CKD), major depressive disorder, dementia, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/21/24, revealed Resident #13 was cognitively intact, had an indwelling urinary catheter, and was always incontinent of bowel. Observation on 06/11/24 at 7:41 A.M. revealed Resident #13 had an uncovered indwelling catheter drainage bag hanging from the left side of the bed which was visible from the hall when the door was open. It was also visible to any visitors that entered the room. Interview at the time of observation with Resident #13 revealed they have had a catheter for almost one year and the facility does not cover the drainage bag. The resident would prefer if the drainage bag were covered and placed on the opposite side of the bed as to not be seen when entering their room. Interview on 06/11/24 at 7:54 A.M. with State Tested Nursing Assistant (STNA) #467 verified Resident 13's indwelling catheter drainage bag was uncovered, visible from the hall when the door is open, and visible to any visitors that enter. Review of facility policy titled Dignity, dated February 2021, revealed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure access to the call light for one dependent resident (Resident #27) reviewed for call lights in reach. The facility census was 67. Findings include: Review of the medical record for Resident #27 revealed an admission date of 03/24/24. Diagnoses included of metabolic encephalopathy, hemiplegia affecting right dominant side, hemiparesis following cerebral infarction affecting right dominant side, schizoaffective disorder, anxiety disorder, and hydrocephalus. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired. The resident was dependent for shower/bathing, personal hygiene, and always incontinent of bowel and bladder. Observation on 06/10/24 at 11:47 A.M. revealed Resident #27 was laying in bed on their back with their call light tied to the right bedrail and hanging down from the bedrail toward the floor, inaccessible to the resident. The call light was a modified with a bulb type of activation. Interview on 06/10/24 at 11:55 A.M. with State Tested Nursing Assistant (STNA) #408 verified the call light for Resident #37 was tied to the right bedrail of Resident #27's bed and hanging down toward the floor, and inaccessible to the resident.

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure the Pre admission Screen and Resident Review (PASARR) forms were completed for a change of condition in mental health diagnosis. This affected one(#34) of two residents reviewed for PASARR compliance. The facility census was 67. Findings include: Review of Resident #34's medical record revealed an admission date of 10/15/20. Diagnoses included cerebral infarction, chronic obstructive pulmonary disease, type II diabetes, anxiety disorder, major depressive disorder, dementia, hallucinations, and schizoaffective disorder bipolar type. Resident #34's schizoaffective disorder diagnosis was added 07/07/23. Review of the Minimum Data Set (MDS) assessment, dated 03/19/24, revealed Resident #34 was cognitively intact. Resident #34 was taking a scheduled antipsychotic at the time of the review. Resident #34 displayed no behaviors during the review period. Review of Resident #34's care plan, revised 03/21/24, revealed supports and interventions for impaired cognitive function, psychoactive wellbeing problem, sexual behaviors, potential to demonstrate verbally abusive behaviors, and psychotropic medication use. Review of Resident #34's Psychiatric Service Progress Note dated 07/06/23 revealed Resident #34 was seen due to an increase in paranoid delusions including visual hallucinations of someone coming in her room at night. She was not sleeping during the night due to increased paranoia and hallucinations. Resident #34's delusions were noted to be altering her perception of reality. Her delusions and paranoia were reported to be getting worse. Resident #34 received a new diagnosis of schizoaffective disorder bipolar type. Review of Resident #34's Preadmission Screening and Resident Review (PASARR) dated 06/14/21 revealed Resident #34 was ruled out due to not having a severe mental health condition, intellectual disability, or developmental disability. The determination indicated if a change occurred suggesting Resident #34 had a mental health condition, intellectual disability, or developmental disability then further evaluation was needed. Further review of Resident #34's medical record found no evidence her PASARR screening was completed following the 07/07/23 addition of her schizoaffective disorder bipolar type diagnosis. Interview on 06/11/24 with Director of Social Services (DSS) #474 revealed residents did not need another PASARR screening unless they had a significant change. DSS #474 reviewed Resident #34's diagnoses and psychological services information and verified with the addition of her schizoaffective disorder bipolar type diagnosis, paranoid delusions, and hallucinations at night a PASARR review request should have been submitted due to a significant change occurring. Review of the facility policy titled Resident Assessment Coordinate with PASARR Program, dated 06/22/22 revealed a resident who exhibited a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples included a resident whose intellectual disability or related condition was not previously identified and evaluated through the PASARR.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on review of the medical record, staff interview, and policy review, the facility failed to include the use of a psychotropic medication for depression in the resident's comprehensive care plan. This affected one (#67) of three residents reviewed for care planning. The facility census was 67. Findings include Review of the medical record for Resident #67 revealed an admission date of 05/15/24. Diagnoses included systolic depressive disorder and anxiety. Review of a physician order dated 05/16/24 revealed the resident had an order for Zoloft 100 milligrams (mg) daily for depression. Review of the care plan for Resident #67 revealed there was no care plan in place for the use of a psychotropic medication for depression. Interview on 06/11/24 at 8:02 A.M., Registered Nurse (RN) #495 verified there was no plan of care in place for Resident #67's use of the psychotropic medication Zoloft for depression. Review of the policy titled Comprehensive Care Plans, dated 10/24/22, revealed the comprehensive care plan would include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure residents were included in the development for their plan of care and failed to have care planning meetings to periodically review the care plan. This affected two (#39 and #67) of three residents reviewed for care planning. The facility census was 67. Findings include: 1. Review of the medical record for Resident #39 revealed an admission date of 02/09/23. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, heart failure, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment, dated 04/17/24, revealed Resident #39 was cognitively intact. Resident #39 required set up assistance with eating and was dependent on staff for toilet use, bathing and dressing. Resident #39 displayed no behaviors during the review period. Review of Resident #39's current care plan, revised 01/29/24, revealed supports and interventions for self-care deficit, psychoactive medication use, risk for falls, and nutritional risk. Interview on 06/10/24 at 9:28 A.M. with Resident #39 found her to be alert and aware. Resident #39 reported she had not participated in her care planning and a care planning meeting had not been held that she was aware of. Review of Resident #39's Care Conference Summary dated 11/30/23 revealed Resident #39's care plan meeting was held with Resident #39's family and facility staff but not the resident. This care plan meeting was held seven months prior and there was no evidence of a quarterly care plan meeting being held. Interview on 06/11/24 at 8:48 A.M. with Director of Social Services (DSS) #474 verified there was no information indicating Resident #39 participated in a care planning meeting. Follow up interview with DSS #474 on 06/11/24 at 10:33 A.M. verified Resident #474's last care planning meeting was held on 11/30/23. DSS #474 stated care planning meetings were to be held seven to ten days of admission, quarterly and if there was a significant change. DSS #474 verified Resident #39's quarterly care planning meeting had not been held. 2. Review of the medical record for Resident #67 revealed an admission date of 05/15/24. Diagnoses included systolic heart failure, hypertension, atrial fibrillation, depressive disorder, anxiety, and chronic kidney disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the medical record revealed no documentation the resident had participated in a care plan conference meeting since admission. Interview on 06/10/24 at 9:18 A.M., Resident #67 revealed he had not had a care plan meeting since his admission. Interview on 06/11/24 at 8:02 A.M., Registered Nurse (RN) #495 verified there was no documentation the resident had a care plan conference since admission. Interview on 06/11/24 at 10:33 A.M., the DSS #474 revealed care plan meetings should be held upon admission, quarterly, and with significant changes in condition. Review of the policy titled Care Planning--Resident Participation, dated 02/27/23, revealed the facility would discuss the plan of care with the resident and/or representative at regularly scheduled care plan conference, and allow them to see the care plan, initially, at routine intervals, and after significant changes.

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure residents were provided with scheduled grooming and bathing. This affected three (#7, #23, and #273) of seventeen residents observed for activities of daily living. The facility census was 67. Findings include: 1. Review of the medical record revealed Resident #7 admitted to the facility on [DATE]. Diagnoses included end stage renal disease, hemiplegia and hemiparesis following subarachnoid hemorrhage, cirrhosis of liver, anxiety disorder, major depression, peripheral vascular disease, anemia, and non-pressure chronic ulcer to right and left foot. Review of the Minimum Data Set assessment, dated 04/25/24, revealed Resident #7 had intact cognition. Resident #7 required assistance with activities of daily living, was incontinent of urine and continent of bowel. Review of the plan of care revealed on 06/26/23 the care plan was revised to address Resident #7's activity of daily living self care performance deficit related to hemiplegia, limited mobility and end stage renal disease. Interventions included there resident prefers showers, requires assistance with personal hygiene care, dependent on staff to provide a bath as necessary, and provide with a sponge bath when a full bath or shower cannot be tolerated. Review of Resident #7's shower schedule noted routine showers scheduled every Tuesday and Saturday. The shower documentation noted between 05/07/24 and 06/11/24, out of eleven opportunities, only three showers were provided on 05/07/24, 05/14/24, and on 06/11/24. No further shower activity was documented in the medical record. Observation on 06/10/24 at 11:56 A.M. noted Resident #7 seated in a wheelchair at the bedside. The resident's hair appeared unkept and with a shiny or greasy sheen. Interview on 06/10/24 at 11:56 A.M., at the time of the observation, Resident #7 stated she did not receive routine showers as scheduled. Interview on 06/11/24 at 1:22 P.M. the Director of Nursing (DON) verified showers were not documented to be provided as scheduled for Resident #7. The DON confirmed Resident #7 was observed with greasy appearing hair. 2. Review of the medical record for Resident #23 revealed an admission date of 12/06/19. Diagnoses included hemiplegia and hemiparesis following cerebral infarction right dominate side, need for assistance with personal care, vascular dementia, major depressive disorder, and right elbow contracture. Review of the MDS assessment, dated 04/04/24, revealed Resident #23 was severely cognitively impaired. Resident #23 required maximum assistance for showers and bathing. Review facility shower schedule revealed Resident #23 was scheduled for showers every Wednesday and Sunday on second shift. Review of the shower sheets for 05/01/24 through 06/12/24 revealed Resident #23 was scheduled to receive 13 showers. The resident only received showers on 05/01/24, 05/08/24, 05/22/24, and 05/29/24. Interview on 06/13/24 at 9:53 A.M. with the DON verified Resident #23 had only received four of the 13 scheduled showers from 05/01/2 through 06/12/24. Review of facility policy titled Resident Showers, dated 11/17, revealed residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. 3. Review of the medical record for Resident #273 revealed an admission date of 06/01/24. Diagnoses included peripheral vascular disease, difficulty walking, osteoarthritis, hypertension, and hemiplegia and hemiparesis following cerebral vascular accident. Review of the admission Functional Abilities and Goals assessment dated [DATE] at 7:32 P.M. revealed the resident was dependent for showers and bathing. Review of the shower schedule revealed Resident #273 was scheduled for showers on Tuesdays and Fridays on day shift. Review of the medical record revealed no documentation Resident #273 had received a shower on 06/04/24 and 06/07/24. Observation on 06/10/24 at 8:53 A.M. revealed Resident #273's hair appeared unkempt. Interview on 06/10/24 8:53 A.M., Resident #273 revealed she would like her hair washed. Resident #273 stated she had not been showered since her admission to the facility. Interview on 06/11/24 at 10:31 A.M., the DON verified there was no documentation Resident #273 had received a shower. Interview on 06/12/24 at 1:48 P.M., Licensed Practical Nurse (LPN) #419 revealed Resident #273 needed her hair washed because she had a bloody nose and had blood in her hair. This deficiency represents non-compliance discovered during the investigation for Complaint Number OH00153731.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on medical record review and staff interview, the facility failed to ensure residents were monitored for bowel movements and interventions for constipation were implemented as ordered. This affected three (#52, #23 and #30) of four residents reviewed for constipation. The facility census was 67. Finding include: 1. Review of Resident #52's medical record revealed an admission date of 06/14/23. Diagnoses included type II diabetes, major depressive disorder, anxiety disorder, polyneuropathy, and insomnia. Review of the MDS assessment, dated 05/20/24, revealed Resident #52 was severely cognitively impaired. Resident #52 was dependent on staff for toilet use and bathing. Resident #52 had hallucinations, delusions, and displayed rejection of care behaviors one to three days during the review period. Review of Resident #52's care plan, revised 05/20/24, revealed supports and interventions for use of psychoactive medications with risk for constipation, urinary and bowel incontinence and risk for constipation due to decreased mobility. Interventions for constipation included encourage to drink adequate fluids, follow the facility bowel protocol for bowel management, medicate as ordered, record bowel movement pattern and monitor, document and report signs and symptoms of complications related to constipation to the physician. Review of Resident #52's Bowel and Bladder Tracking for the last 30 days revealed Resident #52 did not have a bowel movement documented from 05/22/24 until 06/07/24 for a total of 13 days with no bowel movements. No interventions were found in the record for this lack of bowl movements. Review of Resident #52's physician orders revealed an order dated 06/14/23 for docusil 100 milligrams (mg) two times a day for constipation. There was an order dated 06/15/23 for polyethylene glycol 3350 powder 17 grams (gm) once a day for constipation. Resident #52 had no as needed orders for constipation. Review of Resident #52's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the last 30 days revealed all Resident #52's scheduled medications for constipation were administered as ordered and no as needed medications were ordered or administered. Interview on 06/12/24 at 11:52 A.M. with the Director of Nursing (DON) verified there was no documentation Resident #52 had a bowel movement from 05/22/24 through 06/06/24. There was also no additional bowel interventions documented as being administered. 2. Review of the medical record for Resident #23 revealed an admission date of 12/06/19 with diagnoses of hemiplegia and hemiparesis following cerebral infarction right dominate side, dysphagia, need for assistance with personal care, abnormal posture, and vascular dementia. Review of the MDS assessment, dated 04/04/24, revealed Resident #23 was severely cognitively impaired. Further review of the MDS data revealed Resident #23 is dependent for toileting, requires maximum assistance for showers and bathing, and is incontinent of bowel and bladder. Review of orders for Resident #23 revealed an order for Milk of Magnesia Suspension 30 milliliters (ml) once every 24 hours as needed (PRN) for constipation. Review of the Bowel and Bladder Elimination Record for 05/13/24-06/12/24 revealed no documented bowel movements for Resident #23 between 05/15/24 and 06/12/24. Review of the MAR for Resident #23 for the months of May and June 2024 revealed no doses of PRN Milk of Magnesia were administered for constipation. Interview on 06/13/24 at 9:54 A.M. with the DON verified there were no documented bowel movements for Resident #23 on the above dates and the resident did not receive PRN Milk of Magnesia. 3. Review of the medical record for Resident #30 revealed an admission date of 05/18/21. Diagnoses included unspecified psychosis, cognitive communication deficit, chronic obstructive pulmonary disease (COPD), morbid obesity, major depressive disorder, generalized anxiety disorder, gastro-esophageal reflux disease (GERD), hallucinations, osteoporosis, insomnia, intervertebral disc degeneration, spondylosis, spinal stenosis, hypertension (HTN), low back pain, cellulitis of right lower limb, and hyperlipidemia. Review of the MDS assessment dated , 03/27/24, revealed the resident was moderately cognitively impaired. Further review of the MDS data revealed Resident #30 was incontinent of bowel and bladder and dependent for toileting and hygiene. Review of physician orders for Resident #30 revealed an order for Milk of Magnesia Suspension 30 ml once every 24 hours PRN for constipation. Review of the Bowel and Bladder Elimination Record for 05/13/24-06/12/24 revealed no documented bowel movements for Resident #30 on May 15, 17, 18, 19, 20, 21, 23, 27, 29, 30, June 8, 9, and 11. Interview on 06/12/24 at 11:58 A.M. with the DON verified there were no documented bowel movements for Resident #30 on the above dates and the resident did not receive PRN Milk of Magnesia.

CONCERN (D)

