Franciscan Care Ctr Sylvania

Inspectors wroteBased on observation, staff interview, medical record review, and review of facility policies, the facility failed to maintain the kitchen in a clean and sanitary manner, failed to ensure temperatures for food storage were properly monitored to prevent spoilage, failed to ensure the dishwasher temperature was adequately monitored to prevent food-borne illness, and failed to ensure residents were provided with sanitary eating utensils. This had the potential to affect all 65 residents who received food from the facility kitchen. The facility identified one resident (#11) as receiving nothing by mouth. The facility census was 66.

Inspectors wroteBased on observation, review of the facility's Legionella policy and maintenance records, staff interview, and policy review, the facility failed to ensure measures to prevent Legionella growth were implemented per the facility plan, and failed to ensure infection control measures were properly implemented for obtaining resident blood glucose levels and administering injectable medications. This had the potential to affect all 66 residents residing in the facility. The census was 66.

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, and review of facility policies, the facility failed to provide residents with a clean, comfortable, and homelike environment. This directly affected three (#11, #12, and #22) of three residents reviewed for environment with the potential to affect all 12 (#2, #3, #4, #11, #25, #31, #37, #39, #42, #47, #56, and #63) residents who resided on the C-Unit. The facility census was 66.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and policy review, the facility failed to ensure dependent residents received adequate grooming and mobility assistance. This affected four (#3, #20, #23, and #37) of four residents reviewed for activities of daily living. The facility census was 66.

Inspectors wroteBased on medical record review, review of pharmacy documents, staff interview, and review of a facility policy, the facility failed to ensure pharmaceutical recommendations were reviewed and addressed in a timely manner. This affected four (#4, #6, #10, and #30) of five residents reviewed for pharmacist recommendations. The facility census was 66.

Inspectors wroteBased on observation, staff interview, and review of facility policies, the facility failed to ensure medications were stored in a safe and secured manner. This affected two (#6 and #57) of two residents observed for medication storage with the potential to affect 22 (#3, #4, #5, #8, #10, #11, #14, #17, #20, #24, #30, #34, #36, #40, #45, #47, #54, #56, #58, #60, #62, and #63) additional residents whose medications required refrigeration. The facility census was 66.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure residents received education and were offered pneumococcal vaccines timely to maintain vaccination status. This affected five (#14, #18, #22, #27, and #57) of seven residents reviewed for vaccinations. The facility census was 66.

Inspectors wroteBased on medical record review, review of a fall investigation, staff interview, and policy review, the facility failed to make proper notifications after a fall. This affected one (#27) of three residents reviewed for falls. The facility census was 66.

Inspectors wroteBased on medical record review, resident interviews, and staff interviews, the facility failed to ensure Minimum Data Set assessments were completed accurately. This affected three (#22, #23, and #27) of 19 residents reviewed for MDS assessment accuracy. The facility census was 66.

Inspectors wroteBased on medical record review, staff interview, and review of a facility policy, the facility failed to ensure care plans were implemented to include person-centered needs and interventions of residents. This affected three (#23, #30, and #33) of 19 residents reviewed for care plans. The facility census was 66.

Inspectors wroteBased on medical record review, resident interview, resident representative interview, staff interview, and review of a facility policy, the facility failed to ensure care conferences were completed quarterly and residents were included in their care planning process. This affected one (#18) of one residents reviewed for care planning conferences. The facility census was 66.

Inspectors wroteBased on observation, staff interview, medical record review, and policy review, the facility failed to ensure weekly skin assessments were completed as ordered to assess for new wounds. This affected one (#53) of two residents reviewed for skin assessments. The facility census was 66.

Inspectors wroteBased on resident and staff interview, medical record review, and policy review, the facility failed to ensure residents received adequate ear care to facilitate hearing. This affected one (#30) of one residents reviewed for hearing services. The facility census was 66.

Inspectors wroteBased on medical record review, staff interview, and resident interview, the facility failed to ensure pressure ulcer treatments were completed per physician order. This affected one (#31) of one residents reviewed for treatment of pressure ulcers. The facility census was 66.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure residents were assessed for fall risk and were properly assessed following a fall. This affected one (#27) of three residents reviewed for falls. The facility census was 66.

Inspectors wroteBased on observation, medical record review, staff interview, and review of a facility policy, the facility failed to ensure oxygen tubing and humidification was changed timely. This affected three (#22, #33, and #51) of three residents reviewed for respiratory care. The facility census was 66.

