Continuing Healthcare of Gahanna

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure the resident's legal guardian/representative was notified of a significant change in condition and refusal of emergency room/hospital transfer for one resident (#93) of three residents reviewed for change in condition and notification. The facility census was 86.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a resident was free from verbal abuse by staff. This affected one resident (#51) of one reviewed for an allegation of staff-to-resident abuse. The facility census was 86.

Inspectors wroteBased on policy review, observation, resident and staff interviews, and record review ,the facility failed to ensure staff provided adequate supervision to prevent a resident, with altered mental status and was an elopement risk, from leaving the facility unsupervised. This affected one (Resident #33) of two residents reviewed for elopement risk. The facility census was 87.

Inspectors wroteBased on medical record review, review of the self-reported incidents, review of facility witness statements, staff and resident interview, and facility policy review, the facility failed to report an allegation of abuse. This affected one (Resident #26) out of three residents reviewed for abuse. The facility census was 90.

Inspectors wroteBased on medical record review, staff and resident interviews, review of the facility soft file, and facility policy review, the facility failed to thoroughly investigate an allegation of staff to resident abuse. This affected one (Resident #26) out of three residents reviewed for abuse. The facility census was 90.

Inspectors wroteBased on medical record review, staff interview and review of the facility policy and procedure, the facility failed to maintain a resident's dignity in regard to urinary catheters. This affected one resident (#92) of one resident reviewed for catheters. The census was 88.

Inspectors wroteBased on medical record review, observation, staff interview and facility policy review, the facility failed to provide resident privacy during treatment of a pressure wound. This affected one resident (#16 ) of two residents observed for wound care. The census was 88.

Inspectors wroteBased on medical record review, staff interview, review of self reported incident (SRI) and the police report revealed the facility failed to prevent staff to resident verbal abuse. This affected one resident (#89) of ten residents reviewed for abuse. The census was 88.

Inspectors wroteBased on medical record review, observation, staff interview and review of facility policy and procedure, the facility failed to ensure comprehensive weekly assessments of residents with pressure ulcers and failed to ensure pressure relief interventions were in place. This affected two residents (#16, #77) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on record review, observation, staff interview and review of facility policy and procedure, the facility failed to ensure a resident with impaired skin integrity received the necessary care and treatment to promote healing of wounds on her foot. This affected one resident (#7) of three residents reviewed for wounds. The census was 88.

Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to ensure a resident with an urinary catheter received appropriate care and services. This affected one resident (#92) of two residents reviewed for urinary catheters. The census was 88.

Inspectors wroteBased on record review, interviews, review of hospital discharge documents, and policy review, the facility failed to ensure a resident's diabetes was managed when going on Leave of Absences (LOAs). This resulted in Actual Harm on 03/06/26 when Resident #14 went on an undisclosed LOA and went to the Emergency Department (ED) with low blood sugar. This affected one (Resident #14) of one resident reviewed for diabetes management and LOAs. The facility census was 92. [...]

Inspectors wroteBased on employee file reviews and interviews, the facility failed to do annual evaluations for Certified Nursing Assistants (CNAs) and to provide a minimum of 12 hours of in-service for the previous year. This affected three (CNAs #242, #324, and #325) of the three employee files reviewed for CNAs employed for more than one year. This has the potential to affect all residents in the facility. The facility census was 91. Review of employee files for CNAs #242, #324, and #325 revealed no annual evaluations were completed in the last 12 months. There was also no documentation of in-service education. Interview on 04/07/26 at 1:00 P.M. with the Director of Nursing (DON) confirmed there was no record of CNA education (12 hours for the last year) and there was no record of performance evaluations in the past 12 months for the CNAs whose employee files were reviewed.

Inspectors wroteBased on resident medical record review, review of medication regimen reviews, interview, and review of facility policy, the facility failed to complete medication regimen reviews (MRR). This affected four residents (Resident #02, #03, #93, and #99) out of five reviewed for unnecessary medication. The facility census was 91.

Inspectors wroteBased on review of resident medical record, physician orders, medication administration record, interview, and policy review, the facility failed to follow physician orders for blood pressure medication. This affected one resident (Resident #93) of five reviewed for unnecessary medications. The facility census was 91.

Inspectors wroteBased on observation, medical record review, interviews and facility policy review, the facility failed to honor one resident's preference of no male caregivers. This affected one resident (#17) of three residents reviewed for resident rights. The facility census was 83. Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the resident's medical record revealed no plan of care addressing the resident's preference of no male caregivers. Review of the resident's psychiatric note dated 01/28/25 revealed the resident was physically abused by her ex-husband and had trust issues. [...]

Inspectors wroteBased on observation, medical record review, interview and facility policy review, the facility failed to ensure one resident's bed was bariatric in size. This affected one resident (#17) of three residents reviewed for resident rights. The facility census was 83. Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment. On 08/19/25 at 9:00 A.M., observation of Resident #17 revealed the resident was obese and was too large for the standard bed she occupied. [...]