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure recommendations from the audiologist and optometrist were followed. This affected one (Resident #30) of one resident reviewed for vision and/or hearing. The facility census was 67. Findings include: Review of the medical record for Resident #30 revealed an admission date of 05/18/21. Diagnoses included unspecified psychosis, cognitive communication deficit, morbid obesity, major depressive disorder, anxiety disorder, and hallucinations. Review of the Minimum Data Set (MDS) assessment, dated 03/27/24, revealed the resident was moderately cognitively impaired. Further review of the MDS data revealed Resident #30's vision was adequate with corrective lenses and the hearing was not evaluated. Review of the care plan for Resident #30 revealed the facility will arrange consultation with eye care practitioner as required. Review of the optometry visit dated 10/19/22 revealed the resident complained of blurred vision to both eyes. The resident was identified with a cataract but declined surgery. The resident was identified with no glasses and new glasses were recommended for reading. A follow-up visit was recommended on 10/19/23 for the cataract and new glasses. The medical record did not contain any evidence of any optometry visits in 2023 or 2024. Review of the audiology visit on 10/19/23 revealed the resident presented with complaints of ear pain. The audiologist was unable to establish if there was any hearing loss to bilateral ears The recommendations revealed to consult with the physician for wax removal and re-evaluate the resident's hearing after the wax removal. Interview on 06/10/24 at 8:36 A.M., Director of Social Services (DSS) #474 revealed Resident #30 saw an optometrist on 10/19/22 with recommendations to follow up on 10/19/23. DSS #474 stated Resident #30 has not received follow-up optometry care as recommended. Interview on 06/10/24 at 9:38 A.M., Resident #30 reported having told the facility they have difficulty hearing and would like a hearing aid, but the facility has failed to ensure this occurs. Interview on 06/13/24 at 8:36 A.M. with DSS #474 revealed Resident #30 saw an audiologist on 10/19/23 and received recommendations for follow up care with their medical doctor (MD) for bilateral ear wax removal. Interview on 06/13/24 at 10:11 A.M. with the Director of Nursing (DON) revealed Resident #30 did not receive any MD follow up care or medicine for bilateral ear wax removal in October 2023 as recommended by the audiologist. Review of the facility policy titled Dignity, dated 02/21, revealed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Individual needs and preferences are identified through the assessment process.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on review of the medical record, observation, staff interview, review of manufacturer guidelines, and policy review, the facility failed to ensure a thorough wound assessment was completed and failed to provide appropriate pressure reducing devices. This affected one (#28) of three residents reviewed for pressure ulcers. The facility census was 67. Findings include Review of the medical record revealed Resident #28 had an admission date of 06/09/24. Diagnoses included multiple sclerosis, hypertension, dementia, and a pressure ulcer of the left buttock stage four. Review of the admission physician orders dated 06/09/24 revealed there were no orders for pressure reducing devices Review of the admission assessment completed on 06/09/24 at 5:16 P.M. noted the resident had a stage four pressure ulcer. There were no wound measurements or description of the wound documented. Review of a skin one-time observation tool, dated 06/10/24 at 4:02 P.M., revealed the resident had a stage four pressure ulcer to the left buttock measuring one centimeter (cm) in length by one cm in width by 1.6 cm in depth. There was no description of the wound characteristics or surrounding skin. Observations on 06/11/24 at 7:29 A.M., 8:41 A.M., 11:45 A.M., and 1:36 P.M. revealed Resident #28 was lying on a standard pressure reduction mattress. Interview on 06/11/24 at 8:41 A.M., the Director of Nursing (DON) verified the resident was on a standard pressure reduction mattress. The DON revealed the resident should have a low air loss mattress for a stage four pressure ulcer. Observation on 06/12/24 at 7:41 A.M. revealed Resident #28 was sitting in a recliner and had no pressure reducing cushion in place. Observation on 06/12/24 at 9:46 A.M. revealed Resident #28 remained sitting in a recliner without a pressure relieving cushion in place. Interview on 06/12/24 at 10:15 A.M., Nursing Assistant (NA) #468 verified the resident was sitting in the recliner with no pressure reducing cushion. Interview on 06/12/24 at 10:22 A.M., Rehabilitation Director (RD) #601 verified staff could use the pressure cushion from the resident's wheelchair for the resident's recliner. Observation on 06/12/24 at 10:27 A.M. during wound care with Registered Nurse (RN) #600 and Licensed Practical Nurse (LPN) #414 revealed the resident had a stage four pressure ulcer to the left buttock. The wound was approximately one cm in length by one cm in width with an undetermined depth. There was no wound odor and no drainage. The wound had tunneling of three centimeters at one o'clock. The wound was 100% granulation tissue. Interview on 06/12/24 at 2:19 P.M., the DON verified Resident #28 should have a pressure reducing cushion while sitting in her recliner. The DON revealed staff should have obtained an order from the physician for a pressure reducing cushion. The DON also verified there was no documentation in the medical record of a thorough wound assessment for the resident. The DON stated a wound assessment should be completed within 24 hours of admission. Review of manufacturer guidelines for the pressure reduction mattress in use by Resident #28 revealed the mattress may be appropriate for stage one and stage two pressure wounds. Review of the policy titled Skin Assessment, dated 09/14/22, revealed a full body or head to toe skin assessment would be completed upon admission/readmission, daily for three days and weekly thereafter. The assessment may also be performed after a change in condition or after any newly identified pressure injury. Documentation of the skin assessment includes the skin condition, type of wound, and a description of wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). Review of the policy titled Pressure Injury Prevention Guidelines, revised 01/10/23, revealed in the absence of prevention orders, the licensed nurse would utilize nursing judgment in accordance with pressure injury prevention guidelines to provide care and notify the physician to obtain orders. Review of the undated policy titled Pressure Injury Prevention Guidelines revealed the standard set cushion for wheelchairs are pressure redistribution seat cushions. Also to provide alternative support surfaces as needed if the resident cannot be positioned off the existing pressure injury or has a stage three, stage four, unstageable, or deep tissue injury on trunk.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, resident interview, and review of facility policy, the facility failed to obtain orders for the use and maintenance of an indwelling urinary catheter and failed to provide proper urinary catheter cleansing. This affected one (#64) of one sampled residents reviewed for indwelling urinary catheters in a facility census of 67. Findings include: Review of the medical record revealed Resident #64 admitted to the facility on [DATE]. Diagnoses included left radius fracture, arthrodesis, type 2 diabetes mellitus, age related osteoporosis with current pathological fracture, chronic kidney disease, anemia, hypertension, neuromuscular dysfunction of bladder, colostomy, and stenosis. Review of the Minimum Data Set assessment dated [DATE] assessed Resident #64 with intact cognition and utilized an indwelling urinary catheter. Review of the care plan dated 12/11/23 addressed Resident #64's indwelling urinary catheter related to neurogenic bladder. Goals included resident will be/remain free from catheter-related trauma and show no signs or symptoms of urinary infection. Interventions included position catheter bag and tubing below the level of the bladder and away from entrance room door, provide catheter care routinely and as needed (PRN), change as ordered and PRN, and secure catheter securely to thigh to decrease trauma and bladder spasms. Review of physician orders revealed on 02/07/24 the physician ordered catheter care every shift for infection prevention. The record contained no current physician order was contained in the medical record for the placement of an indwelling urinary catheter, the size of urinary catheter to be placed (French (Fr)), or the maintenance of the urinary catheter drainage. Review of the medical record revealed on 02/16/24 a physician evaluation noted the resident to be placed on the antibiotic Macrobid 100 milligrams (mg) twice daily for one week due to tract infection. On 03/14/24 the resident had orders for the antibiotic Keflex Oral Capsule 500 mg by mouth two times a day for seven days for Escherichia Coli and Staphylococcus urinary tract infection. Observation on 06/10/24 at 9:03 A.M. noted Resident #64 with an indwelling catheter in place with associated tubing and drainage bag contained in a privacy bag under the residents wheelchair seat. Interview on 06/10/24 at 9:03 A.M. with Resident #64 at the time revealed she was prone to urinary tract infections. The indwelling catheter has been removed and put into place several times since admission to the facility. The resident reported she was attending an out of facility urology appointment that day to determine potential options related to her urological status. Additional chart review revealed the urology physician evaluation on 06/10/24 noted the resident to request to have her indwelling catheter replaced. The note stated at the facility they were changing her catheter once per week and had upsized her to a 22 French (Fr) due to leakage around the catheter. Recommendations included she go back down to 16 Fr or 18 Fr to avoid urethral erosion which could be a cause of permanent incontinence. Upsizing her catheter will not stop from leaking around during bladder spasms. Observation on 06/11/24 at 9:59 A.M. of urinary catheter care with State Tested Nurse Aide (STNA) #408 noted STNA #408 to apply disposable surgical gloves, obtain a basin of water, bottle of shampoo/body wash, wash clothes and towels. STNA #408 proceeded to Resident #64's bedside. STNA #408 exposed Resident #64 perineum, catheter tubing, and verified the tubing was not secured to the residents thigh. STNA #408 then applied body wash to a wet wash cloth, placed the wash cloth to the tubing and wiped toward the insertion point followed by rinsing and drying the resident perineum with the same technique. STNA #408 also wiped the sides of the residents perineum without changing positions of the cloth. At no time did STNA #408 separate the labia to expose the urinary meatus and point of catheter entry. Interview with STNA #408 on 06/11/24 at 10:23 A.M. verified wiping toward the insertion site of the catheter and not changing portions of the wash cloth with wipes. Review of facility policy titled Catheterization of Female, implemented on 04/25/23, noted urinary catheters are to be inserted by licensed nurses under the orders of the attending physician. When determining catheter size, choose the smallest diameter that will provide good drainage (typically 14-16 French (Fr) in adults), unless the resident has blood clots or sediment that may occlude the lumen. Larger catheter sizes and catheter balloon sizes shall not be routinely used, and when used, shall be for the shortest duration as possible. Once inserted, secure the catheter to the resident's thigh. Documentation of the procedure shall include: The type of catheter inserted, including French size and balloon size. Review of the facility policy titled Catheter Care, revised 5-10-2023, identified when providing catheter care to a female steps included the following: Gently separate the labia to expose urinary meatus. Wipe from front to back with a clean cloth moistened with water and perineal cleaner (soap). Use a new part of the cloth or different cloth for each side. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as not to pull on the catheter. Dry area with a towel. Interview on 06/12/24 at 11:50 A.M. the Director of Nursing (DON) confirmed there were no current orders to address the placement of the indwelling catheter, size of catheter, or related maintenance of the catheter drainage system.

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on resident interview, staff interview, medical record review, and review of the facility policy, the facility failed to ensure sliding scale insulin was provided as ordered for one (#34) of six residents reviewed for unnecessary medications. The facility census was 67. Finding include: 1. Review of Resident #34's medical record revealed an admission date of 10/15/20. Diagnoses included cerebral infarction, asthma, chronic obstructive pulmonary disease, type II diabetes, anxiety disorder, major depressive disorder, dementia, hallucinations, and schizoaffective disorder bipolar type. Review the Minimum Data Set (MDS) assessment, dated 03/19/24, revealed Resident #34 was cognitively intact. Resident #34 received insulin injections seven days during the review period. Resident #34 displayed no behaviors during the review period. Resident #34 required extensive assistance with bed mobility. Resident #34 was dependent on staff for toileting, and parts of dressing. Resident #34 required maximum assistance with bathing. Review of Resident #34's physician orders revealed an order dated 03/28/24, discontinued 05/19/24, and reordered 05/19/24 for Novolog FlexPen subcutaneous solution pen injector 100 unit per milliliter (ml) inject per sliding scale before meals and at bedtime for diabetes mellitus. The sliding scale was as follows: 0-150 = 0, 151-200 = 2, 201-250 = 4, 251-300 = 6, 301-350 = 8, 351-400 =10, 401-450 = 12. Above 450 give max coverage and call physician. Subcutaneously before meals and at bedtime for diabetes mellitus. Review of Resident #34's Medication Administration Record (MAR) for 04/202 revealed on 04/15/24 Resident #34 was administered her 7:00 A.M. sliding scale at 12:28 P.M. and her 11:00 A.M. sliding scale was administered at 12:13 P.M. On 04/24/24 both the 7:00 A.M. and 11:00 A.M. sliding scale doses were administered at 12:12 P.M. All of these entries were completed by Licensed Practical Nurse (LPN) #431. Review of Resident #34's MAR for 05/2024 revealed on 05/01/24 her 7:00 A.M. was administered at 10:09 A.M. On 05/21/24 the 7:00 A.M. sliding scale was administered at 12:12 P.M. and her 11:00 A.M. sliding scale was administered at 12:28 P.M. On 05/22/24 the 7:00 A.M. sliding scale was administered at 11:07 A.M. and her 11:00 A.M. sliding scale was administered at 11:23 A.M. All of these entries were completed by LPN #431. Review of Resident #34's MAR for 06/2024 revealed on 06/06/24 Resident #34's 7:00 A.M. sliding scale was administered at 9:54 A.M. All of these entries were completed by LPN #431. Interview on 06/10/24 at 10:26 A.M. with Resident #34 revealed she was not always getting her blood sugar checks and sliding scale insulin before her meals. Interview on 06/12/24 at 7:41 A.M. with LPN #431 verified she was the nurse who documented Resident #34's sliding scale insulin on 04/15/24, 04/24/24, 05/01/24, 05/21/24, 05/22/24, and 06/06/24. LPN #431 verified Resident #34's 05/01/24 and 06/06/24 were not administered as ordered prior to breakfast. LPN #431 stated she would talk with the Director of Nursing (DON) to see if the actual times of administration could be determined for the other dates. LPN #431 reported the times documented in the MAR were not the actual time of administration. She stated she inadvertently did not correct the time of administration when there were log in issues. Interview on 06/12/24 at 11:05 A.M. with the DON revealed there was no additional documentation regarding Resident #34's sliding scale insulin. The DON verified Resident #34's insulin was documented as not being administered as ordered on 04/15/24, 04/24/24, 05/01/24, 05/21/24, 05/22/24, and 06/06/24. Review of the facility policy titled Timely Administration of Insulin, revised 05/04/22, revealed it was the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition.

CONCERN (D)

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

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on medical record review, staff interview and review of facility policy, the facility failed to ensure physician ordered laboratory (lab) testing was completed as indicated. This affected one resident (#35) of five residents reviewed for unnecessary medications. The facility census was 67. Findings Include: Review of Resident #35's medical record revealed an admission date of 02/09/18. Diagnoses included dementia, type II diabetes, major depressive disorder, psychosis, seizures, anxiety disorder, and insomnia. Review of Resident #35's physician orders revealed an order dated 10/12/21 for divalproex sodium (Depakote) tablet delayed release 250 milligrams (mg). Give 1 tablet by mouth two times a day related to seizures. An order dated 08/22/22 instructed to obtain valproic acid levels every six months due to Depakote drug therapy starting on 22nd. Review of Resident #35's laboratory (lab) results found no lab results for Resident #35's valproic acid levels. Review of Resident #35's 05/10/24 psychiatric note revealed Resident #35's labs were reviewed. There was no indication Resident #35 had valproic acid level lab completed. Interview on 06/13/24 at 8:48 A.M. with the Director of Nursing (DON) verified he had contacted the lab and Resident #35 had not had any valproic labs completed. Review of the facility policy titled Lab and Diagnostic Test Results - Clinical Protocol, revised November 2018, revealed the physician would identify and order diagnostic and lab testing based on the residents diagnostic and monitoring needs. The staff would process test requisitions and arrange for tests.

CONCERN (D)

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, record review, and facility policy review, the facility failed to provide dental services to meet the residents needs. This affected one resident (#30) of one resident reviewed for dental. The facility census was 67. Findings include: Review of the medical record for Resident #30 revealed an admission date of 05/18/21. Diagnoses included unspecified psychosis, morbid obesity, major depressive disorder, generalized anxiety disorder, gastro-esophageal reflux disease (GERD), hallucinations, osteoporosis, insomnia, intervertebral disc degeneration, spondylosis, spinal stenosis, hypertension (HTN), low back pain, cellulitis of right lower limb, and hyperlipidemia. Review of the Minimum Data Set assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of the care plan for Resident #30 revealed they are at risk for oral/dental health problems related to many missing teeth. The facility will coordinate arrangements for dental care, transportation as needed/as ordered. The record had no evidence of Resident #30 seeing a dentist. Interview on 06/10/24 at 9:37 A.M. with Resident #30 revealed they have an upper denture, but it does not fit. Their bottom jaw has multiple missing teeth, with a sharp tooth that catches their tongue. They have told the facility they would like dentures, but their request has not been acted upon. Interview on 06/13/24 at 8:36 A.M. with Director of Social Services #474 revealed Resident #30 has not seen a dentist since their admission. Review of the facility policy titled Ability of Services, Dental, dated 08/07, revealed dental services are available to all residents requiring routine and emergency dental care. Social Services will be responsible for making necessary dental appointments. Inquiries concerning the availability of dental services should be referred to Social Services or to the Director of Nursing. Residents with lost or damaged dentures will be promptly referred to a dentist. Review of the facility policy titled Dental Examination/Assessment, dated 12/13, revealed each resident shall undergo a dental assessment prior to or within ninety (90) days of admission. Residents shall be offered dental services as needed. Records of dental care provided shall be made a part of the resident's medical record. Review of the facility policy titled Dental Consultant, dated 04/07, revealed the facility does not maintain a resident dentist on staff. A consultant dentist is retained by our facility and is responsible for providing a dental assessment of each resident within ninety (90) days of admission and performing or supervising an annual dental reevaluation for each resident. Review of the facility policy titled Dental Service, dated 12/16, revealed it is the facilities policy that routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.

CONCERN (D)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to ensure food provided to residents was palatable and attractive. This had the potential to affect all residents in the facility. The facility census was 67. Findings include: Review of the medical record for Resident #39 revealed an admission date of 02/09/23. Diagnoses included chronic obstructive pulmonary disease, type II diabetes, heart failure, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact. Resident #39 required set up assistance with eating. Review of Resident #39's care plan, revised 01/29/24, revealed supports and interventions for nutritional risk. Interview on 06/10/24 at 9:29 A.M. with Resident #39 reported her bacon was undercooked this morning and her food items were often not cooked well enough and cold. Observation on 06/10/24 at 12:34 P.M. of Resident #39's lunch tray found her to have been provided pizza with cheese on the top that appeared unmelted. Coinciding interview with Resident #39 verified the meal she was provided was unappetizing, cold, the cheese was not melted and the personal pizza appeared to be under cooked. Observation on 06/11/24 at 8:21 A.M. found Resident #39 had been provided her breakfast meal. Coinciding interview with Resident #39 revealed she was unhappy with her breakfast sausage which she stated was cold and undercooked. Resident #39 reported she was not going to eat it because it was grey, spongy, and unappetizing. Resident #39 held up the sausage pointed to one of the sausages ends and stated when the sausage was properly cooked it would be brown like the small area on the end. Resident #34 stated the grey soggy meat was undercooked. Interview on 06/11/24 at 8:24 A.M. with State Tested Nursing Assistant (STNA) #463 verified Resident #39's sausage was grey soggy, undercooked, and unappetizing. Interview on 06/11/24 at 9:03 A.M. with STNA #408 revealed the meat provided from the kitchen was often not cooked well. STNA #408 reported she had brought the residents concerns to the kitchen but for the last few days it has continued to be undercooked. Interview on 06/11/24 at 9:04 A.M. with Dietary Manager (DM) #479 revealed the breakfast sausage came precooked and was heated to 165 degrees before being served. DM #479 broke open Resident #39's uneaten breakfast sausage and showed the meat was grey all the way through. DM #479 verified the meat was grey and stated if it had been raw it would have been pink.

CONCERN (D)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility medical records, staff interview, and review of facility policies, the facility failed to ensure residents received influenza and pneumococcal immunizations. This affected two (#13 and #43) of five residents reviewed for influenza and pneumococcal immunizations in a facility with a census of 67. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 12/13/22. Diagnoses included chronic obstructive pulmonary disease, protein-calorie malnutrition, resistance to multiple antimicrobial drugs, generalized muscle weakness, atrial fibrillation, atherosclerosis of native arteries of extremities, chronic kidney disease, major depressive disorder, dementia, and anxiety disorder. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact. Review of facility immunization consent records revealed the facility obtained verbal consent from Resident #13 on 11/29/23 for the pneumococcal immunization to be administered. Review of the medical record revealed no documentation the pneumococcal immunization was ever administered to Resident #13. Resident #13 was documented as refusing the pneumococcal immunization. Interview on 06/13/24 at 1:02 P.M. with the Assistant Director of Nursing (ADON) verified the facility obtained verbal consent for the pneumococcal immunization for Resident #13 on 11/29/23, but the immunization was not administered to the resident. The ADON also verified Resident #13 had consented to receive the pneumococcal immunization but it was documented in the medical record as refused. 2. Review of the medical record for Resident #43 revealed an admission date of 12/01/22. Diagnoses included convulsions, protein-calorie malnutrition, anxiety disorder, insomnia, sarcopenia, gastro-esophageal reflux disease, anorexia, and gastrostomy status. Review of the quarterly MDS assessment dated [DATE] revealed Resident #43 was cognitively intact. Review of facility immunization consent records revealed the facility obtained a signed consent from Resident #43 on 10/27/23 for the pneumococcal immunization, but there was no documentation of the immunization being administered. Review of Resident #43's Medication Administration Record (MAR) for November 2023 revealed no documentation that pneumococcal immunization was administered. Interview on 06/13/24 at 1:02 P.M. with the Assistant Director of Nursing (ADON) verified the facility obtained written consent for the pneumococcal immunization for Resident #43 on 10/27/23 but the immunization was not administered to the resident. Review of the facility policy titled Pneumococcal Vaccine (Series), dated 03/02/23, revealed each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing-orders. A pneumococcal vaccination is recommended for all adults aged 65 years and older. A pneumococcal vaccination is recommended for adults 19-[AGE] years old who have certain chronic medication or other risk factors.

CONCERN (D)

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

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility medical records, staff interview, and review of the facility policy, the facility failed to ensure residents received COVID-19 immunizations. This affected one (Resident #13) of five residents reviewed for COVID-19 immunizations in a facility with a census of 67. Findings include: Review of the medical record for Resident #13 revealed an admission date of 12/13/22. Diagnoses included chronic obstructive pulmonary disease, protein-calorie malnutrition, resistance to multiple antimicrobial drugs, generalized muscle weakness, atrial fibrillation, atherosclerosis of native arteries of extremities, chronic kidney disease, major depressive disorder, dementia, and anxiety disorder. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact. Review of facility immunization consent records revealed the facility obtained verbal consent from Resident #13 on 11/29/23 for the COVID-19 immunization, but there was no documentation of the immunization being administered. Review of Resident #13's physician orders identified an order dated 12/11/23 for COVID-19 mRNA (Moderna) Intramuscular Suspension (COVID-19 (SARS-CoV-2) mRNA Virus Vaccine). Review of the medical record for December 2023 revealed the immunization was never administered to Resident #13. Resident #13 was documented as refusing immunization. Interview on 06/13/24 at 1:02 P.M. with the Assistant Director of Nursing (ADON) verified the facility obtained verbal consent for the COVID-19 immunization for Resident #13 on 11/29/23, an order was placed for COVID-19 mRNA (Moderna) Intramuscular Suspension (COVID-19 (SARS-CoV-2) mRNA Virus Vaccine) on 12/121/23, but the immunization was not administered to the resident, and the COVID-19 immunization was documented as refused in the resident's medical record. Review of facility policy titled COVID-19 Vaccination, dated 02/14/22, revealed it is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complication from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine.