Inspectors wroteBased on medical record review, staff interview, and review of a facility policy, the facility failed to ensure residents had accurate orders for and received pertinent medications to provide effective pain management. This affected two (#18 and #27) of three residents reviewed for pain. The facility census was 66.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the accurate medication orders were in the medical record. This affected one (#57) of one residents reviewed for accuracy of medication orders. The facility census was 66.

Inspectors wroteBased on observation and staff interview, the facility failed to post daily nurse staffing data as required. This had the potential to affect all 66 residents residing in the facility. The facility census was 66.

Inspectors wroteBased on resident interview, staff interview, review of facility call light logs, review of facility staffing tool, and review of facility policy, the facility failed to ensure sufficient staffing to meet resident needs. This had the potential to affect all facility residents. The facility also failed to timely respond to resident call lights. This affected 42 residents who's call lights alarmed for greater than 30 minutes on 02/15/26 through 02/18/26. The facility census was 71. Findings Include:Review of facility call light logs from 02/15/2026 through 02/18/2026 revealed that 42 residents had call lights that remained activated and unanswered for 30 minutes or longer prior to staff response. Review of the Facility Staffing Tool for 02/12/26 through 02/18/26 revealed facility staffing fell below the Minimum Staffing Requirement on 02/13/25, 02/14/26, and 02/15/26. [...]

Inspectors wroteBased on review of the Facility Assessment, staff interview, and review of facility policy, the facility failed to be administered in a manner that enabled it to use its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, by failing to ensure there was adequate staff per their facility assessment. This affected all facility residents. The facility census was 71. Findings Include:Review of the Facility Assessment, dated 11/15/25, revealed the facility would staff Certified Nursing Assistants (CNAs) at a ratio of one CNA to every 15 to 18 residents. Review of the facility census report for 02/15/26 revealed the facility had a census of 69 residents. Review of overnight staffing records for 02/15/26 revealed that two CNAs were assigned to the facility. [...]

Inspectors wroteBased on observation, staff interview, physician interview, medical record review, review of resident skin assessments, and review of facility policy, the facility failed to ensure timely physician notification of a change in condition for a resident. This affected one(#7) of three residents reviewed for change in condition. The facility census was 71.

Inspectors wroteBased on observation, resident interview, staff interview, medical record review, and review of facility policy, the facility failed to ensure that residents who were dependent on staff for Activities of Daily Living (ADLs) received grooming and feeding assistance. This affected two (#7 and #55) of three residents reviewed for ADL care. The facility census was 71.

Inspectors wroteBased on observation, staff interview, medical record review, and facility policy review, the facility failed to ensure pressure ulcers treatments were implemented per physician order and further failed to ensure pressure ulcer prevention interventions were implemented. This affected two (#27 and #7) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, staff interview, review of the mechanical lift manufactures user manual, medical record review, and review of facility policy, the facility failed to ensure mechanical lifts were maintained in a safe working condition. This affected one (#24) of one resident reviewed for mechanical lifts. The facility identified 22 residents who utilized mechanical lifts for transfers. The facility census was 71.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to obtain Resident #48's weight in January 2026, resulting in an unrecognized, significant unplanned weight loss. This had the potential to affect two residents who the facility identified as having unplanned weight loss. The facility census was 71.

Inspectors wroteBased on observation, medical record review, staff interview, and review of the facility policy, the facility failed to ensure treatments were completed by a licensed nurse. This affected one (#20) of four residents reviewed for administration of treatments. The facility census was 71.

Inspectors wroteBased on observation and facility staff interview the facility failed to ensure residents received meals to meet the resident's nutrition needs. This affected one (Resident #55) of three reviewed for feeding assistance The facility census was 71.

Inspectors wroteBased on staff interviews, review of facility investigation, review of a police report, review of the facilities Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to report an allegation of neglect by a nurse to the State Survey Agency, Ohio Department of Health. This had the potential to affect 13 residents (#3, #5, #16, #18, #25, #32, #34, #47, #56, #60, #65, #66, and #67) in which the nurse was responsible for the night of the allegation of neglect. The facility census was 64.