Inspectors wroteBased on medical record review, interview and facility policy review, the facility failed to notify the power of attorney (POA) of a change in condition. This affected one resident (#43) of three residents reviewed for notification. The facility census was 83. Findings Include:Review of the medical record for Resident #43 revealed an initial admission date of 07/21/23 with the latest readmission of 03/21/24 with diagnoses including human immunodeficiency virus (HIV), psoriasis, protein calorie malnutrition, dysphagia, seizures, gastro-esophageal reflux disease, asthma, major depressive disorder and anxiety disorder. Review of the plan of care dated 02/15/24 revealed the resident had a seizure disorder. [...]

Inspectors wroteBased on medical record review, interviews, review of the facility's self-reported incidents (SRI) and facility policy review, the facility failed to report an allegation of abuse to the required state agency. This affected one resident (#17) of three residents reviewed for abuse. The facility census was 83. Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment. On 08/20/25 at 9:00 A.M., an interview with Resident #17 revealed Licensed Practical Nurse (LPN) #116 had abused her. [...]

Inspectors wroteBased on medical record review, interviews, review of the facility's self-reported incidents (SRI) and facility policy review, the facility failed to investigate an allegation of abuse. This affected one resident (#17) of three residents reviewed for abuse. The facility census was 83.

Inspectors wroteBased on observation, medical record review and interviews, the facility failed to identify, assess and implement care and services to prevent triggers of past trauma. This affected one resident (#17) of three residents reviewed for preferences. The facility census was 83. Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the resident's initial social service assessment dated [DATE] revealed the resident had no Trauma Informed Care Triggers. Review of the resident's psychiatric note dated 01/28/25 revealed the resident was physically abused by her ex-husband and had trust issues. [...]

Inspectors wroteBased on medical record review and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This affected one resident (#17) of three residents reviewed for preferences. The facility census was 83. Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the resident's psychiatric note dated 01/28/25 revealed the resident was physically abused by her ex-husband and had trust issues. The resident also reported having medical conditions that had caused trauma her life like a brain aneurysm. [...]

Inspectors wroteBased on observation, medical record review, interview and facility policy review, the facility failed to ensure medications were administered as physician ordered. This affected one resident (#17) of three residents observed for medication administration. The facility census was 83. Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the plan of care dated 10/24/24 revealed the resident had hypertension. [...]

Inspectors wroteBased on observation, medical record review, interview and facility policy review, the facility failed to ensure medications were not left at bedside during medication administration. This affected one resident (#17) of three residents observed for medication administration. The facility census was 83. Findings Include:Review of the medical record for Resident #17 revealed an initial admission date of 10/08/24 with the diagnoses including but not limited to other specific arthropathies right shoulder, hypertension, hyperlipidemia, diabetes mellitus, pain in right shoulder and gastro-esophageal reflux disease. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment. [...]

Inspectors wroteBased on closed medical record review, review of hospital records, staff interviews, and review of the facility policy, the facility failed to ensure Resident #99's continuity of care information from the hospital to the facility was reviewed and implemented. This resulted in Immediate Jeopardy and the potential for serious life-threatening injuries, negative health outcomes and/or death on [DATE] when Resident #99 returned from the hospital with injuries sustained from a fall including two new fractures of the spine, a closed head injury, a hematoma of the left thigh, and anemia which required ongoing evaluation and treatment which was not identified or implemented by facility staff. Consequently, the resident sustained an additional fall on [DATE] and was admitted to the hospital where he was found to have acute blood loss anemia requiring a transfusion with packed red blood cells. [...]

Inspectors wroteBased on medical record review, review of hospital records, review of fall investigations, staff interviews, and review of facility policy for falls, the facility failed to timely assess and develop comprehensive plans of care for residents with a history of falls prior to admission, failed to complete thorough fall investigations and implement timely and appropriate interventions for the residents with falls in the facility resulting in injuries. This resulted in Immediate Jeopardy when Resident #99 had four falls in eight days resulting in the resident being sent to the hospital on two occasions and suffering injuries including a closed head injury on 06/24/25, two fractures of the lumbar spine on 06/24/25, a large hematoma to the left thigh on 06/24/25, and acute blood loss anemia resulting from falls which required a blood transfusion on 06/26/25; [...]

Inspectors wroteBased on record review, staff interview, review of the facilities Self-Reported Incidents (SRI) and review of the facility abuse policy, the facility failed to timely report an allegation of staff-to-resident physical abuse to the State Survey Agency, Ohio Department of Health. This affected one (Resident #88) out of three residents reviewed for abuse. The facility census was 87. Review of the closed medical record for Resident #88 revealed an admission date of 12/31/24 and a discharge date of 06/19/25. Diagnoses included chronic respiratory failure, psychosis, mood disorder, chronic pancreatitis, and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/19/25, revealed Resident #88 had minimal cognitive impairment. Review of the hospital documentation dated 06/19/25 revealed Resident #88 was sent out from the facility regarding a fall with injuries. [...]

Inspectors wroteBased on record review, staff interview, and review of the facilities abuse policy, the facility failed to investigate an allegation of staff-to-resident physical abuse. This affected one (Resident #88) of three residents reviewed for abuse. The facility census was 87. Review of the closed medical record for Resident #88 revealed an admission date of 12/31/24 and a discharge date of 06/19/25. Diagnoses included chronic respiratory failure, psychosis, mood disorder, chronic pancreatitis, and repeated falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 had minimal cognitive impairment. The resident was assessed as having one fall with major injury, and required supervision or touching assistance from staff with toileting, bathing and the used of a wheeled walker for ambulation. [...]