CONCERN (D)

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, staff interview, review of maintenance repair records, and review of facility policy, the facility failed to ensure all portions of resident call devices were functioning properly. This affected one resident (#58) of eight residents reviewed on the C Hall. The facility census was 67. Findings include: Review of Resident #58's medical record revealed an admission date of 02/01/23. Diagnoses included heart failure, cirrhosis of the liver, severe protein calories malnutrition, edema, and depression. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #58 was moderately cognitively impaired. Resident #58 was dependent on staff for toilet use, bathing, and transfer. Resident #58 required moderate assistance with personal hygiene. Review of Resident #58's care plan revised 03/14/24 revealed supports and interventions for self-care deficit, risk for pain, risk for falls, and bowel and bladder incontinence. Interview on 06/10/24 at 9:54 A.M. with Resident #58 reported her call light had not been functioning properly for the last eight months and no one had been able to fix it. Resident #58 reported repairs were made on a couple occasions but the call light functioned properly for only a couple days and it was broken again. Resident #58 reported it did not light up in her room or in the hallway. Resident #58 activated her call light and it was observed the light in the hallway and the light on the call light panel next to her bed did not light up. Resident #58 stated maintenance was aware of the issue and gave her a stick with bells on it. Resident #58 stated she was also told the indicator light at the nurses station was still functioning when her call light was activated. Resident #58 stated the partially functioning call light was a safety issue because staff working the hallways were not always able to hear the small bells or know the call light was activated because they were often providing care to others and not in range of the nurses station. Interview on 06/10/24 at 9:57 A.M. with the Director of Nursing (DON) verified Resident #58's light above her door was not functioning but her light did register at the nurses station. Interview on 06/11/24 at 4:14 P.M. with Maintenance Director (MD) #457 verified the facility was aware of Resident #58's call light not functioning properly and the light in the hallway did not activate when Resident #58 pushed her call button. MD #457 reported they had some service work done to it and were waiting on a part to have it repaired again. Review of the services work orders for Resident #58's call light revealed a repair was completed 10/31/23. On 02/16/24 a quote for a full call system upgrade was received from a local communication company. On 03/27/24 a component for the call system at the nurses station for Resident #58's room was replaced and Resident #58's call light was functioning at the time. No other repairs were found. Interview on 06/12/24 at 9:38 A.M. with MD #457 revealed the call light issue for Resident #58 began in October of 2023 and was repaired. On 03/27/24 there again was an issue with the call light and a component for the call system at the nurses station for Resident #58's room was replaced and the call light was functioning. On 02/16/24 a quote was received from a local communications company for an upgrade of the call light system. MD #457 reported the quote was sent to corporate and had not yet been approved. Maintenance Director #457 verified Resident #58's call light did not currently function in her room or in the hallway, however, it did signal at the nurses station when Resident #58 pressed her call light. Review of the facility policy titled Maintenance Service, revised December 2009, revealed the maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operational manner at all times.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and review of facility policies, the facility failed to ensure fall interventions were in place and chemicals with a precautionary label were secured. This affected two (#23 and #42) of two residents reviewed for accidents. This had the potential to affect three facility-identified independently ambulatory but cognitively impaired residents (#18, #56, and #60) who resided in the building. The facility census was 67 Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 12/06/19. Diagnoses included hemiplegia and hemiparesis following cerebral infarction right dominate side, need for assistance with personal care, abnormal posture, vascular dementia, hypertension. hyperlipidemia, major depressive disorder, and right elbow contracture. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed [NAME] resident was severely cognitively impaired. Further review of the MDS data revealed Resident #23 was dependent for toileting and requires maximum assistance for showers and bathing and is dependent in all assessed categories for functional status. Review of the plan of care for Resident #23 revealed the resident was at risk for injury related to falls due to gait/balance problems, cerebrovascular accident, and likes to go backwards with wheeled walker. Interventions included a floor mat at bedside. The medical record revealed Resident #23 had a history of falls. Observation on 06/10/24 at 8:47 A.M. revealed resident #23 laying in bed with a blue fall mat leaning against the wall in the room. Interview on 06/10/24 at 8:47 A.M. with State Tested Nursing Assistant (STNA) #467 verified blue fall mat was leaning against the wall in Resident #23's room. STNA #467 revealed the blue fall mat was supposed to be on the floor next to Resident #23's bed as a fall precaution. Interview on 06/12/24 at 9:49 A.M. with Licensed Practical Nurse (LPN) #412 revealed Resident #23 has a history of frequent falls. Review of facility policy titled Falls - Clinical Protocol, dated 03/18, revealed the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. 2. Review of the medical record for Resident #42 revealed an admission date of 02/22/19. Diagnoses included asthma, diabetes mellitus type 2, obesity, disorder of the bone, cervical spinal stenosis, right knee osteoarthritis, hypothyroidism, hypertension, depressive disorder, obstructive sleep apnea, anemia, anxiety, low back pain, right knee pain, and left knee pain. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. Observation on 06/10/24 at 1:26 P.M. revealed a 22-ounce bottle of Powerhouse All Purpose Cleaner with Bleach on the windowsill in Resident #42's room. The label on the bottle revealed a warning label which read: Warning: skin and eye irritant. Do not get in eyes or on clothing. Vapors may irritate. For prolonged use, wear gloves. Not for use by persons with heart conditions or chronic respiratory problems. Keep out of reach of children and pets. Observation on 06/11/24 at 8:08 A.M. revealed the 22-ounce bottle of Powerhouse All Purpose Cleaner with Bleach remained on the windowsill in Resident #42's room. Interview on 06/11/24 at 8:08 A.M., State Tested Nursing Assistant (STNA) #467 verified the 22-ounce bottle of Powerhouse All Purpose Cleaner with Bleach was on the windowsill in Resident #42's room. Review of facility policy titled Storage Areas, Maintenance, revealed cleaning supplies, etc., must be stored in areas separate from food storage rooms and must be stored as instructed on the labels of such products. The facility identified three (#18, #56, and #60) independently mobile and cognitively impaired residents who resided in the building. This deficiency is non-compliance identified during the investigation of Complaint Number OH00153731.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, staff interview, and review of the manufacturer instructions, the facility failed to ensure resident medications were properly labeled and expired medications were not available for use past the expiration date. This affected two medication rooms (C-Hall and B-Hall) and one medication cart (C-Hall). The facility census was 67. Findings include: Observation of the C-Hall medication storage room on 06/12/24 at 8:01 A.M. with the Director of Nursing (DON), revealed two expired blister cards of benzonate 100 milligram (mg) capsules. The first blister card contained three benzonate 100 mg capsules and was marked with an expiration date of 03/28/23. The second blister card contained twenty-nine benzonate 100 mg capsules and was marked with an expiration date of 05/12/24. Further observation of the C-Hall medication storage room revealed ipratropium 0.03% nasal solution with an expiration date of 02/28/23. Interview with the DON at the time of observation verified both blister cards of benzonate and the ipratropium 0.03% nasal solution were expired. Observation of the C-Hall medication cart on 06/12/24 at 8:20 A.M. with Licensed Practical Nurse (LPN) #431, revealed a 10 milliliter (ml) vial of Lantus insulin glargine injection 100 units/ml, that was approximately one-half full, marked with an open date of 05/08/24. There was also one bottle of folic acid 1 mg tablets, containing approximately 75 tablets which was open with no date they were opened identified and no expiration date on the bottle. Review of the manufacturer's instructions for Lantus insulin glargine injection revealed to discard the insulin 28 days after opening. Interview with LPN #431 at the time of observation verified the manufacturer instructions on the vial of Lantus insulin glargine stated it was to be used within 28 days of opening. Interview with the DON on 06/12/24 at 8:20 A.M., verified the bottle of folic acid 1 mg tablets was open, not marked with a date they were opened, and had no expiration date. Observation of the B-Hall medication storage room on 06/12/24 at 8:33 A.M., with the DON revealed one bottle of folic acid 1 mg tablets, containing approximately 75 tables, was open with no date they were opened and no expiration date. Interview with the DON at the time of observation verified the bottle of folic acid 1 mg tablets was open, not marked with a date they were opened, and had no expiration date.

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

Read full inspector narrative →

Based on observation, staff interview, and policy review, the facility failed to ensure meals were served in a sanitary manner. This affected four residents (#50, #54, #19, #11) and had the potential to affect all residents who were receiving meals from the kitchen. The facility census was 67. Findings include Observation on 06/11/24 at 11:35 A.M., of meal plating revealed [NAME] #446 was wearing gloves and directly touched the hamburger buns, lettuce, and tomatoes then touched the plates, counter, scoop handles, tongs and bag containing hamburger buns. The cook then again directly touched the hamburger buns, lettuce, and tomato with the same gloved hands. [NAME] #446 repeated this process four times while plating meals for four residents (#50, #54, #19, #11). After surveyor intervention, [NAME] #446 changed his gloves but completed no hand washing, then used tongs for the hamburger buns, lettuce, and tomato. Interview on 06/11/14 at 11:35 A.M., [NAME] #446 verified he was touching the serving handles, plates, and counter then touching the food directly with the same gloved hands. [NAME] #446 verified he had not washed his hands in between glove changes. Interview on 06/11/14 at 11:44 A.M., Dietary Manager (DM) #479 verified staff should wash their hands when changing gloves. Interview on 06/12/24 at 2:35 P.M., the Director of Nursing (DON) verified all residents received meals from the kitchen. Review of the undated policy titled Hand Washing, revealed employees shall wash their hands and exposed portions of their arms after handling soiled equipment or utensils, following contact with any unsanitary surfaces, before putting on disposable gloves at the beginning of a task or when changing tasks, before distributing trays/meals to residents. Disposable gloves shall not be substituted for proper hand washing. Review of the undated policy titled Disposable Gloves, revealed disposable gloves shall be worn when working with any food to avoid contact with bare hands. Suitable utensils, single use disposable gloves, deli tissues, tongs, or dispensing equipment shall be used to prevent cross-contamination. Disposable gloves shall be used for only one task and shall be discarded when damaged or soiled or when interruption occur in operation. Hand washing shall occur prior to putting on gloves and whenever gloves were changed (if the task has changed) or removed.

Mar 2024 1 deficiency

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 F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical resident interview, staff interview, review of shower schedules and shower documentation, and review of a facility policy, the facility failed to ensure residents were showered as scheduled. This affected one (#70) of three residents reviewed for showers. The facility census was 71. Findings include: Review of the medical record for Resident #70 revealed an admission date of 03/03/24 with diagnoses of subarachnoid hemorrhage and assistance needed for personal care. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 required moderate assistance with showering. Review of the care plan dated 03/08/24 for Resident #70 revealed she had an activities of daily living (ADLs) self-care performance deficit related to subarachnoid hemorrhage and required staff assistance with showering. Review of the shower schedule for Resident #70 revealed she was to have a shower on first shift on Wednesdays and Sundays. Review of the shower sheets for Resident #70 revealed no shower sheets were completed for Sunday, 03/10/24, and Wednesday, 03/13/24. Review of the nurses notes for Resident #70 revealed no documentation of refusals of showers for 03/10/24 and 03/13/24. Interview on 03/25/24 at 7:54 A.M. with Resident #70 stated she only received one shower since being admitted to the facility and was not being bathed as scheduled. Interview on 03/25/24 at 3:02 P.M. with the Director of Nursing (DON) verified Resident #70 did not have a shower on 03/10/24 and 03/13/24 per the resident's shower schedule. Further interview with the DON verified there was no documentation in the nurses notes for Resident #70 refusing her showers. Review of a policy for resident showers, revised March 2022, revealed the facility is to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice. The residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Staff will assist the resident with showering as needed. This deficiency represents non-compliance investigated under Complaint Number OH00152158.

Mar 2024 4 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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and family interview, staff interview, and policy review, the facility failed to ensure residents who were dependent on staff for assistance with activities of daily living were provided showers as scheduled. This affected three (#8, #23 and #72) of four residents reviewed for activities of daily living. The facility census was 74. Finding include: 1. Review of the medical record for Resident #8 revealed an admission date of 02/22/24. Diagnoses included respiratory failure with hypoxia and diabetes mellitus type II. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had moderate cognitive impairment, required moderate assistance from staff for showers and bathing. Review of the care plan dated 03/03/24 revealed Resident #8 had an activities of daily living self care deficit and required assistance with bathing. The identified goal for Resident #8 was to improve in all areas of activities of daily living self performance. Review of the shower schedule revealed Resident #8 was to receive showers on first shift every Wednesday and Saturday. Review of the shower sheets for Resident #8 from admission on [DATE] to 03/04/24 revealed a shower was provided on 02/28/24. Interview on 02/29/24 at 9:45 A.M. with the Power of Attorney (POA) for Resident #8 revealed concerns related to Resident #8 not receiving showers. Interview on 03/04/24 at 11:00 A.M. with the Director of Nursing verified showers were not provided as scheduled for Resident #8. 2. Review of the medical record for Resident #23 revealed an admission date of 12/13/22. Diagnoses included chronic obstructive pulmonary disease, anxiety disorder, and dementia. Review of the care plan dated 06/08/22 and revised on 01/10/24 revealed Resident #23 had an activities of daily living self care performance deficit and required staff assistance for bathing and showering. Review of the quarterly MDS assessment dated [DATE] revealed Resident #23 was cognitively intact and required the physical assistance of one staff for personal care including bathing and showering. Review of the shower schedule revealed Resident #23 was to receive showers on second shift every Tuesday and Friday. Review of the shower sheets from 02/01/24 to 03/04/24 for Resident #23 revealed a shower was provided on 02/09/24 and a bed bath was given on 02/05/24. Interview with Resident #23 on 02/29/24 at 11:50 A.M. verified showers or bed baths were not being provided. Interview on 03/04/24 at 11:00 A.M. with the Director of Nursing verified showers were not provided as scheduled for Resident #23. 3. Review of the medical record for Resident #72 revealed an admission date of 05/29/21. Diagnoses included chronic obstructive pulmonary disease and spinal stenosis. Review of the care plan dated 06/01/21 for Resident #72 revealed a self care performance deficit. Interventions included the assistance of two staff for repositioning in bed, the use of a mechanical lift for transfers, and assistance with personal hygiene, dressing, incontinence care and provide sponge bath when a full bath or shower cannot be tolerated. Review of the quarterly MDS assessment dated [DATE] revealed Resident #72 was cognitively intact and required the substantial assistance for bathing and dressing. Review of the shower schedule revealed Resident #72 was to receive showers on first shift on Monday and Thursday. Review of the shower sheets from 01/29/24 to 03/04/24 revealed Resident #72 received four bed baths during this time on 01/29/24, 02/08/24, 02/19/24 and 03/02/24. Interview on 03/04/24 at 11:00 A.M. with the Director of Nursing verified showers were not provided as scheduled for Resident #72. Review of the facility's undated policy titled Activities of Daily Living - Supporting revealed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. This deficiency represents non-compliance investigated under Master Complaint Number OH00151333 and Complaint Number OH00151010.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, and review of facility policy, the facility failed to provide appropriate incontinence care to residents. This affected two (Residents #16 and #69) of three residents observed for incontinence care. The facility census was 74. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 02/10/24. Diagnoses included chronic obstructive pulmonary disease and periprosthetic fracture around other internal prosthetic joint. Review of the care plan dated 02/02/24 revealed Resident #16 experienced a performance deficit related to activities of daily living, and was incontinent of urine and bowel. Interventions included assistance with personal care as needed, the use of disposable briefs and cleansing of the perineum after each episode of incontinence. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had moderate cognitive impairment, required substantial assistance for toilet use and was frequently incontinent of bowel and bladder. Observation on 03/04/24 at 9:45 A.M. revealed incontinence care for Resident #16 was performed by State Tested Nursing Assistants (STNA) #83 and #84. STNA #83 and #84 removed Resident #16's urine soiled brief and the skin of the front perineal area was cleansed with soap and water, rinsed and dried with a clean washcloth and towel used with each step of cleansing, wiping from front to back. STNA #84 then rolled and tucked the soiled brief between Resident #16's legs. Resident #16 was assisted and rolled onto the right side. STNA #83 removed the soiled brief, placed a new dry disposal brief on the bed and tucked half of the brief under Resident #16's right hip. STNA #83 and #84 then assisted Resident #16 onto the left side, STNA #84 pulled the half of the new brief pulled under resident and STNA #83 and #84 then assisted Resident #16 onto her back and STNA #84 pulled the disposable brief up between Resident #16's legs and secured the top of the brief around the resident's waist. STNA #83 and #84 did not cleanse Resident #16's buttocks during incontinence care. Interview with Licensed Practical Nurse (LPN) #85 on 03/04/24 at 2:14 P.M. who was also present in the room when incontinence care was performed by STNA #83 and #84 on 03/04/24 at 9:45 A.M. for Resident #16 verified the buttocks of Resident #16 was not cleansed when incontinence care was provided and should have been. 2. Review of the medical record for Resident #69 revealed an admission date of 05/22/21. Diagnoses included Alzheimer's disease, anxiety disorder, and neuromuscular dysfunction of the bladder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #69 was cognitively impaired, was dependent on staff for personal hygiene and toilet use, and was always incontinent of bowel and bladder. Review of the care plan for Resident #69 revealed the resident had urinary and bowel incontinence. Interventions included checks for incontinence, cleaning of the perineum, use of disposable briefs and the changing of clothing as needed with each episode of incontinence. Resident #69 was also care planned for activities of daily living self care deficit and was identified as dependent on staff for personal care. Observation on 03/04/24 at 11:05 A.M. of incontinence care for Resident #69 performed by STNA #81 revealed Resident #69 had a slightly discolored brief and upon removal the brief by STNA #81 the brief was observed to be wet. STNA #81 cleansed Resident #69 front perineum with disposal wipes, wiping from front to back using a different disposable wipe with each pass. The soiled brief was rolled and tucked under Resident #69. STNA #81 rolled Resident #69 onto the right side, removed the soiled brief from underneath Resident #69, placed a new brief onto the bed and tucked half the brief under Resident #69's right hip, Resident #69 then rolled onto the left side, the half of the brief tucked under the resident was pulled out and Resident #69 was then positioned onto her back. STNA #81 pulled the brief up between Resident #69's legs and over perineal area and secured the brief at the residents waist. STNA #81 did not cleanse Resident #69's buttocks during incontinence care. Interview on 03/04/24 at 11:10 A.M. with STNA #81 verified the buttocks of Resident #69 were not cleansed when incontinence care was provided. Review of the undated facility policy titled Perineal Care, stated perineal care is to provide cleanliness and comfort to the resident. Steps when providing incontinence care to the female resident included using a wet washcloth with an application of soap or skin cleansing agent. The perineal area is washed from front to back, rinsed thoroughly in the same direction with fresh water and a clean washcloth after which the perineum is gently dried. The resident is then turned onto a side and the rectal area is washed thoroughly with a with soap and water, using a washcloth wipe away and down the buttocks of the resident and rinse and dry thoroughly. Review of the undated facility policy titled Activities of Daily Living - Supporting, revealed residents who were unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate support and assistance will be provided with the consent of the resident and in accordance with the care plan to include hygiene, mobility, elimination, dining and communication to prevent and or minimize a functional decline. This deficiency represents non-compliance investigated under Complaint Number OH00151010, Complaint Number OH00150946, and Complaint Number OH00150705.