Inspectors wroteBased on staff interviews, review of the police report, review of facility policy, and review of the facility's investigation, the facility failed to complete and thorough investigation of possible resident neglect by a nurse. This had the potential to affect 13 residents (#3, #5, #16, #18, #25, #32, #34, #47, #56, #60, #65, #66, and #67) which the nurse was responsible for the night of the allegation of neglect. The facility census was 64.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure adequate and timely wound assessments were completed, physician notifications were made promptly, and treatments were completed as ordered for newly discovered pressure ulcers. This resulted in actual harm when a resident (#514) was discovered to have an open wound to the skin on [DATE] with no notification to the physician made or adequate assessment of the area completed. The resident continued with no treatment orders or notification of the wound to the physician until [DATE] when the wound was assessed to be larger in size, and on [DATE], was determined to be a stage IV pressure ulcer. Subsequently, following implementation of wound treatment orders, the facility failed to complete Resident #514's wound treatments timely which inhibited the resident's wound healing progression. [...]

Inspectors wroteBased on medical record review, resident and staff interview, and facility policy review, the facility failed to ensure dependent residents received timely bathing. This affected two (#515 and #569) of three residents reviewed for showers. The facility census was 70.

Inspectors wroteBased on medical record review, staff interview, and review of the National Library of Medicine webpage, the facility failed to ensure resident bowel movements were monitored to provide interventions to prevent constipation. This affected two (#523 and #552) of two residents reviewed for constipation. The facility census was 70.

Inspectors wroteBased on medical record review, staff interview, and review of a facility protocol, the facility failed to ensure staff received a physician's order prior to removing an indwelling urinary catheter. This affected one (#572) of six residents reviewed with urinary catheters. The facility census was 70.

Inspectors wroteBased on observation, staff interview, medical record review, hospital record review, and review of facility policy, the facility failed to ensure hazardous chemicals were properly stored in a secured area and outside the reach of residents. This resulted in Immediate Jeopardy and serious physical harm, injuries, and/or negative health outcomes on 09/02/25 when Resident #77 applied a mixture of cleaning chemicals to the top of both feet resulting in second degree chemical burns, followed by a repeat incident 30 days later on 10/01/25 when Resident #77 applied an assortment of chemicals to his peri-area and a verbal order was obtained on 10/02/25 to send Resident #77 out to the hospital for evaluation due to altered mental status. On 10/02/25 at 1:18 P.M., Resident #77 was admitted to the Intensive Care Unit (ICU) at 8:03 P.M. [...]

Inspectors wroteBased on review of facility documents, staff interviews, and review of facility policy the facility failed to ensure resident concerns and grievances were addressed timely. This had the potential to affect all residents. The facility census was 70. Review of the grievance logs and reports for April 2025 through September 2025 revealed 30 of 75 grievances filed had not been followed up on. Review of the Resident Council meeting minutes for June 2025 revealed resident concerns related to untimely medication administration and undercooked food. The concerns were not addressed or followed up on. Review of the Resident Council meeting minutes for July 2025 revealed resident concerns related to staffing, staff approach, and showers were not addressed or followed up on. [...]

Inspectors wroteBased on review of medical records, staff interviews, resident interviews, and review of facility documents, the facility failed to ensure sufficient staffing to provide timely and adequate care to residents. The affected three (#37, #86, and #97) of three residents reviewed for activities of daily living with the potential to affect all residents. The facility census was 70. Review of the medical record for Specified Resident #37 revealed an admission date of 10/02/24, diagnoses included obstructive hypertrophic cardiomyopathy, left bundle branch block, cervical disc degeneration, solitary pulmonary nodule, depression, anxiety, and borderline personality disorder. [...]

Inspectors wroteBased on observations, resident interviews, staff interviews, and review of facility policy, the facility failed to ensure foul odors were maintained on A, B and C halls. This had the potential to affect all 54 residents on halls A, B, and C. The facility census was 70. Observation on 10/06/25 between 11:45 A.M. and 12:30 P.M. on A, B, and C halls revealed an intermittent foul urine odor throughout each hallway not associated with a resident, resident rooms, or soiled utility room. Observation on 10/07/25 at 11:15 A.M. on A hall revealed an intermittent foul urine odor throughout the hallway and into the adjacent dining room. The odor was not associated with a resident, adjacent resident rooms or soiled utility rooms. Observation on 10/08/25 at 9:10 A.M. [...]

Inspectors wroteBased on medical record review, review of the facility self-reported incidents (SRI), staff interviews, and review of the facility policy the facility failed to complete thorough investigations for five of five SRIs reviewed. This affected six (#39, #46, #54, #85, #105, and #108) residents reviewed for facility self-reported incidents. The facility census was 70. Review of the five facility reported self-reported incidents (SRI)'s: 259637 dated 04/23/25, 259639 dated 04/23/25, 259788 dated 04/28/25, 260722 dated 05/22/25, and 262712 dated 07/12/25 revealed thorough investigations were not completed to include any or all of the following: staff interviews and/or statements, resident statements, assessments of like residents, and/or staff education. 1. [...]