Inspectors wroteBased on record reviews and staff interviews, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's falls in the facility. This affected two (#91 and #99) out of the six residents reviewed for falls. The facility census was 87.1. Closed record review for Resident #99 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included muscle wasting and history of falling. Record review for Resident #99 revealed the resident had a fall on 06/18/25 in which he scraped his elbow, had a fall on 06/22/25 in which he sustained an abrasion to the left side of his nose, and had a fall on 06/24/25 which resulted in two fractures of the lumbar spine, a closed head injury, a hematoma to the left thigh, and a laceration to the right side of his eye. [...]

Inspectors wroteBased on record reviews and staff interviews, the facility failed to ensure new interventions to prevent falls were added to the care plan timely. This affected one (#99) of six residents whose care plans were reviewed for falls. The facility census was 87. Closed record review for Resident #99 revealed the resident was admitted to the facility on [DATE] and had diagnoses which included difficulty walking and history of falling. The resident was discharged from the facility on 06/26/25. Review of the comprehensive care plan, dated 06/06/25, revealed Resident #99 was at risk for falls and injuries as evidenced by history of, may not always recognize own needs or limitations, metabolic encephalopathy, Parkinson’s disease, cognitive deficits, and history of amnesia. The goal was for Resident #99 to be free from falls/injuries over the next 90 days. [...]

Inspectors wrote4. Record review of Resident #11 revealed an admission date with 04/13/22 with pertinent diagnoses of: cerebral palsy, hemiplegia, protein calorie malnutrition, neuromuscular dysfunction of the bladder, hypertension, convulsions, mood disorder, depression, benign paroxysmal vertigo, schizoaffective disorder, anxiety disorder, and calculus of kidney. Review of the 01/19/25 annual Minimum Data Set (MDS) assessment revealed the Resident was cognitively intact and used a walker and wheelchair to aid in mobility. The Resident required supervision or touching assistance for personal hygiene. Review of the medical record revealed Resident #11 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of the medical records revealed on 12/09/24 Resident #11 discharged to the hospital for a nephrostomy tube removal and returned 12/12/24. [...]

Inspectors wrote5. Record review of Resident #74 revealed an admission date of 10/11/24 with pertinent diagnosis of: traumatic brain injury, dysarthria following cerebral infarction, type two diabetes mellitus, seizures, post traumatic stress disorder, history of falling, presence of cerebrospinal fluid drainage device, gastro-esophageal reflux disease, dementia without behaviors, noninfective gastroenteritis, anxiety disorder, and major depressive disorder. Review of the 01/16/25 quarterly Minimum Data Set (MDS) assessment revealed the Resident was severely cognitively impaired and used a wheelchair to aid in mobility. The Resident had a coded diagnosis of post traumatic stress disorder. Review of the 12/17/24 Notice of Level II PASSR outcome revealed Resident #74 is approved for six months in the Nursing facility and is required services to include: [...]

Inspectors wrote4. Record review of Resident #63 revealed an admission date of 06/29/23 with pertinent diagnoses of: hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side, epilepsy, human immunodeficiency virus, unspecified asthma, muscle wasting and atrophy, abnormalities of gait and mobility, anemia, autoimmune hepatitis, low back pain, congestive heart failure, and personal history of sudden cardiac arrest. Review of the 01/03/25 quarterly Minimum Data Set (MDS) assessment revealed the Resident is cognitively intact and uses a wheelchair to aid in mobility. Review of the 01/31/25 smoking assessment revealed that staff will store Resident #63 smoking materials. Observation on 03/03/25 at 1:33 P.M. revealed Resident #63 had a lighter in her room. Interview with the Director of Nursing (DON) on 03/06/25 at 2:33 P.M. [...]

Inspectors wrote4. Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses that included heart failure, chronic respiratory failure, type II diabetes, anxiety disorder, major depressive disorder, bipolar disorder, and mood disorder. The quarterly MDS dated [DATE] revealed Resident #30 was cognitively intact. The MDS also revealed Resident #30 had a mood score of 10 which typically indicated a moderate level of depression. Resident #30 had no delusions during the assessment time period. Review of the pharmacy monthly reviews from June 2024 through February 2025 revealed no documentation if Resident #30 had any recommendations. A recommendation dated 06/12/24 was provided that revealed Resident #30 was ordered Invega Sustenna (antipsychotic) one milliliter intramuscularly every 28 days for bipolar. [...]

Inspectors wroteBased on observation, interview, and review of facility policy the facility failed to ensure foods that did not meet hot holding temperature were reheated. This had the potential to affect 79 of 79 residents who consumed food from the kitchen. The facility identified two residents (#69 and #80) who consumed nothing from the kitchen. The facility census was 81.