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of facility policy, the facility failed to ensure medications were administered according to physician's orders, resulting in a medication error rate which exceeded five percent. 25 opportunities were observed with two medication errors, resulting in 8.0 percent error rate. This affected one (Resident #51) of five residents observed for medication administration. The facility census was 74. Findings include: Review of the medical record revealed Resident #51 was admitted on [DATE]. Diagnoses included congestive heart failure, diabetes mellitus type II, and vascular dementia. Review of the care plan dated 04/27/21 and last revised on 07/25/23 revealed Resident #51 had diabetes and interventions included for diabetes medication to be administered as ordered. Resident #51 also had a care plan dated 10/27/20 with a revision date of 07/25/23 for congestive heart failure. Interventions included for cardiac medications to be administered as ordered and for the resident to be monitored for signs and symptoms of congestive heart failure such as distended neck veins, weakness, weight gain, increased heart rate, lethargy, and disorientation with any symptoms to be documented and reported to the physician. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was cognitively intact, had medically complex conditions, and received insulin injections on a daily basis. Review of the current physician orders for Resident #51 revealed an order written on 10/11/23 for 22 units of Lantus insulin to be injected subcutaneously in the morning for type II diabetes mellitus and an order written on 07/25/23 for aspirin 325 milligrams (mg), one tablet by mouth once a day for congestive heart failure. Observation and interview on 03/04/24 at 7:50 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #80 was preparing medications for Resident #51. LPN #80 used the calculator on the computer to divide 325 by 81 followed by LPN #80 removing four 81 mg chewable baby aspirin from the multi-use bottle of baby aspirin labeled 81 mg located in the top drawer of the medication cart, placing them into a medication cup. LPN #80 then removed a vial of Lantus 100 units per milliliter from the top right hand drawer of the medication cart along with an alcohol swab and an insulin needle. LPN #80 proceeded to open the alcohol swab, and cleanse the top of the Lantus insulin vial. With the insulin vial in the left hand of LPN #80, the insulin syringe cap was removed and the plunger was pulled back to 22 units. LPN #80 then stuck the insulin needle into the Lantus insulin vial, injecting the air and then LPN #80 withdrew 22 units of Lantus insulin into the syringe, removed the needle from the insulin vial, sat the vial on the right hand corner of the medication cart, inspected the fluid in the syringe, pushed to needle protector sleeve over the needle and sat the syringe onto the medication cart. The vial of Lantus insulin sitting on the top of the medication cart was labeled for Resident #49, not Resident #51. Interview with LPN #80 at the time of the observation stated the Lantus insulin for Resident #51 could not be found therefore another resident's insulin vial (Resident #49) was used. Continued observation of LPN #80 revealed LPN #80 walked into the room of Resident #51. The medication cup of pills were first handed to the resident along with the cup of water. Resident #51 took the oral medications and handed the empty medication cup back to LPN #80 along with the empty water glass. LPN #80 donned a pair of gloves and informed Resident #51 of the insulin injection and injected the 22 units of Lantus insulin into the left lower abdomen of Resident #51. Interview on 03/04/24 at 8:02 A.M. with LPN #80 verified four tablets of 81 mg baby aspirin and 22 units of Lantus insulin were administered to Resident #51. LPN #80 verified Resident #51 had an order for one tablet of 325 mg of aspirin to be administered and the Lantus that was administered to Resident #51 was not labeled for Resident #51. Interview on 03/04/24 at 11:00 A.M. with the Director of Nursing verified four tablets of 81 mg baby aspirin was not the same as 325 mg of regular aspirin and further verified medications labeled for one resident cannot and should not be used for another resident. Medications were only to be administered to the resident for which the medication is prescribed and labeled for. Review of the undated facility policy titled Medication Orders, stated uniform guidelines are used in receiving and recording medication orders with each resident under the care of a licensed provider authorized to practice medicine in the state and each resident medication order specify the type, route, dosage, frequency and strength of medication ordered. This deficiency represents non-compliance investigated under Master Complaint Number OH00151333 and Complaint Number OH00150705.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, family and resident interviews, medical record review, review of the Resident Council meeting minutes, review of the facility assessment, and review of the staffing schedules, the facility failed to maintain staffing levels to meet the needs of the residents. This affected three residents (#8, #23 and #72) of four residents reviewed for showers and had the potential to affect all 74 residents who resided in the facility. The facility census was 74. Findings include: 1. Review of the Facility Assessment, dated 08/10/23 revealed an average daily census of 72 to 78 residents. Staffing to ensure resident care included one nurse to twenty-six residents and one state tested nursing aide (STNA) for every twelve residents for the night shift. Review of the staffing on 03/03/24 from 10:00 P.M. to 6:00 A.M. on 03/04/24 revealed three nurses and two STNA for a census of 74. Review of the Resident Council meeting minutes from 12/04/23 and 01/03/24 revealed there were resident concerns with evening care. Observation on 03/04/24 at 7:15 A.M. revealed a strong foul odor of urine when ambulating the A, B and C halls of the facility. Interview on 03/04/24 at 7:45 A.M. with Licensed Practical Nurse (LPN) #82 stated staffing was an issue on second and third shift. LPN #82 stated there were many nights with only two to three STNA. LPN #82 further added proper care was not provided and residents were not getting showers as scheduled. Interview on 03/04/24 at 11:10 A.M. with STNA #81 verified at the start of the shift at 6:00 A.M. on 03/04/24 many of the residents required total bed changes and baths due to incontinence. STNA #81 stated there was only two STNAs in the building for the night shift. STNA #81 stated there were days resident showers were not given due to staffing. Interview on 03/04/24 at 1:00 P.M. with the Director of Nursing verified the staffing for the night shift from 10:00 P.M. on 03/03/24 to 6:00 A.M. on 03/04/24 was two STNAs and three nurses for a census of 75. 2. Review of the medical record for Resident #8 revealed an admission date of 02/22/24. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 required moderate assistance from staff for showers and bathing. Review of the shower schedule revealed Resident #8 was to receive showers on first shift every Wednesday and Saturday. Review of the shower sheets for Resident #8 from admission on [DATE] to 03/04/24 revealed a shower was provided on 02/28/24. Interview on 02/29/24 at 9:45 A.M. with the Power of Attorney (POA) for Resident #8 revealed concerns related to Resident #8 not receiving showers. Interview on 03/04/24 at 11:00 A.M. with the Director of Nursing verified showers were not provided as scheduled for Resident #8. 3. Review of the medical record for Resident #23 revealed an admission date of 12/13/22. Review of the care plan dated 06/08/22 and revised on 01/10/24 revealed Resident #23 required staff assistance for bathing and showering. Review of the quarterly MDS assessment dated [DATE] revealed Resident #23 required the physical assistance of one staff for personal care including bathing and showering. Review of the shower schedule revealed Resident #23 was to receive showers on second shift every Tuesday and Friday. Review of the shower sheets from 02/01/24 to 03/04/24 for Resident #23 revealed a shower was provided on 02/09/24 and a bed bath was given on 02/05/24. Interview with Resident #23 on 02/29/24 at 11:50 A.M. verified showers or bed baths were not being provided. Interview on 03/04/24 at 11:00 A.M. with the Director of Nursing verified showers were not provided as scheduled for Resident #23. 4. Review of the medical record for Resident #72 revealed an admission date of 05/29/21. Review of the quarterly MDS assessment dated [DATE] revealed Resident #72 was cognitively intact and required the substantial assistance for bathing and dressing. Review of the shower schedule revealed Resident #72 was to receive showers on first shift on Monday and Thursday. Review of the shower sheets from 01/29/24 to 03/04/24 revealed Resident #72 received four bed baths during this time on 01/29/24, 02/08/24, 02/19/24 and 03/02/24. Interview on 03/04/24 at 11:00 A.M. with the Director of Nursing verified showers were not provided as scheduled for Resident #72. This deficiency represents non-compliance investigated under Master Complaint Number OH00151333, Complaint Number OH00151010, and Complaint Number OH00150946.

Dec 2023 5 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 F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure call lights were within reach and accessible for residents. This affected two residents (#11 and #17) of ten residents reviewed for call light placement. The Facility census was 76. Findings Include: 1. Review of the medical record for Resident #11 revealed an admission date of 08/12/23. Diagnoses included type II diabetes mellitus, anxiety disorder, anemia, chronic kidney disease, hypothyroidism, hypertension, major depressive disorder, peripheral vascular disease, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated 08/16/23, revealed Resident #11 had cognitive impairment, was total dependence of two staff for bed mobility and personal hygiene and had no functional limitations of the upper extremities. Observation on 12/11/23 at 9:00 A.M. of Resident #11 revealed the call light cord was hanging from the reset box in the room at the foot of the resident's bed and outside the reach of the resident. Concurrent interview with Licensed Practical Nurse (LPN) #558 verified the call light was outside the reach of Resident #11. Additionally, LPN #558 stated the call light was not functioning properly. 2. Review of medical record for Resident #17 revealed an admission date of 03/09/23. Diagnoses included metabolic encephalopathy. mild protein calorie malnutrition, end stage renal disease, dysphagia, dementia, and impaired visual loss. Review of the quarterly MDS assessment, dated 12/03/23, revealed Resident #17 was moderately cognitively impaired, had no functional impairment and required moderate assistance for bed mobility. Observation on 12/07/23 at 2:04 P.M. of Resident #17 revealed the call light was on the floor beneath the left side of the bed. Resident #17 was sitting upright in bed with the head of the bed elevated. Continuous observation on 12/07/23 from 4:38 P.M. through 5:05 P.M. of Resident #17 revealed the resident was sitting upright in bed and the call light remained on the floor under the left side of the bed. Resident #17 was grabbing and reaching for things. Resident #17 was observed to have the bed control cord in her hand. The resident felt up and down the cord, pulling at the cord until it could no longer be pulled. Resident #17 then dropped the bed control and started to reach and sift through the blanket. Interview on 12/07/23 at 5:05 P.M. with State Tested Nursing Assistant (STNA) # 586 verified the call light for Resident #17 was on the floor and outside the resident's reach. Review of facility policy titled Call Lights: Accessibility and Timely Response, dated 08/10/22, revealed staff will ensure the call light is within reach of the resident and secured, as needed. Call lights will be accessible to the resident while in their bed. This deficiency represents non-compliance investigated under Complaint Number OH00148388.

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and review of facility policy the facility failed to ensure dependent residents were provided feeding assistance with meals. This affected two Residents (#17 and #21) of three residents reviewed for feeding assistance. The facility identified eleven residents that required feeding assistance. The facility census was 76. Findings include: 1. Review of medical record for Resident #17 revealed an admission date of 03/09/23. Diagnoses included metabolic encephalopathy. mild protein calorie malnutrition, end stage renal disease, dysphagia, dementia, and impaired visual loss. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/03/23, revealed Resident #17 was moderately cognitively impaired, was highly impaired visually with object identification in question, required set up with meals to ensure awareness of what food was served, the location on the plate and to provide eating utensils. Review of the care plan dated 03/09/23 revealed Resident #17 had an activities of daily living (ADLs) self care deficit. Interventions included set up required for meals and encourage/allow resident to feed self and provide assistance as needed. Observation on 12/07/23 at 4:38 P.M. of dinner meal tray delivery revealed State Tested Nurse Aide (STNA) #586 delivered a meal tray to Resident #17. The resident was sitting upright in bed, with her eyes closed. STNA #586 sat the meal tray on the over bed table, located to the left of the resident's bed, removed a red colored lid from the plate and, without speaking to Resident #17, walked out of the room. The over bed table was outside the reach of Resident #17. Observation of the meal cart at the time of meal service to Resident #17 revealed a sign on the top right hand corner of the meal cart that contained a picture of the red lid and below the picture of the red lid the sign stated red lid equals assist resident with eating. Continuous observation on 12/07/23 from 4:38 P.M. through 5:05 P.M. of Resident #17 revealed the resident grabbed at the air in the direction of the over bed table. Resident #17 grabbed the bed control cord, felt it up and down, dropped the cord, and sifted through the blanket. Resident #17 stopped, put her hands in her lap, leaned back on the pillow and closed her eyes. Interview on 12/07/23 at 5:05 P.M. with STNA #586 verified a red lid on a meal indicated a resident needed assistance with eating. STNA #586 verified she removed a red lid from Resident #17's meal, placed in on the over bed table, and the over bed table was not in Resident #17's reach. STNA #586 stated she had no knowledge Resident #17 required assistance with eating and also had no know knowledge of Resident #17 being highly visually impaired. 2. Review of the medical record for Resident #21 revealed an admission date of 12/16/19. Diagnoses included hemiplegia, hemiparesis following a cerebral infarct, type II diabetes mellitus, hypertension, major depressive disorder, and vascular dementia. Review of the quarterly MDS, dated [DATE], revealed Resident #21 required maximal assistance with eating. Observation on 12/07/23 at 4:40 P.M. of dinner tray meal delivery revealed STNA #586 delivered a meal tray to Resident #21. STNA #586 placed the tray on the over bed table, pushed the table diagonally over the left side of the bed, removed a red lid from the plate, and sat the red lid on the night stand. STNA #586 exited the resident's room. Continuous observation on 12/07/23 from 4:40 P.M. through 5:05 P.M. of Resident #21 revealed the resident, using his right hand, scooped food off the plate, located on the over bed table positioned on his left. As the resident continued to scoop food and attempt to get it into his mouth, the food dropped onto the chest of Resident #21 or onto the bed and floor. Observation on 12/07/23 at 5:05 P.M. revealed the meal ticket on the dinner tray for Resident #21 stated assist with meals, cut up meat. Interview with STNA #586 on 12/07/23 at 5:05 P.M. verified the meal ticket stated assist with meals and STNA #586 stated she had no knowledge Resident #21 required maximal assistance with eating. Review of the undated facility policy titled Activities of Daily Living, revised March 2018, revealed residents unable to carry out activities of daily living independently will receive the services necessary. This deficiency represents non-compliance investigated under Complaint Number OH00148388 and is an example of continued noncompliance from the survey dated 10/05/23.

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on medical record review, review of a community referral form, staff interview and review of facility policy, the facility failed to complete assessments on new admission to timely meet residents needs. This affected one (#87) of three residents reviewed for discharge. The facility census was 76. Findings include: Review of the medical record for Resident #87 revealed an admission date of 11/16/23 at 5:02 P.M. and a discharge date of 11/16/23 with a time of 7:03 P.M. Diagnoses included osteoarthritis of right hip, hyperlipidemia, gastroesophageal reflux, and obesity. Resident #87 had a right hip replacement on 11/15/23 and was being admitted to the facility for therapy to improve balance, strength, and endurance prior to returning home. Plan for services were needed for less than 30 days. Review of the community referral form dated 11/16/23 and timed 1:03 P.M. revealed Resident #87 was ordered to receive aspirin 81 milligrams (mg) once a day, extra strength Tylenol 1000 mg every eight hours as needed for pain for 14 days, celecoxib 200 mg once daily for 14 days, vitamin D3 5000 units, one tablet once a day, Pepcid 20 mg once a day in the morning, Gaviscon 80-14.2 mg chewable tablets, two once a day at bedtime, Protonix 40 mg once a day in the morning for 30 days, oxycodone five mg one tablet every four hours as needed for severe pain for seven days, docusate sodium two tablets twice a day for 14 days as needed for constipation, and tramadol 50 mg one tablet every four hours as needed for moderate pain for up to seven days. Review Resident #87's medical record revealed no evidence the physician was notified of the resident's admission or wish to leave against medical advice (AMA), completion of a nursing admission assessment, or orders. The only items contained in Resident #87's medical record was the signed AMA form. Interview on 12/11/23 at 10:00 A.M. with the Administrator verified Resident #87's medical record was silent for any care provided, including physician notification of admission and leaving AMA, nursing admission assessment, or orders, during the two hours the resident remained in the facility. Follow-up interview on 12/11/23 at 3:00 P.M. with the Administrator verified there was no evidence the resident or family were provided education on the risks and benefits of leaving AMA. Review of the facility policy titled Transfer and Discharge, including Against Medical Advice, dated 10/24/22, revealed when choosing to leave against medical advice, the facility will ensure the resident and family are informed of the risks involved, the benefits of staying at the facility, and the alternatives to both. This deficiency represents non-compliance investigated under Master Complaint Number OH00148980.

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 F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, medical record review, staff interview, review of the manufacturer's recommendations and review of the facility policy on insulin administration, the facility failed to ensure insulin was administered as ordered. This affected one (#7) of four residents reviewed for medication administration. The facility census was 76. Findings include: Review of the medical record for Resident #7 revealed an admission date of 11/06/20. Diagnoses included metabolic encephalopathy, type II diabetes mellitus, anxiety disorder, and hypertension. Review of the current physician orders for Resident #7 revealed an order dated 10/05/22 for 26 units of insulin glargine to be injected subcutaneously one time a day using a Basaglar Kwik pen Solution Pen-Injector 100 units per milliliter (ml). Observation on 12/11/23 at 9:10 A.M. of insulin administration for Resident #7 with Licensed Practical Nurse (LPN) #558 revealed LPN #558 removed an insulin pen from the top drawer of the medication cart, followed by pen needle and alcohol wipes. LPN #558 closed the drawer, removed the cap from the insulin pen with the left hand and sat the cap on the top of the left side of the medication cart. LPN #558 then opened the pen needle package, placed the wrapper in the trash, attached the pen needle to the top of the insulin pen, dialed the pen to 26 units, picked up the alcohol wipe and proceeded into Resident #7 room. LPN #558 assisted Resident #7 in removing bed linen and lifted Resident #7's shirt to expose the resident's abdomen. LPN #558 opened the alcohol prep pad, swabbed the left middle abdomen, placed the top of the insulin pen needle against the left middle abdomen and pressed the injector button for the pen to administer the 26 units of insulin to Resident #7. After the administration, LPN #558 assisted Resident #7 to straighten clothing and bed linens and exited the room. LPN #558 approached the medication cart, removed the pen needle from the insulin pen and disposed of the pen needle into sharps container, picked up the insulin pen cap and placed it back on the insulin pen, unlocked the medication cart and placed the insulin pen for Resident #7 back into the top drawer of the medication cart. Interview on 12/11/23 at 9:15 A.M. with LPN #558 verified she did not prime the Basaglar Kwik insulin pen for Resident #7 prior to administration, stating it did not require priming when the pen needle was attached to the insulin pen. Interview on 12/11/23 at 3:00 P.M. with the Director of Nursing (DON) verified the Basaglar Kwik pen is required to be primed when the needle is attached. Review of the manufacturers recommendation, dated November 2022, revealed the Basaglar Kwik pen required priming of two units of insulin to ensure insulin comes out of the needle tip, to ensure the pen is working correctly and removes all air bubbles, and to ensure the correct dose of insulin is provided. Review of a policy titled, Insulin Pen, dated 05/10/23, revealed the facility uses insulin pens in order to improve the accuracy of insulin dosing. When attaching the pen needle to the insulin pen, the dose selector is turned clockwise to two units and, with the needle pointed up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. This deficiency represents non-compliance investigated under Master Complaint Number OH00148980.