Inspectors wroteBased on observations, medical record reviews, staff interviews, resident interviews, review of the facility investigation file, review of personnel files, and review of facility policies the facility failed to ensure accurate orders and documentation were in resident medical records. This affected three (Residents #37, #86, and #97) of three residents reviewed for accurate and complete documentation, one (Resident #37) of one resident reviewed for medication administration, and one (Resident #106) of one resident reviewed for treatment administration. The facility census was 70.1. Review of the medical record for Specified Resident #37 revealed an admission date of 10/02/24, diagnoses included obstructive hypertrophic cardiomyopathy, left bundle branch block, cervical disc degeneration, solitary pulmonary nodule, depression, anxiety, and borderline personality disorder. [...]

Inspectors wroteBased on observations, staff interview, and review of facility policy, the facility failed to ensure meal trays were served in a clean and sanitary manner. This affected eight (#34, #48, #51, #53, #54, #58, #65, and #81) of eight residents observed during meal tray service. The facility census was 70. Observation on 10/06/25 between 12:25 and 12:45 revealed Certified Nurse Assistant (CNA) #525 delivering meal trays to residents. CNA #525 did not perform hand hygiene before she retrieved a meal tray from the cart in the hallway and delivered it to Resident #81's bedside table. CNA #525 touched the bedside table and set up the meal tray for Resident #81; she opened silverware, removed lids from bowls and plates, and inserted a straw into a cup. CNA #525 did not perform hand hygiene before leaving Resident #81's room. [...]

Inspectors wroteBased on record review, staff interview, review of the facility Self-Reported Incident (SRI), and review of the facility policy the facility failed to timely report an allegation of abuse. This affected one (#105) of one resident reviewed for timely reporting. The facility census was 70. Review of the medical record revealed Resident #105 had an admission date of 08/21/24 with a diagnosis of dementia. Resident #105 was discharged on 06/23/25. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/04/25, revealed Resident #105 was cognitively impaired. Interview on 10/16/25 at 11:10 A.M. with the Administrator stated on 05/19/25 the Former DON #610 met with Resident #105's daughter and the incident of alleged abuse was reported to Former DON #610. [...]

Inspectors wroteBased on record review, staff interview and review of the facility policy, the facility failed to notify the appropriate state agency (The Ohio Department of Mental Health) of a significant change in a resident's mental health condition as required. This affected one Resident (#77) of one resident reviewed for pre admission screening and resident review (PASRR) assessment. The facility census was 70. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, protein-calorie malnutrition, anxiety, sarcopenia, and epilepsy. Review of the significant change minimum data set (MDS) assessment dated [DATE] revealed Resident #77 had intact cognition. [...]

Inspectors wroteBased on observation, medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure wound care orders were accurate and completed as ordered. This affected one (#60) of three residents reviewed for wound care. The facility census was 70. Review of the medical record for Resident #60 revealed an admission date of 07/01/25, diagnoses included disruption of wound healing, infection following procedure, dehiscence of amputated stump, gangrene, acidosis, and peripheral vascular disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was cognitively intact, did not refuse care, and required assistance with activities of daily living. [...]

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident was seen by a provider during the duration of the admission from 05/07/25 through discharge on [DATE]. This affected one resident (#104) reviewed for physician services. The facility census was 70. Review of the medical record for Former Resident #104 revealed an admission date of 05/07/25 and a discharge date of 08/21/25. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] for Resident #104 revealed she was cognitively intact. Review of the medical record for Resident #104 for physician notes revealed there were no physician progress notes for the resident from admission to discharge. [...]

Inspectors wroteBased on record review, staff interview, and review of the facility policy, the facility failed to timely address psychosocial needs and failed to implement individualized interventions in a timely manner to maintain the highest level of mental and psychosocial functioning and well-being. The resident had a history of paranoia, hoarding behaviors, and the resident was identified to have a history of acquiring items from the facility including hazardous chemicals. This affected one (#77) of one resident reviewed for mood/behavior/emotional status. The census was 70. Review of the medical record for Resident #77 revealed an admission date of 08/08/22. Diagnoses included unspecified protein-calorie malnutrition, anxiety, sarcopenia, paranoia, and epilepsy. A diagnosis of schizophrenia with disorganized thoughts was added in April 2025. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.