Inspectors wroteBased on interview and review of documents the facility failed to ensure the arbitration agreement allowed the resident/responsible party to communicate with federal, state, or local officials . This had the potential to affect 23 residents (#2, #6, #8, #17, #26, #40, #45, #49, #72, #76, #78, #80, #82, #83, #84, #188, #189, #190, #191, #192, #193, #194, #196) who had admitted since 08/01/24. The total facility census was 81.

Inspectors wroteBased on interview and review of documents the facility failed to ensure the arbitration agreement allowed for a convenient venue and neutral arbitrator. This had the potential to affect 23 residents (#2, #6, #8, #17, #26, #40, #45, #49, #72, #76, #78, #80, #82, #83, #84, #188, #189, #190, #191, #192, #193, #194, #196) who had admitted since 08/01/24. The total facility census was 81.

Inspectors wroteBased on observation, interview, and review of resident medical records, the facility failed to ensure Resident #192's dignity was maintained when his catheter bag was uncovered. This affected one Resident #192 of one resident reviewed for catheters. The facility census was 81.

Inspectors wroteBased on record review, staff interview, and facility policy the facility failed to ensure that Resident #84 and #8 had appropriate diagnoses for the psychotropic medications they were prescribed. This affected two (Resident's #84 and #8 ) out of three residents reviewed for psychotropic medications. The facility census was 83.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #85's discharge from the facility was appropriately documented. This affected one Resident #85 of five residents reviewed for hospitalization. The facility census was 81.

Inspectors wroteBased on review of the medical record and interview with the staff the facility failed to ensure a Significant Change assessment was completed for Resident #42 after initiating hospice services. This affected one resident (Resident #42) of 24 residents reviewed for comprehensive assessments. Facility census was 81.

Inspectors wroteBased on interview and medical record review the facility failed to ensure Resident #69 and Resident #192 had accurate Minimum Data Set (MDS) 3.0 assessments. This affected two Residents #69 and #192 of 24 medical records reviewed. The facility census was 81.

Inspectors wroteBased on staff interview and record review the facility failed to incorporate the recommendations of the pre-admission screening and resident review (PASRR) level II determination into the assessment, care planning, and transitions of care. This affected one, Resident #74, of two Residents reviewed for PASRR. The facility census was 81.

Inspectors wroteBased on staff interview and record review the facility failed to ensure resident Pre-admission Screening and Resident Review (PASRR) documents were accurate regarding resident current conditions and diagnoses. This affected one, Resident #11, of two residents reviewed for PASRR documents. The census was 81. Findings Include: Record review of Resident #11 revealed an admission date with 04/13/22 with pertinent diagnoses of: cerebral palsy, hemiplegia, hydronephrosis, protein calorie malnutrition, neuromuscular dysfunction of the bladder, hypertension, convulsions, mood disorder, depression, benign paroxysmal vertigo, schizoaffective disorder, anxiety disorder, and calculus of kidney. Review of the 01/19/25 annual Minimum Data Set (MDS) assessment revealed Resident #11 was cognitively intact and used a walker and wheelchair to aid in mobility. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure an accurate baseline care plan was developed and implemented within 48 hours of admission. This affected one, Resident #88, out of six residents reviewed for baseline care plans. Facility census was 81.

Inspectors wrote2. Review of Resident #68's medical record revealed an admission date of 02/25/24 and diagnoses including cerebral infarction, apraxia, seizures, heart failure, anxiety disorder, hypertension, end stage renal disease with dependence on renal dialysis, coagulation defect, aphasia, muscle wasting and atrophy, altered mental status, and other lack of coordination. Review of Resident #68's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had severely impaired cognition. Review of Resident #68's medical record revealed she had two care conferences on 02/26/24 and 09/10/24. Interview on 03/03/25 at 4:42 P.M. with Resident #68's responsible party revealed care conferences were far in between. Interview on 03/03/25 at 9:13 A.M. and 9:43 A.M. [...]

Inspectors wroteBased on record review, policy review, hospital record review, and interview, the facility failed to develop and implement a comprehensive, resident centered wound management program for Resident #45 who sustained an injury/area of non-pressure related skin impairment to the right lower leg. This affected one (#45) of two reviewed for skin impairments. The total facility census was 81.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure Residents #68 and #69 who had splints or braces had orders for the device and orders for monitoring for their use. This affected two residents (#68 and #69) of three residents reviewed for positioning and mobility. The facility census was 81.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure Resident #192 had orders for an indwelling catheter. This affected one resident (#192) of three residents with an indwelling catheter. The facility census was 81.

Inspectors wroteBased on observation, interview, and medical record review the facility failed to ensure Resident #68's fluid restriction was followed, and her noncompliance was documented in the medical record. This affected one resident (#68) of two residents on dialysis. The facility census was 81.

Inspectors wroteBased on observation, interview, and medical record review the facility failed to ensure Resident #69's tube feeding was running at the ordered rate. This affected one resident (#69) of one resident reviewed for tube feeding. The facility census was 81.

Inspectors wroteBased on record review and interview, the facility failed to administer oxygen to Resident #30 as ordered. This affected one (Resident #30) out of one resident reviewed of oxygen use. Facility census was 81.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the residents PTSD and minimize triggers and/or re-traumatization. This affected one (Resident #74) of three Residents reviewed for behavior emotional. The facility census was 81.