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 F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and review of facility policy, the facility failed to ensure a functional call light system. This affected one (#11) of ten residents reviewed for call lights. The facility census was 76. Findings include: Review of Resident #11's medical record revealed an admission date of [DATE]. Diagnoses included type II diabetes mellitus, anxiety disorder, anemia, chronic kidney disease, hypothyroidism, hypertension, major depressive disorder, peripheral vascular disease, and atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #11 had cognitive impairment, required total dependence of two staff for bed mobility and personal hygiene, and had no functional limitations of the upper extremities. Observations on [DATE] at 8:00 A.M. and from 10:20 A.M. to 10:45 A.M., when care was being provided by State Tested Nursing Assistant (STNA) #587, revealed the call light alert outside Resident #11's room was lit. Interview on [DATE] at 10:45 A.M. with STNA #587 verified the light was broken and not functioning properly. STNA #587 stated the call light could not be reset to turn the light off outside Resident #11's room. Additional observation on [DATE] at 3:00 P.M. revealed the call light alert remained on outside Resident #11's room. Interview on [DATE] at 3:00 P.M. with Licensed Practical Nurse (LPN) #558 verified the call light in Resident #11's room was not functioning properly, and the light alert could not be turned off from the room or the nurses station. LPN #558 stated maintenance was aware. Observation on [DATE] at 9:00 A.M. revealed the call light alert for Resident #11 was on outside the room and the call button in the room was hanging from the reset box in the room. Concurrent interview with LPN #558 verified the call light system for Resident #11's room had not yet been repaired. LPN #558 stated the call light alert stays on all the time. LPN #558 verified Resident #11 had not been provided with an alternative call system and stated Resident #11 did not use the call light so it did not matter anyway. Interview on [DATE] at 11:00 A.M. with the Director of Maintenance (DM) #577 verified the call light for Resident #11's room was not working properly. DM #577 was unable to provide evidence of a timeline for which the call light system had not been functioning properly and was unable to produce work orders related to the notification of the malfunctioning call light. Interview on [DATE] at 2:45 P.M. with the Director of Nursing (DON) revealed no knowledge of the call light for Resident #11 not functioning properly and stated, per the facility policy, when call lights were not functioning properly, the residents were to be provided a hand bell at bedside until the call light system problem is resolved. Review of the facility policy titled Call Lights: Accessibility and Timely Response, dated [DATE], revealed the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. The policy also stated staff will report problems with call lights immediately to the supervisor and or to maintenance and will provide immediate or alternative solutions until the problem can be remedied. This deficiency represents non-compliance investigated under Master Complaint Number OH00148980.

Nov 2023 1 deficiency 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

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to follow their policy to for skin assessments, failed to assess the presence of a new pressure ulcer, failed to provide pressure relief interventions as ordered, and failed to ensure the resident was kept dry without a saturated dressing. Actual harm occurred when Resident #1 was discovered with irritant dermatitis to the left buttock with no initial treatment ordered and no additional pressure relieving interventions were implemented. On 10/16/23 the resident was discovered with a stage 3 pressure ulcer to the coccyx identified to be of five days duration. Ordered pressure reduction was not implemented as ordered following the identification of the pressure ulcer and the resident was discovered in bed with a saturated brief and dressing to the pressure ulcer. This affected one (#1) of three sampled residents reviewed for skin breakdown prevention management. The facility identified five current residents with pressure ulcers. Facility was census 76. Findings include: Review of the medical record revealed Resident #1 admitted to the facility on [DATE]. Diagnoses included gastrostomy, sacral pressure ulcer stage 3, anxiety disorder, osteoarthritis, lymphedema, dementia, hypertension, venous insufficiency, dysphagia, acute cystitis, and sepsis. The resident readmitted to the facility from the hospital on [DATE]. Review of the 10/03/23 nursing admission assessment revealed Resident #1 was assessed with severe cognitive impairment, lethargic, dependent on staff for activities of daily living, including transfer and positioning requiring two persons, had a pressure area to the right heel and scar to sacrum, and was incontinent of bladder. Review of the skin breakdown risk assessment dated [DATE] revealed Resident #1 was assessed at a very high risk for the development of skin breakdown. Review of the significant change Minimum Data Set assessment, dated 10/07/23, revealed Resident #1 had severe cognitive impairment, was dependent on staff for the completion of activities of daily living, was incontinent of bowel and bladder, was at risk for pressure ulcer development and admitted with a stage 2 pressure ulcer. Review of the nursing plan of care, revised on 07/13/23, revealed Resident #1 was at risk for skin breakdown. Interventions included encourage and assist with repositioning routinely and as needed, follow facility policies and procedures for prevention and treatment of skin breakdown, pressure relieving mattress to bed, inform resident/family/caregiver of any new area of skin breakdown, monitor document and report to physician changes in skin status such as appearance, color, wound healing, signs and symptoms of infection, wound size and stage. Review of wound specialist documentation noted the resident was evaluated on 10/09/23 and discovered irritant dermatitis to the left buttock as a result of body fluid. No further skin breakdown was assessed and no new intervention to promote skin integrity were implemented. No treatment was ordered at the time of this observation. Review of physician orders revealed on 10/11/23 a physician order was initiated to apply zinc oxide based barrier cream every shift and as needed. The treatment was added to the plan of care. Review of the wound specialist note dated 10/16/23 revealed Resident #1 had a stage 3 pressure wound to the coccyx identified as full thickness with a duration of greater than five days. The pressure ulcer measured 6.0 centimeters (cm) long by 4.0 cm wide by 0.2 cm deep with moderate serous exudate. Recommendations included limit sitting to 60 minutes, off-load wound, reposition per facility protocol, and a low air loss mattress. No documentation was contained in the medical record identifying Resident #1 was assessed with skin breakdown to the coccyx until the 10/16/23 documentation which identified the area as a stage 3 pressure wound. Review of the progress notes dated 10/18/23 by Certified Nurse Practitioner (CNP) #1 documented Resident #1 was found resting in bed, appears uncomfortable, and moaning. Unit Manager present for visit. The resident was not able to speak and was inconsistently following some very simple commands. The low air loss (LAL) mattress was still in delivery packaging and not on the bed as ordered. Resident #1 was found in a brief soaked in urine with the dressing to the coccyx soiled. Review of the transfer form documentation on 10/21/23 at 10:00 P.M. revealed Resident #1 was discharged to the hospital due to fever. Review of the facility policy titled Pressure Injury Prevention Guidelines, revised 01/10/2023, interventions will be implemented in accordance with physician orders, including type of prevention devices to be used and for tasks the frequency performing them. Interventions will be documented in the care plan and communicated to all relevant staff. Preventative skin care includes inspecting skin while providing care, paying close attention to bony prominence's. Avoid positioning the resident on an area of redness whenever possible. Keep skin clean and dry. Manage incontinence with absorptive products. Check every two hours and provide perineal care as needed after incontinent episodes. Diaper usage when in bed is not recommended. Consider use of prophylactic dressings for prevention of sacral and heel pressure injuries. Routine repositioning schedule: every two hours, using both side lying and back positions. Provide alternative support surfaces as needed. Considerations for utilizing specialized support surfaces include medical condition and weight, stage 3, 4, unstageable, or deep tissue injury on trunk. Review of the facility policy titled Skin Assessment, implemented 09/14/22, revealed a full body, or head to toe assessment will be conducted by a licensed or registered nurse upon admission/readmission, daily for three days, and weekly thereafter. Document skin assessment to include date and time, observations, type of wound, and wound description. Interview on 11/01/23 at 1:45 P.M. with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Administrator confirmed a skin assessment was completed on admission of 10/03/23. However, no additional skin assessments were completed between 10/04/23 and 10/16/23. The DON confirmed nursing staff are to inspect resident skin integrity with each shower/bath twice weekly, during incontinence care, three days following admission and then weekly. No documentation included skin assessment or physical interventions to promote further skin breakdown from 10/09/23, when skin integrity was observed to be compromised with irritant dermatitis, until 10/16/23 when the wound specialist completed an assessment of the stage 3 pressure ulcer to the coccyx and a treatment was implemented. The ADON stated the air mattress recommended on 10/16/23 was not placed to the bed until 10/18/23 at approximately 2:00 P.M. The DON also verified Resident #1 required frequent incontinence checks and changes. No documentation was provided indicating the facility assessed and established specific toileting habits for Resident #1 and on 10/18/23 the resident was discovered by the Certified Nurse Practitioner #1 soaked in urine, including the coccyx dressing. This deficiency represents non-compliance investigated under Complaint Number OH00147704.

Oct 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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, and facility policy review, the facility failed to ensure residents who required assistance from staff with activities of daily living received showers/bed baths as scheduled. This affected two (#10 and #13) of three residents reviewed for hygiene. The facility census was 76. Findings include: 1. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, spinal stenosis, and age related osteoarthritis. Review of the Minimum Data Set (MDS) assessment, dated 09/08/23, revealed Resident #13 was cognitively intact. Resident #13 required staff assistance with bathing. Review of the care plan, revised 02/14/23, revealed Resident #13 had activities of self care performance deficit and interventions included the resident was dependent on staff for showers. Review of the shower sheets, dated 09/04/23 to 10/04/23, revealed Resident #13 had three documented bed baths in the last 30 days including 09/18/23, 09/25/23, and 10/02/23. Interview on 10/04/23 at 10:38 A.M. with Resident #13 revealed she does not want a shower but was supposed to get a bed bath every Monday and Thursday. Resident #13 reported she had one on Monday (10/02/23) but stated it was a long time prior to that. Interview on 10/04/23 at 2:45 P.M. with the Administrator verified the residents receiving showers getting completed have been a concern. The Administrator verified Resident #13 had three showers in the last thirty days documented. 2. Review of the medical record revealed Resident #10 was admitted on [DATE]. Diagnoses included multiple sclerosis, muscle weakness, respiratory disorder, and neuromuscular dysfunction of bladder. Review of the Minimum Data Set (MDS) assessment, dated 09/25/23, revealed Resident #10 was cognitively intact. Resident #10 was independent for personal hygiene and required one-person physical assistance and physical help in part of bathing. Review of the care plan, revised on 07/19/22, revealed Resident #10 had activities of self care performance deficit and interventions included to staff to assist the resident to bathe/shower. Review of the shower sheets, dated 09/04/23 to 10/04/23, revealed Resident #10 had three documented bed baths in the last 30 days including 09/18/23, 09/25/23, and 10/02/23. Interview on 10/04/23 at 8:59 A.M. with Resident #10 revealed he did not have a shower for eight days stating he had a shower on 10/02/23 but not eight days before that. Resident #10 stated he would like to shower at least every other day. Interview on 10/04/23 at 2:45 P.M. with the Administrator verified the residents receiving showers getting completed have been a concern. The Administrator verified Resident #10 had three showers in the last thirty days documented. Review of the policy titled Supporting Activities of Daily Living (ADLs), revised March 2018, verified appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and accordance with the care plan including hygiene. This deficiency represents non-compliance investigated under Complaint Number OH00146281.

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 Environment (Tag F0921)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observations, resident and staff interviews, and facility policy review, the facility failed to ensure resident rooms were maintained in a clean and sanitary manner. This affected of thee (#10, #13, and #21) of three residents reviewed for physical environment. The facility census was 76. Findings include: Observation on 10/04/23 at 8:55 A.M. of Resident #10's room revealed the bathroom floor was stained and dirty, the blinds covering the large window near the bed had splatters of possibly food or drink and were covered with a thick dust, the valance above the window had a think layer of dust, and the wall vent had a thick layer of dust. Interview on 10/04/23 at 8:59 P.M. with Resident #10 revealed his room was not cleaned well and pointed to the window blinds. Resident #10 stated the bathroom floor was always dirty. Interview on 10/04/23 at 9:11 A.M. with Housekeeping #201 verified Resident #10's bathroom floor, blinds, window valance, and vent were not appropriately clean. Interview on 10/04/23 at 10:38 A.M. with Resident #13 revealed the carpet in her room was stained terrible and it has not been shampooed in three years. Interview on 10/04/23 at 10:46 A.M. with Housekeeping #201 verified Resident #13's resident carpet was stained. Housekeeping #201 reported the facility has a carpet cleaner but there was no schedule for deep cleaning the carpets and it likely has not been done in a while. Interview on 10/04/23 at 10:49 A.M. with Housekeeping #202 verified resident rooms with carpet were very dirty. Subsequent observation of Resident #21's carpet revealed there were stains and Housekeeping #202 verified the stains. Review of the facility policy titled Environmental Services Cleaning Guidelines, dated June 2020, revealed the facility will be maintained in a clean and sanitary condition. Carpets will be cleaned on a regular bases determined by internal policy. Curtains and blinds will be done when dust/soil is visible. Daily damp high dusting will be done to minimize aerosolization of dust particles. Review of the facility policy titled Routine Cleaning and Disinfection, dated 05/10/23, revealed the facility will ensure the provision of routine cleaning and disinfection to provide a safe and sanitary environment. Cleaning of walls, blinds, and window curtains will be conducted when visibly soiled. This deficiency represents non-compliance investigated under Master Complaint Number OH00146862 and Complaint Number OH00146281.

Jul 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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, review of facility policy, and review of housekeeping task checklists, the facility failed to ensure resident rooms and bathrooms were maintained in a clean and sanitary manner. This affected two (#1 and #60) of three residents reviewed for clean and sanitary environment. The facility census was 75. Findings include: 1. Review of Resident #1's medical record revealed an admission date of 05/29/21. Diagnoses included spinal stenosis, myocardial infarction, hypertension, dysphagia, and osteoporosis. Review of the annual Minimum Data Set (MDS) assessment, dated 05/03/23, revealed the resident was cognitively intact. Interview on 07/27/23 at 8:21 A.M., with Resident #1 revealed she did not use her bathroom, but staff utilized it to get water to assist her with washing up daily. Concurrent observation of Resident #1's room revealed a urine odor. Resident #1 denied being soiled and stated she was not sure where the odor was coming from. Continued observation of the adjoining bathroom revealed a strong urine odor, two used gloves on the floor, as well as several paper towels on the floor. Resident #1 stated she did not know anything about the bathroom. Interview on 07/27/23 at 11:18 A.M., with State Tested Nurse Aide (STNA) #253 confirmed she provided a bed bath to Resident #1 this morning and utilized the bathroom to get water to provide care. STNA #253 stated Resident #1 was incontinent and did not use the restroom, but the wash basins used for care were kept in the bathroom. Concurrent observation, with STNA #253, of Resident #1's bathroom confirmed approximately five paper towels on the floor, two used gloves on the floor, and a strong urine odor. STNA #253 picked up the used gloves and paper towels and put them in the garbage can. STNA #253 stated there was a soiled brief in the bathroom garbage can, which was likely causing the odor. STNA #253 stated she noticed the odor earlier today but had not removed the garbage bag with the soiled brief or picked up the debris laying on the floor. STNA #253 removed the garbage bag with the soiled brief, tied it up and removed it from the room. 2. Review of Resident #60's medical record revealed an admission date of 12/16/20. Diagnoses included cerebral infarction, type II diabetes, asthma, chronic obstructive pulmonary disease, contracture right knee, contracture left knee, psychotic disorder with delusions due to known physiological condition, hypertension, major depressive disorder, hallucinations, osteoporosis, atrial fibrillation, dementia, and schizoaffective disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #60 was cognitively intact. Observations on 07/27/23 at 8:08 A.M., 9:09 A.M., and 9:50 A.M., of Resident #60's room revealed several crumpled tissues and pieces of paper, a meal ticket, and a straw laying on the floor. In addition, multiple dried brown splatter spots on the floor near the foot of the bed next to the window, as well as multiple dried brown splatter spots on the heat register and on the wall under the window. Interview on 07/27/23 at 10:40 A.M., with Resident #60 revealed her room was only cleaned occasionally. Resident #60 stated it was unusual for her room to be cleaned two days in a row. While Resident #60 stated she did not use her bathroom, other residents did, and she had heard it was not clean. Observation of Resident #60's bathroom revealed a strong urine odor, two quarter sized brown/yellowish spots on the floor near the toilet, and paper towels on the floor. Further observation of Resident #60's room revealed a brown substance smeared on the resident's call light and multiple brown spots on the wall near the head of the resident's bed. Observation, and concurrent interview, on 07/27/23 at 10:58 A.M., with Interim Administrator (IA) of Resident #60's room verified the brown substance on the resident's call light, spots on the wall near the head of the resident's bed, paper, tissues, and straw on the floor, brown splatter on the floor, heat register, and wall under the window. IA also confirmed the meal ticket on the floor was from dinner service on 07/26/23. Lastly, IA verified the strong urine odor in the bathroom, brown/yellowish spots on the floor near the toilet, and paper towels on the bathroom floor. IA stated the room was not up to standards and she would have it taken care of. Review of policy titled Environmental Services Cleaning Guidelines, dated June 2020, revealed the facility will be maintained in a clean and sanitary condition with a written schedule of cleaning and decontamination based on the area of the facility, type of surface to be cleaned, type of soil present, and tasks being performed in the area. Further review revealed surfaces, such as tabletops, window ledges, bedside stands, counters, sinks, tubs, shower floors, toilet seats, floors, etc. will be cleaned daily. These surfaces will also be cleaned as needed when spills or soiling occur. Review of the undated checklist titled Housekeeping Assignments, revealed resident room daily tasks included vacuum and spot clean carpet or sweep and mop floors, empty and wipe out trash cans, clean tray tables, dust televisions and tops of furniture, wash off any spots on walls, make sure room is organized, clean toilet, sink, fixtures, wipe off mirror, and sweep and mop all bathrooms. This deficiency represents noncompliance investigated under Complaint Number OH00144869.