Inspectors wroteBased on staff interview and record review the facility failed to ensure a resident with dementia received appropriate treatment and services to maintain his of highest practical physical, mental, and psychosocial well being when they failed to have a plan of care to address the resident's dementia needs and services. This affected one (Resident #74) of one reviewed for dementia care. The facility census was 81.

Inspectors wroteBased on record review, resident and facility staff interview and policy review the facility failed to ensure failed to ensure Resident #16 and #82 received medications as ordered. This affected two resident (Resident #16 and #82) of five reviewed for un necessary medications. The total facility census was 81. Findings Include: 1. Review of the medical record revealed Resident #16 was admitted on [DATE] and was readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, bipolar disorder, altered mental status, peripheral vascular disease, hypertension, major depressive disorder, history of transient ischemic attack, and anxiety disorder. The annual MDS dated [DATE] revealed Resident #16 was cognitively intact. Resident #16 had impairment to both lower extremities (amputation) and used a wheelchair. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #45 and #66 had parameters in place for as needed pain medication. The facility also failed to document the location of the pain and the non-pharmacological interventions that were attempted. This affected two (Resident #45 and #66) out of five residents reviewed for unnecessary medications. Facility census was 81.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #82 had appropriate diagnoses for the psychotropic medications he was prescribed. This affected one resident (#82) of five residents reviewed for unnecessary medications. The facility census was 81.

Inspectors wroteBased on staff interview and record review the facility failed to ensure resident laboratory tests (lab/labs) were completed as ordered. This affected two (Resident #63 and #82) of six resident reviewed for lab values. The facility census was 81.

Inspectors wroteBased on observation, interview, and review of the menu, the facility failed to ensure Resident #194 and Resident #196 received food according to the planned menu. This affected two residents (#194 and #196) of 79 residents who consumed food from the kitchen. The facility identified two residents (#69 and #80) who consumed nothing from the kitchen. The facility census was 81.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure resident discharge needs were met. This affected two residents (#22 and #33) of four residents reviewed for discharge planning. The facility census was 83.

Inspectors wroteBased on medical record review, hospital record review, staff interview, and facility policy review, this facility failed to ensure appropriate care and monitoring was in place for a resident who was receiving medication for high blood pressure including the administration of blood pressure medication, personalized care plan for management of hypertension, and monitoring residents blood pressure to ensure the effectiveness of medication. This affected one (Resident #85) of the four residents reviewed for medication administration. The facility census was 79.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure physicians orders were followed in regard to laboratory (Lab) test. This affected two (Resident #57 and Resident #73) of four resident records reviewed. The census was 72.

Inspectors wroteBased on observations, policy review, and staff interview, the facility failed to properly store food items in a safe and sanitary manner. This had the potential to affect 76 of 76 residents who eat food from the kitchen. The facility census was 78.

Inspectors wroteBased on observations, record review, policy review, and staff and resident interviews, the facility failed to provide timely assistance with eating for residents who required assistance from staff with activities of daily living. This affected two (Residents #3 and #17) of three residents reviewed for eating assistance. The facility census was 78.

Inspectors wroteBased on nurse aide registry review, time punch detail review and staff interview, the facility failed to ensure one State Tested Nursing Assistant (STNA) nurse aide registry was in good standing. This affected one out of three personnel files reviewed and had the potential to affect all 83 residents residing in the facility. Findings Include: Review of the nurse aide registry for STNA #130 dated 02/07/24 revealed the STNA was not in good standing and was not eligible to work. Further review revealed STNA #130 had not changed her name on the nurse aide registry following a name change. Review of STNA #130's time punch card from 01/21/24 to 02/05/24 revealed the STNA was hired on 02/02/23. Further review revealed STNA #130 worked full time and last worked on 02/05/24 with the registry not in good standing and not eligible to work. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Minimum Data Assessments (MDS) were coded accurately in the area of skin for two residents (#79 and #80). This affected two (Resident #79 and #80) of four sampled residents. The facility census was 83. Findings Include: 1. Review of the medical record for Resident #80 revealed an initial admission date of 01/11/24 with diagnoses including chronic obstructive pulmonary disease (COPD), epilepsy, arteriovenous malformation of cerebral vessels, cerebral infarct, adult failure to thrive, dysphagia, hypertension, abdominal aortic aneurysm, hyperlipidemia, peripheral vascular disease and disorder of thyroid. The resident discharged home on [DATE] with hospice services. [...]

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to develop a comprehensive plan of care for residents in the area of skin and eating. This affected two (Resident #33 and #73) of four sampled residents. The facility census was 83. Findings Include: 1. Review of the medical record for Resident #33 revealed an initial admission date of 09/21/23 with the latest readmission of 12/21/23 with the diagnoses including alcohol abuse, falls, cerebrovascular accident with left sided hemiplegia, generalized muscle weakness, difficulty in walking, gastro-esophageal reflux disease, hypertension, unsteadiness on feet, muscle wasting and atrophy, hyperlipidemia, cognitive communication deficit, dysphagia and benign prostatic hyperplasia (BPH). [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to identify, assess, monitor and implement interventions for Resident #33 who had multiple stasis ulcers. This affected one (Resident #33) of three residents reviewed for wounds. The facility census was 83. Findings Include: Review of the medical record for Resident #33 revealed an initial admission date of 09/21/23 with the latest readmission of 12/21/23 with the diagnoses including alcohol abuse, falls, cerebrovascular accident with left sided hemiplegia, generalized muscle weakness, difficulty in walking, gastro-esophageal reflux disease, hypertension, unsteadiness on feet, muscle wasting and atrophy, hyperlipidemia, cognitive communication deficit, dysphagia and benign prostatic hyperplasia (BPH). [...]

Inspectors wroteBased on observation, record review, interviews and facility policy review, the facility failed to ensure an initial comprehensive wound assessment and subsequent wound assessments were conducted as required for one resident (#79) with a stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister.). This affected one ( Resident #79) of three residents reviewed for wounds. The facility census was 83. Findings Include: [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one resident (#33) received routine podiatry care. This affected one (Resident #33) of three reviewed for podiatry care. The facility census was 83. Findings Include: Review of the medical record for Resident #33 revealed an initial admission date of 09/21/23 with the latest readmission of 12/21/23 with the diagnoses including alcohol abuse, falls, cerebrovascular accident with left sided hemiplegia, generalized muscle weakness, difficulty in walking, gastro-esophageal reflux disease, hypertension, unsteadiness on feet, muscle wasting and atrophy, hyperlipidemia, cognitive communication deficit, dysphagia and benign prostatic hyperplasia (BPH). Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. [...]

Inspectors wroteBased on record review, interviews and facility policy review, the facility failed to ensure one resident (#73) was not provided food inconsistent with the physician ordered diet. This affected one of thee sampled residents reviewed for special diets. The facility census was 83. Findings Include: Review of the medical record for Resident #73 revealed an initial admission date of 07/21/23 with the latest readmission of 09/22/23 with the diagnoses including encephalopathy, human immunodeficiency virus (HIV), decreased white blood cell count, generalized muscle weakness, cognitive communication deficit, dysphagia, asthma and muscle wasting and atrophy. Review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to maintain infection control practices to prevent the potential spread of infection during wound dressing change for one resident (#33). This affected one ( Resident #33) of three residents reviewed for wounds. The facility census was 83. Findings Include: Review of the medical record for Resident #33 revealed an initial admission date of 09/21/23 with the latest readmission of 12/21/23 with the diagnoses including alcohol abuse, falls, cerebrovascular accident with left sided hemiplegia, generalized muscle weakness, difficulty in walking, gastro-esophageal reflux disease, hypertension, unsteadiness on feet, muscle wasting and atrophy, hyperlipidemia, cognitive communication deficit, dysphagia and benign prostatic hyperplasia (BPH). [...]

Inspectors wroteBased on observation, record review, interviews and facility policy review, the facility failed to ensure one resident's (#73) call light was in working order. This affected one ( Resident #73) of three residents reviewed for call lights. The facility census was 83. Findings Include: Review of the medical record for Resident #73 revealed an initial admission date of 07/21/23 with the latest readmission of 09/22/23 with the diagnoses including encephalopathy, human immunodeficiency virus (HIV), decreased white blood cell count, generalized muscle weakness, cognitive communication deficit, dysphagia, asthma and muscle wasting and atrophy. Review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. [...]

Inspectors wroteBased on observation, record review, staff interview and facility policy review, the facility failed to ensure the sit to stand lift was maintained in a sanitary manner for one resident (#33). This affected one ( Resident #33) of one resident who utilized the facility's sit to stand lift on the first floor. The facility census was 83. Findings Include: Review of the medical record for Resident #33 revealed an initial admission date of 09/21/23 with the latest readmission of 12/21/23 with the diagnoses including alcohol abuse, falls, cerebrovascular accident with left sided hemiplegia, generalized muscle weakness, difficulty in walking, gastro-esophageal reflux disease, hypertension, unsteadiness on feet, muscle wasting and atrophy, hyperlipidemia, cognitive communication deficit, dysphagia and benign prostatic hyperplasia (BPH). [...]

Inspectors wroteBased on observation, staff interviews, medical record review, and facility policy review, the facility failed to ensure staff wore personal protective equipment appropriately, doffed PPE appropriately, and cleaned/disinfected high touch surfaces that were potentially contaminated with COVID-19. This had the potential to affect all 84 residents in the facility. The facility also failed to ensure a glucometer was appropriately cleaned/disinfected between use with residents. This affected two (#28 and #46) out of seven residents who received glucose monitoring using the glucometer from the second floor medication cart. The census was 84.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure residents received adequate assistance with transfers to prevent falls. This affected one resident (#6) out of three residents reviewed for falls. The facility census was 84.

Inspectors wroteBased on record review, interview, self-reported incident review (SRI) , and review of facilities Inservice record, the facility failed to prevent the misappropriation of narcotic medication for Resident #50, #60, #70 and #80. This affected four residents (#50, #60, #70, and #80) of four residents reviewed for misappropriation of narcotic medication. The facility census was 84.