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

Administration (Tag F0835)

Minor procedural issue · This affected most or all residents

Read full inspector narrative →

Based on observation, resident interview, staff interview, and review of housekeeping staff schedules, review of policy, review of housekeeping check list, the facility failed to ensure sufficient housekeeping staff to ensure a clean and sanitary environment. This had the potential to affect all 75 residents. The facility census was 75. Findings include: Interview on 07/27/23 at 7:50 A.M., with Housekeeping Supervisor (HS) #216 revealed she had been in her position for approximately one month. HS #216 stated, while she had housekeeping staff, she could probably use at least one more Housekeeping Aide (HA). HS #216 stated ideally there would be three housekeepers scheduled each day to meet the needs of residents. HS #216 confirmed each resident room, along with common areas, were to be cleaned daily. Interview and observation on 07/27/23 at 8:21 A.M., with Resident #1 revealed she did not use her bathroom, but staff utilized it to get water to assist her with washing up daily. Concurrent observation of Resident #1's room revealed a urine odor. Resident #1 denied being soiled and stated she was not sure where the odor was coming from. Continued observation of the adjoining bathroom revealed a strong urine odor, two used gloves on the floor, as well as several paper towels on the floor. Resident #1 stated she did not know anything about the bathroom. Observation on 07/27/23 at 8:00 A.M., of C Hall revealed near nurses station straw wrappers, other wrapper debris, food crumbs on floor. HS #216 approached and picked up the debris. Observations on 07/27/23 at 8:08 A.M., 9:09 A.M., and 9:50 A.M., of Resident #60's room revealed several crumpled tissues and pieces of paper, a meal ticket, and a straw laying on the floor. In addition, multiple dried brown splatter spots on the floor near the foot of the bed next to the window, as well as multiple dried brown splatter spots on the heat register and on the wall under the window. Interview on 07/27/23 at 10:40 A.M., with Resident #60 revealed her room was only cleaned occasionally. Resident #60 stated it was unusual for her room to be cleaned two days in a row. While Resident #60 stated she did not use her bathroom, other residents did, and she had heard it was not clean. Observation of Resident #60's bathroom revealed a strong urine odor, two quarter sized brown/yellowish spots on the floor near the toilet, and paper towels on the floor. Further observation of Resident #60's room revealed a brown substance smeared on the resident's call light and multiple brown spots on the wall near the head of the resident's bed. Observation, and concurrent interview, on 07/27/23 at 10:58 A.M., with Interim Administrator (IA) of Resident #60's room verified the brown substance on the resident's call light, spots on the wall near the head of the resident's bed, paper, tissues, and straw on the floor, brown splatter on the floor, heat register, and wall under the window. IA also confirmed the meal ticket on the floor was from dinner service on 07/26/23. Lastly, IA verified the strong urine odor in the bathroom, brown/yellowish spots on the floor near the toilet, and paper towels on the bathroom floor. IA stated the room was not up to standards and she would have it taken care of. Review of the staff schedule from 07/13/23 through 07/27/23 revealed the following HA's were scheduled: on 07/14/23 one HA, on 07/15/23 and 07/16/23 two HA's, on 07/20/23 one HA, on 07/22/23 and 07/23/23 two HA's, and on 07/27/23 one HA. Follow-up interview on 07/27/23 at 1:49 P.M., with IA with HS #216 verified there was only one HA in the facility today. HS #216 explained the other HA had requested paid time off (PTO) and did not actually call off as the schedule indicated. HS #216 confirmed the PTO had been approved approximately two weeks ago and the HA had not been replaced on the schedule. IA stated HS #216 was a working supervisor, so she was able to assist as needed with housekeeping tasks. In addition, IA stated laundry staff were also part of the same department and could be pulled to assist housekeeping. HS #216 verified there was typically one laundry aide scheduled so pulling them to do housekeeping would result in laundry not being done. IA and HS #216 confirmed the scheduled reflected three HA's were needed each day and only one was actually working today. IA and HS #216 verified on 07/14/23, 07/15/23, 07/16/23, 07/20/23, 07/22/23, 07/23/23, and 07/27/23 the facility did not have sufficient housekeeping staff to provide necessary services. Additional interview on 07/27/23 at 2:03 P.M., of IA confirmed the facility could utilize another housekeeper to ensure sufficient coverage. She stated she spoke with the corporate human resources person today and a housekeeper position was going to be advertised today. Interview on 07/27/23 at 2:16 P.M., with HA #259 revealed about twice per week she was the only HA working and responsible for cleaning the entire facility, including resident rooms and common areas. HA #259 stated when she returns to work after her days off, she finds her usually assigned areas are not cleaned because there was insufficient staff to cover her areas. HA #259 stated housekeeping could pull staff from laundry to assist, but, since there is usually only one staff in laundry, there would not be anyone to ensure there were clean linens for the residents. When she was the only HA in the facility, like today, HA #259 stated her responsibilities included cleaning the lobby, front two lobby area bathrooms, the skilled bed area, and completing deep cleans. HA #259 explained a deep clean was completed after a resident discharged and the room needed cleaned from top to bottom and took approximately one- and one-half hour each to complete. HA #259 stated she had two deep cleans on her schedule for today. HA #259 verified she had not cleaned any resident rooms on the A, B, and C Halls or hallways today and was unlikely to be able to do any cleaning on those halls before the end of her shift today. Lastly, HA #259 stated housekeeping tasks were split into three assignments and three housekeeping staff were needed to ensure all tasks could be completed. Review of policy titled Environmental Services Cleaning Guidelines, dated June 2020, revealed the facility will be maintained in a clean and sanitary condition with a written schedule of cleaning and decontamination based on the area of the facility, type of surface to be cleaned, type of soil present, and tasks being performed in the area. Further review revealed surfaces, such as tabletops, window ledges, bedside stands, counters, sinks, tubs, shower floors, toilet seats, floors, etc. will be cleaned daily. These surfaces will also be cleaned as needed when spills or soiling occur. Review of undated checklist titled Housekeeping Assignments, revealed resident room daily tasks included vacuum and spot clean carpet or sweep and mop floors, empty and wipe out trash cans, clean tray tables, dust televisions and tops of furniture, wash off any spots on walls, make sure room is organized, clean toilet, sink, fixtures, wipe off mirror, and sweep and mop all bathrooms. This deficiency represents non-compliance investigated under Complaint Number OH0144869.

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 F0838 (Tag F0838)

Minor procedural issue · This affected most or all residents

Read full inspector narrative →

Based on review of the facility assessment and staff interview, the facility failed to timely review and update the facility assessment to identify needed resources to provide care and services to residents. This had the potential to affect all 75 residents. The facility census was 75. Findings include: Review of the Facility Assessment revealed it was last reviewed on 04/29/22. Interview on 07/27/23 at 2:52 P.M., of Interim Administrator (IA) verified the Facility Assessment was last reviewed on 04/29/22 and did not reflect the most current resources needed to provide care and services to the resident.

Mar 2023 4 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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident representative was notified of new physician treatment orders. This affected one (Resident #9) of three residents reviewed for notification of change in condition. The facility census was 72. Findings include Review of the medical record for Resident #9 revealed an admission date of 01/28/23. Diagnoses included cerebrovascular disease, hypothyroidism, vascular dementia, atrial fibrillation, anxiety disorder, abdominal aortic aneurysm, and repeated falls. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #9 had impaired cognition. Review of the plan of care initiated 02/17/23 revealed Resident #9 was at risk for wandering. Interventions included to assure Wanderguard was on and functional every shift, check Wanderguard to ensure it in place on left ankle, engage in purposeful activity, provide care in a calm reassuring manner, provide re-orientation to surroundings as necessary, redirect away from exit doors, and talk to resident in a calm reassuring manner. Review of a physician order dated 02/17/23 identified orders for Resident #9 to have a Wanderguard (a bracelet/ankle device used to set off an alarm when a wandering residents opens or goes near an exterior door to alert staff of potential elopement) to the left ankle, check placement and function every shift. Review of a nurses note dated 02/17/23 at 10:48 A.M. revealed a Wanderguard was placed on Resident #9's left ankle. Further review of the nurses' notes from February 2023 revealed no documentation the resident's representative was notified of the Wanderguard placement. Interview on 03/02/23 at 8:49 A.M., the Director of Nursing (DON) verified there was no documentation the resident's representative was notified of the Wanderguard placement. Review of facility policy titled, Notification of Changes, revised 08/10/22, revealed the facility would promptly notify the resident's representative when there was a change requiring notification including circumstances requiring a need to alter treatment. This deficiency represents non-compliance investigated under Complaint Number OH00140516.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of shower documentation, interviews and policy review, the facility failed to ensure residents were provided showers based on their scheduling preferences. This affected two (Residents #2 and #17) of three residents reviewed for showers. The facility census was 72. Finding include 1. Medical record review for Resident #2 revealed an admission date of 07/18/22. Diagnoses included secondary malignant neoplasm of the brain, hypertension, major depressive disorder, osteoarthritis, and malignant neoplasm of the left kidney. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had mild cognitive impairment. The resident required supervision with transfers and physical help, limited to transfers only, for bathing self-performance. Interview on 02/28/23 at 4:51 P.M., Resident #2 reported her shower days were on Mondays and Thursdays. Resident #2 reported she did not receive a shower as scheduled yesterday, 02/27/23. Observation at the time of the interview revealed Resident #2's hair was dry, disheveled, and appeared to need washed. Review of the shower documentation revealed Resident #2 was not given a shower on 02/27/23. Interview on 03/01/23 at 1:49 P.M. the Director of Nursing (DON) verified there was no documentation Resident #2 received a shower on 02/27/23. 2. Medical record review for Resident #17 revealed an admission date of 12/04/20. Diagnoses included end stage renal disease, hemiplegia and hemiparasite following nonromantic sugarcane hemorrhage affecting right dominant side, peripheral vascular disease, anxiety disorder and type two diabetes mellitus. Review of the annual MDS assessment dated [DATE] revealed Resident #17 had intact cognition. The resident required limited assistance of one staff for transfer assistance. The bathing activity had not occurred in the look back period. Interview on 02/28/23 at 4:58 P.M., Resident #17 reported her shower days were on Tuesdays and Fridays. The resident reported the facility staff had not been about providing showers the past week. Observation at the time of the interview revealed Resident #17's hair was dry, disheveled, and appeared to need washed. Review of the shower documentation revealed Resident #17 did not received her scheduled showers on 02/21/23 and 02/24/23. Interview on 03/01/23 at 1:49 P.M. the DON verified there was no documentation Resident #17 received a shower on 02/21/23 and 02/24/23. Review of the Resident Council meeting minutes dated 01/04/23 revealed residents voiced concerns about not receiving their showers regularly and staff were making excuses why they could not give them showers. Education was provided to staff and the concern was noted as resolved on 01/10/23. Review of the facility policy, Resident Showers, revised 03/29/22, revealed residents would be provided showers as per request or as per facility schedule protocols and based upon resident safety. This deficiency represents non-compliance investigated under Complaint Number OH 00140158.

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 F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure medications were available for administration following admission. This resulted in a significant medication error for one (Resident #12) of three residents reviewed for medication administration. The facility census was 72. Findings include: Review of the medical record for Resident #12 revealed an admission date of 02/20/23 and a discharge date of 02/22/23. Diagnoses included acute respiratory failure, type two diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, dysphagia, presence of coronary bypass graft, end stage renal disease, systolic heart failure, atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, hypertension, hyperlipidemia, anemia, benign neoplasm of meninges. Review of the five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #12 had intact cognition. Review of the hospital discharge medication orders dated 02/20/23 for Resident #12 revealed physician orders for amiodarone (medication used to treat heart rhythm problems) 200 milligrams (mg) two tablets (400 mg) by mouth in the morning and at bedtime for seven days, then two tablets (400 mg) in the morning for seven days, then one tablet (200 mg) in the morning. Also ordered was vancomycin (antibiotic) 125 mg capsule, take one capsule by mouth in the morning, at noon, in the evening, and at bedtime for ten days. Review of a nursing progress note dated 02/20/23 at 11:03 P.M. revealed Resident #12 admitted to the facility on [DATE] at 9:00 P.M. Review of the physician orders dated 02/20/23 for Resident #12 revealed an order for amiodarone oral tablet 200 mg, give two tablets orally two times a day for heart until 02/27/23. The resident also had an order for Firvanq (antibiotic) 25 mg/mL solution reconstituted, give 125 mg by mouth four times a day in the morning, at noon, in the evening, and at bedtime for 10 days. The resident was ordered Vancocin (antibiotic) oral capsule 125 mg give one capsule by mouth four times a day in the morning, at noon, in the evening, and at bedtime for 10 days. Review of Resident #12's Medication Administration Records (MAR) for February 2023 revealed the resident was not administered two doses of the amiodarone on 02/21/23. The resident was also not administered four doses of the Vancocin on 02/21/23 or four doses of the therapeutic interchange Firvanq for the Vancocin on 02/21/23. Interview on 03/01/23 at 1:56 P.M., the Director of Nursing (DON) verified Resident #12's medications were not ordered until 5:15 A.M. on 02/21/23. The DON stated the pharmacy flagged the order for the amiodarone as a profile instead of a medication order. The DON also revealed the pharmacy thought the facility had the amiodarone in their contingency supply but verified the facility did not. The DON verified the resident was not administered the amiodarone on 02/21/23. The DON revealed the Firvanq antibiotic was a therapeutic interchange for the vancomycin, which was also not administered to the resident. Review of the policy titled, Medication Reordering, dated 07/01/22, revealed it is the policy of the facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. This deficiency represents non-compliance investigated under Complaint Number OH00140572.

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 F0925 (Tag F0925)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure a resident's room remained free of ants. This affected one (Resident #4) of three residents reviewed for pest control. The facility census was 72. Findings include: Medical record review for Resident #4 revealed an admission date of 09/24/20. Diagnoses included hemiplegia affecting left nondominant side, type two diabetes mellitus, dementia and chronic kidney disease stage three. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had intact cognition. Observation on 03/01/23 at 5:48 A.M. of Resident #4's room, revealed there were two [NAME] ant hills on the floor, next to the exterior window door close to the base board heater. The two ant hills were covered in ants and many ants were crawling in a straight line up the wall. Interview on 03/01/23 at 5:48 A.M., State Tested Nursing Assistant (STNA) #210 verified there were two ant hills covered in ants as well as ants crawling up the walls in Resident #4's room. Review of the facility policy titled, Pest Control, dated 2020, revealed the facility wound maintain an effective pest control program to remain free of pests and rodents with on going measure to prevent, contain, and eradicate common household pests such as roaches, ants, mosquitoes, flies, mice and rats. This deficiency represents non-compliance investigated under Complaint Number OH00140158.

Jun 2022 6 deficiencies

CONCERN (D)