Inspectors wroteBased on record reviews, interviews, self-reported incident review (SRI) , and review of facilities Inservice record, the facility failed to maintain an accurate reconciliation of all controlled medications for their first floor Sage and Lavender Hall medication carts which resulted in misappropriation of narcotic medications. This affected four Residents (#50, #60, #70, and #80) out of four residents reviewed for misappropriation. The facility census was 84.

Inspectors wroteBased on record review, interview, and policy review the facility failed to notify a responsible representative of the misappropriation of narcotic medications per facility policy. This affected one resident (Resident #80) out of the four residents reviewed for misappropriation. The facility census was 84.

Inspectors wroteBased on record review, review of Self Reported Incidents (SRI), interview, and policy review, the facility failed to implement their policy related to reporting allegations of abuse, protecting residents after an allegation of abuse was made, and completing a thorough investigation. This affected two residents (#57 and #84). The facility census was 80.

Inspectors wroteBased on Self-reported Incident (SRI) review, medical record review, interview and facility policy review, the facility failed to timely report an allegation of abuse. This affected one resident (#84). The facility census was 80.

Inspectors wroteBased on medical record review, review of Self Reported Incidents (SRI), interview and policy review, the facility failed to thoroughly investigate an allegation of sexual abuse, and failed to prevent further potential abuse when a specified perpetrator was not removed from the facility timely. This affected two residents (#57 and #84). The facility census was 80.

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to ensure a resident who required staff assistance with personal hygiene was provided nail care and showers. This affected one resident (#36) of three residents reviewed for bathing. The census was 80.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policies, the facility failed to ensure skin assessments were completed, failed to monitor and remove sutures timely and as ordered, failed to initiate wound care and failed to arrange transportation for a follow up appointment. This affected seven residents (Residents #13, #52, #233, and #246) of 29 residents reviewed during the annual survey. The facility census was 84. Actual harm occurred to Resident #52 when the facility failed to assess the resident's skin and Resident #52 developed two new vascular wounds to his feet resulting in the resident experiencing pain and additional medical treatment.

Inspectors wroteBased on interview, record review and policy review, the facility failed to provide pressure ulcer wound care as ordered by the physician. This affected one resident (Resident #240) of one resident reviewed for pressure ulcers. The facility census was 84 residents.

Inspectors wrote2. Record review for Resident #59 revealed this resident was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, mild cognitive impairment, muscle weakness, violent behavior, unspecified dementia with behavioral disturbance, and depression. Review of the admission MDS assessment, dated 08/15/22, revealed this resident was assessed to have moderately impaired cognition evidenced by a BIMS assessment score of 04. This resident was assessed to require extensive assistance from one staff member for bed mobility and transfers and to be dependent on one staff member for toileting. Review of the care plan, dated 08/09/22, revealed this resident was at risk for elopement. Interventions included to follow facility elopement procedures. [...]

Inspectors wrote9a . Review of the medical record for Resident #51 revealed an admission date of 08/10/22. Diagnoses included cerebral infarction, non-dominant, left side (L)hemiplegia and hemiparesis following a cerebral infarction (CVA), hypertension (HTN), heart disease, and dysphagia. Review of the comprehensive MDS assessment, dated 08/17/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 (no impairment) and no documented behaviors. The resident required limited to extensive assistance of one to two or more staff for all Activities of daily Living (ADL's). Review of the resident's weights revealed he was weighed per facility policy on admission which measured 168 pounds (lbs.), but no weight was obtained the next day per policy. [...]

Inspectors wrote2. Record review for Resident #11 revealed this resident was admitted to the facility on [DATE] and had diagnoses including fibromyalgia, chronic obstructive pulmonary disease, low back pain, osteoarthritis, pain in right leg, pain in left leg, and depression. Review of the quarterly MDS assessment, dated 06/25/22, revealed this resident had intact cognition evidenced by a BIMS assessment score of 13. This resident was assessed to require supervision from one staff for bed mobility and toileting and to be independent with setup help only for transfers and eating. This resident was assessed to have had pain in the past five days which limited day to day activities. Review of care plan, revised 03/17/20, revealed this resident had the potential for an alteration in comfort. Interventions included to administer medications as ordered to manage pain. [...]

Inspectors wroteBased on staff interview, resident interview, observations, record review, and facility policy review, the facility failed to provide sufficient staff to meet resident needs. This had the potential to affect all 84 residents residing in the facility.

Inspectors wroteBased on staff interview and review of facility policies, the facility failed to ensure the time frames for addressing pharmacy recommendations contained time frames for completion. This had the potential to affect all 84 residents residing in the facility who received medications from the facility. The facility census was 84.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed in a timely manner as required. This affected six residents (Resident #2, Resident #3, Resident #18, Resident #232, Resident #233, and Resident #243) of six residents reviewed for resident assessment. The facility census was 84 residents.

Inspectors wroteBased on staff interview, resident interview, observations, medical record review, facility policy review, the facility failed to ensure care plans were comprehensive. This affected six Residents (Residents #14, #51, #55, #66, #68, and #233) of 29 residents reviewed for care plans. The facility census was 84.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policies, the facility failed to ensure showers and nail care were completed for residents who were dependent upon staff for assistance. This affected six residents (Residents #13, #28, #52, #59, #68, and #235) out of the nine residents who were reviewed for Activities of Daily Living (ADL's) during the annual survey. The facility census was 84.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure activities were provided on weekends for cognitively impaired residents. This affected four residents (Residents #28, #36, #52, and #68) out of the four residents reviewed for activities during the annual survey. The facility census was 84.

Inspectors wroteBased on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to ensure Resident #30 had a way to orient to time and date and failed to ensure Resident #237 was permitted to leave the facility as he wished. This affected two (#30 and #237) of five residents reviewed for dignity. The facility census was 84.

Inspectors wroteBased on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to ensure Resident #66's call light was within reach. This affected one (Resident #66) of three residents reviewed for call light access. The facility census was 84.

Inspectors wroteBased on observations, medical record review, resident interview, and staff interview, the facility failed to ensure residents had the right to make choices about aspects of their life that are significant and to choose bathing schedules. This affected two of 25 sampled residents (#14 and #29). The facility census was 88.

Inspectors wroteBased on staff interview, observations, medical record review, and facility policy review, the facility failed to allow Resident #247 visitors. This affected one of five residents reviewed for dignity (Resident #247). The facility census was 84.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to ensure the physician was notified when a resident was out of ordered enteral feeding solution. This affected one resident (Resident #52) reviewed for tube feeding during the annual survey. The facility census was 84.

Inspectors wroteBased on record review and interview, the facility failed to notify the Long-Term Care Ombudsman (LTCO) of resident transfers/discharges as required. This affected one resident (Resident #18) of three residents reviewed for admission, discharge and transfer rights. The facility census was 84 residents.

Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure all of Resident #240's medications were available upon his discharge home. This affected one resident (Resident #240) of three residents reviewed for admission, discharge and transfer rights. The facility census was 84 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete comprehensive assessments within 14 calendar days after admission. This affected two of three residents (#9 and #73) reviewed for assessment completion. The facility census was 88.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure quarterly assessments were completed timely. This affected one of three residents (#67) reviewed for assessments. The facility census was 88.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #17's Pre-admission Screening and Resident Review (PASARR) was completed accurately. This affected one resident (#17) of two residents reviewed for PASARR's.

Inspectors wroteBased on staff interview, resident interview, observations, and medical record review, the facility failed to ensure Resident #66 was provided the appliances needed for hearing adequately. This affected one (Resident #66) of one resident reviewed for communication sensory. The facility census was 84.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Resident #17 and Resident #49 with foot care and refer them to podiatry. This affected two residents (Residents #17 and #49) of nine residents reviewed for activities of daily living. The facility census was 84.

Inspectors wroteBased on interview, record review and policy review, the facility failed to provide appropriate catheter care and monitoring. This affected one resident (Resident #240) of two residents reviewed for catheter care. The facility census was 84 residents.

Inspectors wroteBased on staff interview, resident interview, observations, medical record review, facility policy review, the facility failed to ensure enteral feeding was provided as ordered for Residents #52, #232, and #243. This affected three residents (Residents #52, #232, and #243) of four residents who had a feeding tube. The facility census was 84.

Inspectors wroteBased on interview and record review the facility failed to complete pre-dialysis and post-dialysis assessments for Resident #14 and Resident #30. This affected two residents (#14 and #30) of two residents reviewed for dialysis. The facility census was 84.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policies, the facility failed to ensure appropriate spacing between bed rails and mattresses was maintained and failed to ensure assessments for the use of bed rails were completed. This affected two residents (Residents #13 and #64) out of the two residents reviewed for use of bed rails during the annual survey. The facility census was 84.

Inspectors wroteBased on observation, record review, policy review, and staff interviews, the facility failed to ensure pharmacy recommendations were accurately reviewed by the physician, failed to ensure physician approved pharmacy recommendations were implemented, and failed to ensure medications were necessary. This affected three residents (#32, #51, and #59) out of the five residents reviewed for unnecessary medications during the annual survey. The facility census was 84.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #55's 'as needed' psychotropic medication did not exceed 14 days and was used with appropriate monitoring. This affected one resident (#55) of five residents reviewed for unnecessary medication. The facility census was 84.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident was free from significant medication errors when medications ordered for treatment of cerebral infarction, anemia, kidney disease, hypertension were not given as ordered on days the resident went out for dialysis. This affected one of three residents (#14) reviewed for dialysis. The facility census was 88.

Inspectors wroteBased on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to keep medications in locked containers and the facility failed to ensure prescription creams and ointments were not expired. This affected two residents (Resident #235 and #243). The facility census was 84.

Inspectors wroteBased on staff interview, resident interview, medical record review, and facility policy review, the facility failed to failed to ensure resident medical records contained complete and accurate information. This affected four of 29 residents reviewed (Residents #14, #32, #237, and #246). The facility census was 84.

Inspectors wroteBased on observations, staff and resident interviews, and record reviews, the facility failed to ensure resident call lights were in good working order. This affected one resident (#68) out of the four residents reviewed for call lights during the annual survey. The facility census was 84.