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, resident and staff interview, and record review, the facility failed to ensure a resident received proper care and treatment to improve maintain hearing abilities. This affected one (#22) of two residents reviewed for communication. The facility census was 70. Findings include: Review of the medical record for Resident #22 revealed an admission date of 03/07/19, with diagnoses including hypothyroidism, and gastro-esophageal reflux disease. Review of the Minimum Data Set (MDS) assessment completed on 04/11/22 revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating the resident was moderately cognitively impaired. Review of MDS assessments dated 06/11/19, 09/04/19, 11/07/19, 02/14/20, 04/10/20, 07/03/20, 10/02/20, 04/08/21, 07/08/21, 08/27/21, 10/15/21, 01/12/22, and 04/11/22 revealed the resident had moderate difficulty with hearing and did not have hearing aids. MDS assessments dated 12/13/20 and 01/18/21 indicated the resident's hearing was highly impaired and the resident had no hearing aids. Review of hospital documentation with a review date of 08/05/21 revealed in the category of hearing hard of hearing/hearing concerns, Deaf was noted. Review of Resident #22's plan of care, dated 04/11/22, revealed the resident had a communication problem related to hearing deficit. Interventions included asking the resident simple yes or no questions as appropriate and anticipating and meeting the resident's needs. Review of an undated audiology roster list revealed Resident #22 was not included on the roster of residents who had requested or were in need of audiology services. Interview on 06/13/22 at 10:45 A.M., with Resident #22 revealed the resident was extremely hard of hearing and stated he needed hearing aids and was on a list to see an audiologist at the facility. Observation and interview of Resident #22 on 06/15/22 at 9:46 A.M., revealed the resident was extremely hard of hearing and was unable to understand any questions from the surveyor. No communication devices or interventions were observed in the resident's room. Interview on 06/15/22 at 2:43 P.M., with Social Services Director ##430 revealed an audiologist typically came to the facility on a quarterly basis to see any residents in need of services. Social Services Director #430 reported she had worked at the facility since 01/28/22, an audiologist had not been to the facility since prior to that date, and she was waiting for the audiologist provider to contact her to schedule a visit. Social Services Director #430 verified Resident #22 had not been on the list to see an audiologist until the need was brought to her attention during the survey. Interview on 06/16/22 at 1:53 P.M., with State Tested Nurse Aide (STNA) #435 revealed Resident #22 kind of yelled during conversations, and continuously asked staff to repeat themselves. STNA #435 was unaware of any interventions or devices to assist in communicating with Resident #22. STNA #435 stated she was unsure of if the resident had hearing aids somewhere or if he needed to get some. Interview on 06/16/22 at 2:44 P.M., with the Director of Nursing (DON) verified Resident #22 had not seen an audiologist since residing at the facility and interventions consisted of asking the resident yes or no questions and anticipating and meeting his needs. Review of the policy titled Hearing and Vision Services, dated 06/01/22, revealed it is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. The policy further stated the facility would use the comprehensive assessment process for identifying and assessing a resident's hearing abilities in order to provide care, needs would be referred to the social worker, and the social worker was responsible for assisting residents and their families in locating and utilizing any available resources for the provision of the hearing services needed by the resident.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident and staff interviews, the facility failed to ensure a resident was turned and repositioned every two hours per the plan of care to prevent skin breakdown. This affected one (#6) of one resident reviewed for turning/repositioning to prevent skin breakdown. The facility identified three current residents with pressure sores and 61 residents receiving preventive skin care. Facility census was 70. Findings include: Review of the medical record reviewed Resident #6 was admitted to the facility on [DATE], with diagnoses including spinal stenosis, anxiety, and depression. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required the extensive assistance of two staff for bed mobility. The resident was noted to be cooperative with care. Review of the pressure sore risk assessment dated [DATE] revealed the resident was at high risk for development of pressure sores. Review of Resident #6's plan of care dated 05/20/22 revealed the resident was at risk for skin breakdown due to decreased mobility and incontinence. Interventions included encouraging and assisting the resident with repositioning routinely and as needed. Review of activities of daily living (ADL) tasks revealed the resident was to be repositioned/turned every two hours. Interview on 06/13/22 at 12:35 P.M., with Resident #6 revealed the resident's bottom was feeling sore and that staff had not been repositioning her. Observation on 06/15/22 at 9:44 A.M., revealed Resident #6 was lying in her bed with the head of the bed slightly elevated. The resident was on her back with no pillows placed behind her on either her left or right side. Two pillows were observed on an unoccupied chair located in the resident's room, one with a pillow case and one without a pillow case. Observation on 06/15/22 at 12:06 P.M., revealed Resident #6 was in the same position. The pillows were observed in the same position in the chair. Observation on 06/15/22 at 1:58 P.M., revealed Resident #6 was in the same position with the head of her bed slightly less elevated. The pillows were observed in the same position in the chair. Observation on 06/15/22 at 3:12 P.M., revealed Resident #6 was in the same position and the pillows were still in the same position in the chair. Interview and observation on 06/15/22 at 3:18 P.M., with Licensed Practical Nurse (LPN) #411 revealed LPN #411 was unsure of whether Resident #6 was supposed to be turned/repositioned throughout the day. LPN #411 verified Resident #6 was lying on her back at the time of the observation and denied seeing her in any other position throughout the day. Resident #6 stated she had not been turned or repositioned at all on 06/15/22 and then stated I'm not sure if I have to be turned since I don't have any sores right now. LPN #411 then stated see, that's probably why. Interview on 06/15/22 at 3:22 P.M., with LPN #411 stated that during the previous observation Resident #6 stated she did not want to be turned and that was likely why she wasn't repositioned throughout the day. The surveyor stated Resident #6 did not say she did not want to be turned, but that she was unsure of whether staff were supposed to be repositioning her as she was not being repositioned. LPN #411 stated okay and proceeded to walk away. Review of the policy titled Activities of Daily Living (ADLs), Supporting, revised March 2018, revealed appropriate care and services would be provided for residents who were unable to carry out ADLs independently in accordance with the plan of care, including mobility.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, family and staff interview, review of safety data sheets, and review of the safety manual, the facility failed to securely store hazardous materials. This affected one (Resident #46) of two facility identified independently mobile, cognitively impaired residents. The facility census was 70. Findings include: Review of the medical record for Resident #46 revealed an admission date of 10/06/21, with diagnoses of malignant neoplasm of overlapping sites of colon, dementia, and intervertebral disc degeneration lumbar region. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #46 had impaired cognition and required limited assistance of one person for transfers and walking. Review of the medical record for Resident #19 revealed an admission date of 06/17/21, with diagnoses of cardiomegaly, nonrheumatic aortic valve stenosis, and hypertensive heart disease without heart failure. Observation on 06/13/22 at 11:05 A.M., revealed bottles of bleach and cleaner in Resident #46's bathroom. Interview on 06/13/22 at 11:08 A.M., with the Housekeeping Supervisor #415 confirmed bleach and cleaner were in Resident #46's bathroom. Further interview identified the bleach as Clorox Bleach and the cleaner as Neutral Quat Disinfectant. Continued interview confirmed bleach and cleaner should not be left in a resident room or bathroom. Interview with Resident #46's daughter on 06/14/22 at 2:12 P.M., revealed Resident #46 enters the bathroom independently. Review of the Safety Data Sheet for Clorox Bleach revealed a precautionary label of causes severe skin burns and eye damage. Review of the Safety Data Sheet for Neutral Quat Disinfectant revealed a precautionary label of toxic if swallowed, cause severe skin burns and eye damage and harmful if inhaled. Review of the safety manual titled Infection Prevention and Control Manual for Environmental Services, Housekeeping, and Laundry, effective date 03/21/22, revealed chemicals must always be either in direct possession of the staff or locked in the appropriate cabinet. This is to protect the residents who are confused, from potential exposure to hazardous chemicals.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the policy, and staff interview, the facility failed to ensure the proper psychiatric diagnoses was in the medical record for a resident receiving anti-psychotic medications. This affected one (#75) of five residents reviewed for anti-psychotic medications. The facility identified 13 residents utilizing antipsychotic. The current census is 70. Findings include: Review of Resident #75's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses include: dementia, encephalopathy, muscle weakness, falls, anxiety and depression. Review of Resident #75's comprehensive Minimum Data Set, (MDS) assessment dated [DATE], revealed the resident impaired cognition, was a 1-2 person assist with Activities of Daily Living (ADL), and was receiving antipsychotics. Per the MDS assessment the resident has non-Alzheimer's dementia. No psychosis diagnoses was noted in the assessment. Per the MDS dated [DATE], the resident was not diagnosed with bipolar, psychotic disorder, schizophrenia, or Post Trauma Stress Disorder. Per the assessment the resident was having no behaviors. Review of Resident #75's physician orders revealed on 06/08/22 the resident was ordered to receive Risperdal, (antipsychotic) 0.5 milligram, (mg), two times a day for dementia without behavioral disturbance and Quetiapine (antipsychotic) 25 mg daily. Review of Resident #75's Medication Administration Record, (MAR) dated 05/2022 and 06/2022 revealed the resident was receiving all medications per physician order. Review of Resident #75's care plan dated 06/02/22 revealed a focus for psychotropic medication use related to behaviors as evidence by high anxiety, fear of being alone, stripping clothes off, tearfulness, and potential for complications. Interventions include offer activities, psych consult, administer medications and monitor for side effects, report to physician side effects and adverse reactions of psychotropics medications. Further review of Resident #75's medical record including physician progress notes revealed there was no psychiatric referral or diagnoses for psychosis in the medical record. Interview on 06/16/22 at 3:00 P.M., with the Director of Nursing (DON) verified there was no psychiatric diagnoses in the resident's current medical record. Per the DON, the resident had diagnosis for psychosis in a previous admission but the diagnosis was not included in the current record. Review of the policy titled, Antipsychotic Medication Use dated 09/2021, revealed anti-psychotic medications are to be used for specific diagnoses including psychosis with the absence of dementia.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review, resident and staff interviews, the facility failed to ensure all medications were secured during medications administration for residents. This affected two (#5 and #18) of five residents reviewed for medication administration. The current census is 70. Findings include: 1. Review of Resident #18's medical record revealed an admission date of 05/13/19, with diagnoses including: heart failure, hypertension, depression, and ischemic heart failure. Review of Resident #18's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was a set up for ADLs. Review of Resident #18's care plans dated 05/2019 revealed a focus for an Activities of Daily Living (ADL) self-care performance related to heart failure and receiving hospice services. Interventions include praise efforts for self-care, provide care for ADLs and monitor for changes. Review of Resident #18's physician prescribed medications revealed all medications are given upon rising and at bedtime. No medications are given during the afternoon, no specific times are noted on the medical record. Further review of Resident #18's medical record revealed no documentation the resident was able to self-administer medications. Observation on 06/13/22 at 10:35 A.M., revealed there was a medication cup with 7 pills in Resident #18's room on her bedside table. Interview on 06/13/22 at 10:37 A.M., with Licensed Practical Nurse, (LPN) #600 denied the nurse left the pills in the room despite the observation with the surveyor. LPN #600 confirmed there were 7 pills in a cup in the resident's room when interviewed in the room. 2. Review of Resident #5's medical record revealed an admission date of 02/11/22, with diagnoses including: fracture of the left acetabulum, muscle weakness, diabetes type two, pulmonary embolism, and end stage renal disease. Review of Resident #5's MDS comprehensive assessment dated [DATE] revealed the resident had intact cognition and was a one person assist with ADLs. Review of Resident #5's care plans dated 02/2022 revealed a focus for ADL self-care performance related to limited mobility related to fall and fracture. Interventions include monitor for self-care performance and provide assistance with care. Further review of Resident #5's medical record revealed no documentation the resident was able to self-administer medications. Observation on 06/16/22 at 9:00 A.M., of Resident #5 revealed the resident was sitting in her room eating breakfast. Two pills in a cup were observed next to the resident's tray. No nurse was observed in the resident's room. Interview on 06/16/22 at 9:00 A.M., with Resident #5 revealed the nurses often leave some of her pills in her room for her to take by herself. Resident #5 stated she thought the pills were for her dialysis but was not too sure. Resident #5 confirmed the nurse had put the pills in her room before her breakfast tray arrived and did not observe Resident #5 taking her medications. Interview on 06/16/22 at 9:20 A.M., with Registered Nurse (RN) #400 verified she had administered Resident #5's morning medications. RN #400 denied leaving any medications at the beside and stated she observed the resident taking the medications. RN #400 would not verify the two pills in the cup next to the resident. Interview on 06/16/22 at 3:00 P.M., with the Director of Nursing (DON) revealed the facility policy is for all nurses administering medications to stay at the bedside until the residents have taken the medications. DON verified the standard practice for nurses was to observe the entire medication administration process. Review of the policy titled, Medication Administration dated 09/2021, revealed the nurse will conduct the five checks during the medication administration, which include the proper resident receiving the prescribed medications being administered. This deficiency substantiated Complaint Number OH00133210.

CONCERN (E)

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

Deficiency F0568 (Tag F0568)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on review of facility documents and staff interview, the facility failed to verify residents with a trust fund account received quarterly bank statements. This affected 37 (#6, #8, #9, #10, #12, #15, #16, #17, #18, #21, #22, #23, #24, #25, #26, #29, #30, #31, #32, #33, #34, #35, #37, #39, #40, #43, #44, #50, #51, #53, #57, #64, #65, #66, #67, #69, and #71) of 37 residents with a resident trust fund account. The facility census was 70. Findings include: Interview on 06/16/22 at 11:05 A.M., with the Business Office Manager #438 revealed she could not verify the facility had provided quarterly statements to residents or their representatives who had trust fund accounts with the facility. Further interview revealed the facility had 37 (#6, #8, #9, #10, #12, #15, #16, #17, #18, #21, #22, #23, #24, #25, #26, #29, #30, #31, #32, #33, #34, #35, #37, #39, #40, #43, #44, #50, #51, #53, #57, #64, #65, #66, #67, #69, and #71) residents with a trust fund account. Review of the undated facility documented titled, Authorization to Manage Resident Trust Fund revealed residents with an account would receive a quarterly statement of their account.

Jul 2019 10 deficiencies

CONCERN (D)

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

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family and staff interview, and review of facility policy, the facility failed to ensure residents were bathed as desired. This affected one (#11) out of four residents reviewed for choices. The facility census was 95. Findings include: Review of Resident #11's medical record revealed an admission date of 09/02/17. Diagnoses included chronic obstructive pulmonary disease, dementia, muscle weakness, lymphedema, hypertension, dizziness and giddiness, anxiety disorder, obesity, insomnia, radiculopathy of cervical region, anemia, and chronic kidney disease. Review of Resident #11's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating Resident #11 was cognitively intact. Resident #11 required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #11 required limited assistance with walking, and locomotion. Resident #11 displayed no behaviors during the review period. Review of Resident #11's care plan revised 05/22/19 revealed supports and interventions for group programs, resident decision to not follow the recommended fluid restriction, difficulty falling asleep, demeaning and degrading to staff, risk for skin breakdown, risk for falls, risk for pain, risk for dehydration due to diuretic use, self-care deficit, antidepressant medication use, potential for nutritional problem, and non-complaint with care. Resident #11 would refuse medications, treatments, daily weights, fluid restrictions, repositioning, and keeping her legs elevated. Review of Resident #11's State Tested Nursing Assistant (STNA) documented Tasks for the last 30 days revealed Resident #11 received a bed bath on 07/01/19, and 07/02/19. Resident #11 refused bathing on 07/04/19. The review revealed no showers were listed as being provided. Review of Resident #11's shower sheets revealed showers were provided on 06/20/19, 06/23/19, and 07/15/19. A note was found on the shower sheet dated 07/22/19 indicating Resident #11 was not to have a shower until Thursday, 07/25/19 due to leg wraps. Resident #11's electronic and written shower documentation revealed Resident #11 two showers in the month of July which had ten showers to be completed. Resident #11 refused only one shower on 07/04/19. Review of Resident #11's physician orders revealed an order dated 07/22/19 do not remove wraps from lymphedema. Review of Resident #11's assessments revealed Weekly Skin/Wound Assessments were completed 07/15/19, 07/08/19, and 07/01/19. Review of Resident #11's progress notes revealed no notations regarding bathing or showers. Interview on 07/22/19 at 1:56 P.M. with Resident #11's daughter revealed Resident #11 had not had a shower in weeks because of her leg wraps. Resident #11's daughter wanted Resident #11 to be bathed twice a week as Resident #11 was scheduled and Resident #11 wanted. Interview on 07/25/19 at 10:04 A.M. with State Tested Nursing Assistant (STNA) #110 revealed Resident #11 was cooperative with care and able to make to make her needs known. STNA #110 reported Resident #11 was to get bathed two times a week on second shift. STNA #11 reported bathing was documented in the electronic record or on shower/skin sheets. Interview on 07/25/19 at 10:22 A.M. with Licensed Practical Nurse (LPN) #205 revealed Resident #11 was cooperative with care and was able to make her needs known. LPN #205 reported the STNA's were not able to apply Resident #11's leg wraps following a shower. LPN #205 reported the nurses would need to apply the leg wraps. LPN #205 reported Resident #11's bathes were done on second shift so she had never been asked to reapply Resident #11's wraps since she was a first shift nurse. Interview on 07/25/19 at 11:12 A.M. with Registered Nurse (RN) #300 verified Resident #11 was scheduled to be bathed twice a week and only received two bed baths and one shower for the month of July 2019. Interview on 07/25/19 at 2:41 A.M. with STNA #131 revealed she was the second shift STNA assigned to Resident #11. STNA #131 reported she had only worked in the facility for a few weeks and was not familiar with Resident #11. STNA #131 was not sure about Resident #11's scheduled showers. STNA #131 reported in the times she had worked she had not provided Resident #11 with a shower. STNA #131 checked the shower schedule and reported Resident #11 was due for a shower today and would get one before 10:00 P.M. STNA #131 went on to say Resident #11 was usually a one assist with the bathroom and was able to make her needs known. Review of the facility policy titled, Bathing Frequency, policy revised 12/12/11 revealed residents were interviewed during the admission process regarding their preferences to bathing/showering. The frequency of the bath/shower was reviewed at least quarterly during care planning with the resident. Changes were to be implemented if indicated by the resident. Review of the facility's undated document titled, Nursing Home Residents' [NAME] of Rights, revealed residents has the right to make choices about aspects of his or her life in the facility that are significant to the resident. This deficiency represents ongoing non-compliance from the survey dated 06/25/19.

CONCERN (D)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #53's medical record revealed an admission date of 04/28/19 and a discharge date of 07/15/19. Resident #53 was re-admitted to the facility on [DATE]. Diagnoses included sepsis, acute cystitis, hypertension, obstructive and reflux uropathy, osteoporosis, malignant neoplasm of kidney, anxiety disorder, depressive disorder, psychosis, and acute kidney failure. Review of Resident #53's nursing notes dated 07/15/19 revealed the resident was transferred to the hospital and admitted . The record review revealed there was no documentation of written notice of transfer/discharge to the hospital being provided to the resident or responsible party. Interview on 07/25/19 at 1:55 P.M. with the Administrator verified the facility does not give notice when Resident #53 was transferred/admitted to the hospital. Review of Nursing Home Residents's [NAME] of rights, Ohio Revised code Sections 3721.10-3721.18 revealed at the time of transfer of a resident for hospitalization, except in an emergency, the home was to notify a resident and the resident's sponsor in writing or by certified mail, return receipt requested, in advance of any proposed transfer or discharge from the home. The notice was to include the reason for the transfer, right to appeal, and the address of the legals services of the Department of Health and Ombudsman. Based on medical record review, review of facility policy, resident, family and staff interview and policy review, the facility failed to ensure residents and responsible parties were provided a written notice of transfer upon discharge from the facility to a hospital. This affected two (#37 and #53) of two residents reviewed for hospitalizations. The facility identified six residents discharged from the facility to acute care facilities. The facility census was 95. Findings include: 1. Review of the medical record for Resident #37 revealed the resident was admitted to the facility on [DATE]. Diagnoses include hemiplegia affecting left side, muscle weakness, cerebral infarction, lymphedema, hypertension, diabetes mellitus type II, hypothyroidism, osteoarthritis and epidermal cyst. Review of a quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficits and required extensive assistance with activities of daily living. Review of progress notes dated 03/27/19 at 4:45 A.M. revealed the resident had developed multiple bouts of dark brown emesis and was transported to the hospital. Progress notes dated 03/29/19 revealed the resident returned to the facility at 11:50 A.M. The record review revealed there was no evidence of the resident and/or representative being notified of he transfer in writing. Interview with Resident #37 on 07/22/19 at 1:16 P.M. revealed she was not provided any information regarding her transfer to the hospital when she left. Interview with the family member for Resident #37 on 07/22/19 at 2:00 P.M. revealed she was not provided information regarding a notice of transfer when the resident was transferred to the hospital Interview with the Administrator on 07/25/19 at 1:55 P.M. verified the facility did not provide the notice of transfer to residents or the responsible parties upon discharge/transfer from the facility. The Administrator verified there was no facility specific policy for a notice of transfer.

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #53's medical record revealed an admission date of 04/28/19 and a discharge date of 07/15/19. Resident #53 was re-admitted to the facility on [DATE]. Diagnoses included sepsis, acute cystitis, hypertension, obstructive and reflux uropathy, osteoporosis, malignant neoplasm of kidney, anxiety disorder, depressive disorder, psychosis, and acute kidney failure. Review of Resident #53's nursing notes dated 07/15/19 revealed the resident was transferred and admitted to the hospital. Further review of the medical record revealed there was no documentation of the bed hold notice being provided to the resident or representative when the resident was transfer/discharge to the hospital. Interview on 07/25/19 at 1:55 P.M. with the Administrator verified the facility did not provide Resident #53 or the representative a bed hold notice when the residents are transferred to the hospital. Review of Nursing Home Residents's [NAME] of rights, Ohio Revised code Sections 3721.10-3721.18 revealed a bed-hold notice was to be provided upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specified the duration of the bed-hold policy. Review of an undated facility policy Bed Holds and Therapeutic leaves revealed the facility was to provide written information to the resident and his/her family member or legal representative about the bed hold policy when a resident was transferred to the hospital or went on a therapeutic leave. Based on medical record review, resident, family and staff interview and policy review, the facility failed to ensure residents and responsible parties were provided a bed hold policy upon discharge from the facility to a hospital. This affected two (#37 and #53) of two residents reviewed for hospitalizations. The facility identified six residents discharged from the facility to acute care facilities. The facility census was 95. Findings include: 1. Review of the medical record for Resident #37 revealed the resident was admitted to the facility on [DATE]. Diagnoses include hemiplegia affecting left side, muscle weakness, cerebral infarction, lymphedema, hypertension, diabetes mellitus type II, hypothyroidism, osteoarthritis and epidermal cyst. Review of a quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficits and required extensive assistance with activities of daily living. Review of progress notes dated 03/27/19 at 4:45 A.M. revealed the resident had developed multiple bouts of dark brown emesis and was transported to the hospital. Progress notes dated 03/29/19 revealed the resident returned to the facility at 11:50 A.M. Review of a bed hold reservation dated 01/28/19 revealed the resident had marked she accepted the bed hold reservation upon her admission to the facility. No further bed hold notices were found. Interview with Resident #37 on 07/22/19 at 1:16 P.M. revealed she was not provided any information regarding her bed holds when she left. Interview with the family member for Resident #37 on 07/22/19 at 2:00 P.M. revealed she was not provided information regarding a a bed-hold notice when the resident was transferred to the hospital. Interview with Admissions Director #404 on 07/25/19 at 1:40 P.M. revealed residents and responsible parties were only provided the bed hold reservation policy upon admission to the facility. She verified there was no bed-hold notice provided on any transfers or discharges from the hospital, regardless of financial class.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff, resident and family interview and policy review, the facility failed to provide oral care to a resident. This affected one resident (#37) of three residents reviewed for activities of daily living. The facility identified 24 residents who required assistance with oral care. The facility census was 95. Findings include: Review of the medical record for Resident #37 revealed the resident was admitted to the facility on [DATE]. Diagnoses include hemiplegia affecting left side, muscle weakness, cerebral infarction, lymphedema, hypertension, diabetes mellitus type II, hypothyroidism, osteoarthritis and epidermal cyst. Review of a quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficits and required extensive assistance with activities of daily living. The resident did not refuse care. Review of the resident's plan of care revealed the resident required assistance with personal hygiene. Review of State Tested Nursing Assistant (STNA) charting dated 07/11/19 through 07/24/19 revealed personal hygiene was provided each day. Interview with STNA # 110 on 07/25/19 at 1:50 P.M. and STNA #111 on 07/25/19 at 1:00 P.M. verified they had not performed or assisted with oral care for Resident #37. The STNA's stated the resident did not ask and they did not offer. STNA #111 further stated she just got busy and forgot about it, knowing the resident wanted her teeth brushed after breakfast. STNA #110 and #111 both stated oral care was to be offered to each resident every day. Interview with Resident #37 on 07/22/19 at 11:00 A.M. revealed she hardly ever received mouth care from an STNA. Resident #37 stated if she wanted her teeth brushed, her family would have to do it. Interview with the family member of Resident #37 on 07/22/19 at 2:00 P.M. revealed she was only aware of staff assisting with her mother's teeth once or twice since she had been at the facility and if she wanted it done, she had to help her mother. Review of facility policy Activities of Daily Living (ADL) supporting, dated 03/2018 revealed residents were to be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living, this included oral care.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident and staff interview and review of a facility policy, the facility failed to obtain a physician's order for a resident's skin treatment. This affected one (#15) of five residents reviewed for skin conditions. The facility census was 95. Findings include: Medical record review revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included neoplasm of unspecified bone, soft tissue and skin, malignant neoplasm of the prostate and hypertension. Review of the quarterly Minimum Data Set assessment, dated 04/13/19, revealed the resident was cognitively intact. The resident did not have any wounds. Review of a Skin Observation Tool, dated 07/08/19, revealed the resident had a tumor on the front of his left lower leg that measures approximately one centimeter long by one centimeter wide. The wound was not open. The resident had his own bandage on the tumor site. The nurse removed the dressing, cleaned the site and covered it with a foam bandage. Review of Resident #15's physician orders revealed no treatment order for the resident's tumor on the front of his left lower leg. Observation on 07/22/19, at 9:04 A.M., revealed a foam type dressing on the front of Resident #15's left lower leg. The dressing was dated 07/08/19. Interview with the resident at the same time revealed he had a tumor on the front of his leg that a nurse put a dressing on. The resident was not sure of the last time the dressing was changed. Interview on 07/22/19 at 9:34 A.M., Licensed Practical Nurse (LPN) #208 confirmed the resident had a dressing on the front of his left lower leg dated 07/08/19. LPN #208 was unable to find an order for the dressing or when it was supposed to be changed. Review of an undated facility policy titled, Treatment of Wounds/Skin Tears, revealed the Physician or Certified Nurse Practitioner would be contacted for treatment orders. Residents would be monitored for potential infection and be treated accordingly.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure non-pharmacological interventions were attempted prior to administering as needed psychotropic medications. Additionally, the failed to ensure as needed psychotropic medications were limited to 14 days. This affected two residents (#52 and #87) of six residents reviewed for unnecessary medications. The facility census was 95. Findings include: 1. Medical record review revealed Resident #52 admitted to the facility on [DATE]. Diagnoses included Diabetes mellitus, heart failure and anxiety. Review of the quarterly Minimum Data Set assessment, dated 06/14/19, revealed the resident had impaired cognition. Review of the the resident's physician orders revealed the resident had an active order dated 12/10/18 for Alprazolam 0.5 milligrams (anti-anxiety medication) to be administered as needed (PRN) up to three times a day. The record review revealed no documentation was found regarding if the Physician re-evaluated the resident for the use of this medication within 14 days of the order. Review of Resident #52's Medication Administration Record (MAR) revealed the resident was administered Alprazolam 0.5 milligrams on 06/09/19, 06/17/19, 06/23/19, 07/03/19, 07/04/19, 07/07/19, 07/08/19, 07/15/19, 07/17/19, and 07/18/19. No evidence staff attempted any non-pharmacological interventions was found in the medical record. Interview on 07/24/19 at 5:04 PM, Corporate Clinical Nurse (CCN) #650 confirmed the resident received Alprazolam 0.5 milligrams on the above dates. CCN #650 further confirmed there was no documented evidence staff attempted any non-pharmacological interventions prior to administering the anti-anxiety medication. CCN #650 further confirmed there was no evidence the resident's Physician re-evaluated the resident for the use of the medication with in 14 days of the order. 2. Review of the medical record for Resident #87 revealed the resident was admitted to the facility on [DATE]. Diagnoses include acute kidney failure, muscle weakness, dysphagia, chronic obstructive pulmonary disease, altered mental status, altered mental status, diabetes type II, acute respiratory failure, chronic kidney disease stage 3, dementia, constipation, urine retention, hypertension, psychosis and depression. Review of a quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident had severe cognitive deficits, no behaviors or rejection of care. The resident required extensive assistance with all activities of daily living and received antipsychotic medication daily during the assessment period, on a routine basis only. Review of a physician order dated 07/01/19 revealed Risperdal (anti-psychotic medication) 0.5 milligrams was ordered every 24 hours by mouth PRN for agitation. There was no stop date. Review of the Medication Administration Record dated 07/2019 and nursing progress notes dated 07/18/19 revealed the resident did receive the PRN Risperdal on 07/18/19. Interview with CCN #650 on 07/2519 at 1:45 P.M. verified the resident's PRN Risperdal was not re-evaluated by the physician or prescriber at the 14 day cut-off period. Review of facility policy Psychotropic Medications ordered on an As Needed PRN Basis dated 09/21/17 revealed PRN orders for anti-psychotic drugs were limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. PRN orders for anti-psychotic drugs written with no stop date indicated would be automatically discontinued in 14 days. The 14 day discontinuation dated was to be indicated on the prescription label and the pharmacy was to send a notification form to the facility indicating the automatic discontinuation. Facility staff was to contact the prescriber to arrange for appropriate follow up after the discontinuation. The required evaluation of a resident before writing a new PRN for an antipsychotic entailed the attending physician or prescribing practitioner directly examine the resident and assess the resident's current condition condition and progress to determine if the PRN antipsychotic medication was still needed. the physician was to document if the antipsychotic medication as still needed on a PRN basis, the benefit to the resident and if there had been any improvements. The updated PRN order was still subject to the 14 day order.

CONCERN (E)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation and resident and staff interview, the facility failed to ensure residents were served meals in a dignified manner. This affected 16 (#9, #70, #5, #90, #86, #29, #85, #4, #3, #46, #64, #32, #16, #42, #2 and #25) of 16 residents who received meals in the main dining room. The facility census was 95. Findings include: Observation of the lunch meal on 07/22/19 between 12:15 P.M. and 12:45 P.M. revealed 16 (#9, #70, #5, #90, #86, #29, #85, #4, #3, #46, #64, #32, #16, #42, #2 and #25) residents were seated at 12 tables. On 07/22/19 at 12:30 P.M. the first resident meal was served in the dining room, Resident #42 was served first. There was one other resident (#16) at his table at that time who was not offered their lunch tray. Staff were then observed to serve Resident #32 who was seated at another table. Staff were then observed to skip the second resident at that table (Resident #64) and went to Resident #46 who was at another table with three additional residents (#3, #85, #4). These three residents were skipped and staff served Resident #70 at another table. Two additional residents (#9, #5) were not served their lunch at that time and staff went to serve Resident #90 who was at his own table. Staff then began to randomly serve the residents who were seated at the tables watching the other residents at their table eating. The last tray was served in the dining room at 12:50 P.M. Interview with Residents #16 and #64 on 07/22/19 between 12:32 P.M. and 12:50 P.M. revealed they would prefer to get their meals at the same time as the other residents at their table. Interview with the Dietary Manager #410 on 07/22/19 at 12:40 P.M. revealed these 16 (#9, #70, #5, #90, #86, #29, #85, #4, #3, #46, #64, #32, #16, #42, #2 and #25) residents were the ones who normally attended the dining room but any resident in the facility was provided the choice to eat in the dining room. Dietary Manager #410 verified all residents at the same table were to be served together and this was not done. She stated residents were permitted to sit anywhere they wanted and staff was to check with residents were at each table and let the cook know so trays could be served together. Dietary Manager #410 further verified on 07/25/19 at 2:40 P.M. there was no facility policy on serving residents at the same tables together but staff were aware they were supposed to.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, resident and staff interview and review of a facility policy, the facility failed to ensure medications were dated when they were opened. This affected four resident's (#7, #40, #64, #390) of 30 resident's whom resided on the B hall. Additionally, the facility failed to ensure staff observed residents during medication administration to ensure the resident took/consumed their medication. This affected two residents' (#15 and #190) of six residents reviewed for medications. The facility census was 95. Findings include: 1. Medical record review revealed Resident #7 admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD) and heart failure. Review of the resident's physician orders revealed the resident had an active order, dated 06/04/19, for Advair Diskus (bronchodilator used to treat asthma and chronic bronchitis, including COPD associated with chronic bronchitis) one puff by inhalation twice a day for COPD. Observation on 07/24/19 at 8:15 A.M., of the B hall medication cart with Licensed Practical Nurse (LPN) #210, revealed two Advair Diskus for Resident #7. One was open and one was not. There was no date when the Advair Diskus was opened was observed. Interview on 07/24/19 at 8:18 A.M., Licensed Practical Nurse (LPN) #210 revealed all Advair Diskus were supposed to be dated when opened so staff would know when the medication expired and needed to be discarded. LPN #210 confirmed the resident's open Advair Diskus was not dated. 2. Medical record review revealed Resident #40 admitted to the facility on [DATE]. Diagnoses included asthma, chronic obstructive pulmonary disease (COPD) and sleep apnea. Review of the resident's physician orders revealed the resident had an active order, dated 02/22/19, for Advair Diskus (bronchodilator used to treat asthma and COPD associated with chronic bronchitis) one puff by inhalation twice a day for COPD. Observation on 07/24/19 at 8:15 A.M., of the B hall medication cart with LPN #210, revealed two Advair Diskus for Resident #40. One was open and one was not. There was no date when the Advair Diskus was opened was observed. Interview on 07/24/19 at 8:18 A.M., LPN #210 revealed all Advair Diskus were supposed to be dated when opened so staff would know when the medication expired and needed to be discarded. LPN #210 confirmed the resident's open Advair Diskus was not dated. 3. Medical record review revealed Resident #64 admitted to the facility on [DATE]. Diagnoses included Diabetes mellitus type two. Review of the resident's physician orders revealed the resident had an active order, dated 07/18/19, for Levemir insulin, 100 units per milliliter, give 110 units subcutaneous every morning and 55 units subcutaneous in the afternoon for Diabetes mellitus. Observation on 07/24/19 at 8:15 A.M., of the B hall medication cart with LPN #210, revealed one open vial of Levemir insulin for Resident #64. There was no date when the Levemir insulin vial was opened. Interview on 07/24/19 at 8:18 A.M., LPN #210 revealed all vials of insulin were supposed to be dated when opened so staff would know when the medication expired and needed to be discarded. LPN #210 confirmed the resident's open vial of Levemir insulin was not dated. 4. Medical record review revealed Resident #390 admitted to the facility on [DATE]. Diagnoses included Diabetes mellitus type two. Review of the resident's physician orders revealed the resident had an active order, dated 07/12/19, for Lantus insulin, 100 units per milliliter, give 20 units subcutaneous twice a day for Diabetes mellitus. Observation on 07/24/19 at 8:15 A.M., of the B hall medication cart with LPN #210, revealed one open vial of Lantus insulin for Resident #64. There was no date when the Lantus insulin vial was opened. Interview on 07/24/19 at 8:18 A.M., LPN #210 revealed all vials of insulin were supposed to be dated when opened so staff would know when the medication expired and needed to be discarded. LPN #210 confirmed the resident's open vile of Lantus insulin was not dated. 5. Medical record review revealed Resident #15 admitted to the facility on [DATE]. Diagnoses included neoplasm of unspecified bone, soft tissue and skin, malignant neoplasm of the prostate and hypertension. Review of the quarterly Minimum Data Set assessment, dated 04/13/19, revealed the resident was cognitively intact. The resident did not have any wounds. Observation on 07/22/19, at 9:04 A.M., revealed there was a medicine cup with seven pills in it sitting on the resident's bed-side table. Interview with the resident at the same time revealed the nurse often left the medication in the resident's room for him to take when he was ready. Interview on 07/22/19 at 9:34 A.M., Licensed Practical Nurse (LPN) #208 confirmed she left the resident's medication on his bed-side table so the resident could take the medication when he was ready. 6. Review of Resident #190's medical record revealed an admission date of 07/12/19. Diagnoses included heart disease, diabetes, chronic kidney disease, chronic obstructive pulmonary disease, anxiety disorder, dementia, and age-related cognitive decline. Review of Resident #190's Minimum Data Set (MDS) assessment revealed the resident was a new admission and had not had a cognitive assessment completed at the time of the review. Review of Resident #190's care plan revealed the resident was receiving hospice services. Review of Resident #190's admission assessment dated [DATE] revealed the resident was alert, and oriented to person, place, time and situation. Further review of Resident #190's Medication Administration Record (MAR) dated July 2019 revealed the following medications were documented as being administered between the hours of 7:00 A.M. and 10:00 A.M., Atenolol 50 milligrams (mg) orally, Claritin 10 mg orally, Colace 100 mg orally, Lasix 20 mg orally, Omeprazole 20 mg orally, potassium chloride 10 milliequivalent (mEq) orally, and Percocet 5/325 mg orally. Observation on 07/22/19 at 9:25 A.M. of Resident #190 revealed the resident alone in her room with a cup of water in one hand and a medicine cup with medications in it in the other hand. Interview on 07/22/19 at 9:30 A.M. with Licensed Practical Nurse (LPN) #210 verified Resident #190 did not consume her medications at the time of administration. Review of a facility policy titled, Medication Storage in the Facility, revision date 06/08/18, revealed medications and biologicals were to be stored safely, securely and properly. Review of a facility policy titled, Medication Administration, most recent revision date 03/20/18, revealed medications were supposed to be administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Residents' were to be observed during the administration to ensure the medications were completely ingested.

CONCERN (F)

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

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on review of employee personnel files, staff interview and facility policy, the facility failed to ensure state tested nursing assistants (STNA) had performance evaluations completed every 12 months. This affected five STNA's (#112, #122, #139, #150 and #151) of 10 nurse aide employee files reviewed. This had the potential to affect all 95 residents residing in the facility. The facility census was 95. Findings include: 1. Review of STNA #150's personnel file revealed a date of hire of 04/11/18. STNA #150's annual evaluation had not been completed in April 2019. 2. Review of STNA #151's personnel file revealed a date of hire of 04/05/18. STNA #151's annual evaluation had not been completed in April 2019. 3. Review of STNA #139's personnel file revealed a date of hire of 04/03/78. STNA #139's annual evaluation had not been completed in April 2019. 4. Review of STNA #122's personnel file revealed a date of hire of 05/31/17. STNA #122's annual evaluation had not been completed in May 2019. 5. Review of STNA #112's personnel file revealed a date of hire of 02/25/15. STNA #112's annual evaluation had not been completed in February 2019. Interview on 07/23/19 at 2:30 P.M. with Human Resources (HR) #405 verified the above evaluations had not been completed. The facility confirmed this had the potential to affect all 95 residents residing in the facility. Review of facility policy titled Performance Evaluation dated 07/01/16 revealed department managers will conduct performance evaluations at the completion of the introductory period and again on an annual basis.

CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

2. Review of the facilities Infection Control Data Log revealed the type of infectious organism was not identified, the treatments used were not identified, and the location of the infections were not consistently tracked. The form identified six facility acquired urinary tract infections for May 2019, five facility acquired urinary track infections for June 2019, and seven facility acquired urinary tract infections in the month of July 2019. None of the 18 facility acquired urinary tract infections indicated the type of organism or the treatment used. The month of June 2019 and July 2019 from 07/16/19 to 07/25/19 did not identify the location of the infection. Interview on 07/25/19 at 8:10 A.M. with Registered Nurse (RN) #300 revealed she had only been in the roll of Infection Control Nurse for a couple months and the Infection Control Data Log provided was the only tracking system in use at the facility for monitoring and tracking of infections. Interview on 07/25/19 at 8:49 A.M. with RN #300 verified the current infection tracking system did not include location, type of antibiotic used, and had no organism type indicated. The facility confirmed this had the potential to affect all 95 residents residing in the facility. Review of the facility policy titled, Infection Control Program, revealed the facility would develop prevention surveillance and control measures to protect residents and personnel from acquired infections. The facility was to analyze clusters of infections and note any increase in the rate of infection. Based on observation, staff interview, review of the facility infection control data log and facility policy, the facility failed to ensure urinary and colostomy collection devices were properly stored. This affected five (#31, #190, #44, #88, #53) of six residents who had urinary/colostomy collection devices in their rooms and not covered. This had the potential to affect all 95 residents who reside in the facility. In addition, the facility failed to ensure a proper infection control monitoring system was in place. The facility census was 95. Findings include: 1. Observation on 07/24/19 between 10:45 A.M. and 11:00 A.M. of Residents (#31, #44, #53, #88, #190) bathrooms revealed urinary catheter collection devices were on the back of the toilets uncovered with no barrier on the bottom of the collection devices. In addition, Resident #31 also had a colostomy collection device sitting on the back of the toilet uncovered with no barrier in place. Interview on 07/24/19 at 11:00 A.M. with Registered Nurse (RN) #300 verified Residents #31, #44, #53, #88 and #190's collection devices were not properly stored. RN #300 stated the collection devices should be stored in a bag when not in use.

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

"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

• 68 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• Grade F (35/100). Below average facility with significant concerns.

Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.

Email me this report

About This Facility

What is Franciscan Care Ctr Sylvania's CMS Rating?

CMS assigns FRANCISCAN CARE CTR SYLVANIA 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 Franciscan Care Ctr Sylvania Staffed?

CMS rates FRANCISCAN CARE CTR SYLVANIA's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes.

What Have Inspectors Found at Franciscan Care Ctr Sylvania?

State health inspectors documented 68 deficiencies at FRANCISCAN CARE CTR SYLVANIA during 2019 to 2025. These included: 1 that caused actual resident harm, 65 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Franciscan Care Ctr Sylvania?

FRANCISCAN CARE CTR SYLVANIA 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 COMMONSPIRIT HEALTH, a chain that manages multiple nursing homes. With 96 certified beds and approximately 69 residents (about 72% occupancy), it is a smaller facility located in TOLEDO, Ohio.

How Does Franciscan Care Ctr Sylvania Compare to Other Ohio Nursing Homes?

Compared to the 100 nursing homes in Ohio, FRANCISCAN CARE CTR SYLVANIA's overall rating (1 stars) is below the state average of 3.2 and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Franciscan Care Ctr Sylvania?

Based on this facility's data, families visiting should ask: "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?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.

Is Franciscan Care Ctr Sylvania Safe?

Based on CMS inspection data, FRANCISCAN CARE CTR SYLVANIA has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Ohio. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Franciscan Care Ctr Sylvania Stick Around?

FRANCISCAN CARE CTR SYLVANIA has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.

Was Franciscan Care Ctr Sylvania Ever Fined?

FRANCISCAN CARE CTR SYLVANIA 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 Franciscan Care Ctr Sylvania on Any Federal Watch List?

FRANCISCAN CARE CTR SYLVANIA is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 96
Avg. Residents: 69
Occupancy: 72.5%
Ownership: For profit - Corporation
Chain: COMMONSPIRIT HEALTH
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
1 Actual Harm citation: -5
68 Deficiencies: -10
Final Score: 35/100

Nearby Alternatives

OHIO LIVING SWAN CREEK 5-star ELIZABETH SCOTT COMMUNITY 5-star KINGSTON CARE CENTER OF SYLVAN... 5-star

View all in TOLEDO →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 365907