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Inspectors wroteBased on observations, staff interviews, and review of facility policy review, the facility failed to ensure food was protected from potential contamination and/or spoilage. This had the potential to affect all residents in the facility, as the facility identified all residents received food from the kitchen. The facility census was 119.

Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to ensure proper medication storage and handling practices. Five medication carts were observed out of ten total medication carts and four medication carts were observed of eight total medication rooms in the facility. This had the potential to affect all 121 residents residing in the facility who receive medications from the facility.

Inspectors wroteBased on observations, staff interview, and a review of facility policy, the facility failed to store food in a safe and sanitary manner. This had the potential to affect all 121 residents who received food from the kitchen. The facility census was 121 residents.

Inspectors wroteBased on observation, record review, resident, family and staff interviews, and policy review, the facility failed to provide a bed and mattress at an appropriate length for Resident #5, the facility failed to ensure Resident #64's hospital bed worked appropriately, and failed to ensure the call light was within reach for Resident #55. This affected three (Residents #5, #55, and #64) of 10 residents reviewed for activities of daily living. The facility census was 121.

Inspectors wroteBased on family interview, staff interview, record review, and facility policy review, the facility failed to ensure the resident's bathing preferences were honored. This affected one (Resident #93) of two residents reviewed for choices. The facility census was 121.

Inspectors wroteBased on observation, interview with phlebotomist (specialized healthcare professional trained to draw blood for tests), and policy review, the facility failed to ensure the resident had privacy during a blood draw. This affected one (Resident #123) of 43 residents reviewed for privacy. The facility census was 121.

Inspectors wroteBased on medical record review, staff and resident interviews, observations, and policy review, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADL) received adequate and timely bathing and personal hygiene. This affected three (Residents #2, #12 and #151) of nine residents reviewed for ADLs. The facility census was 121.

Inspectors wroteBased on observations, medical record review, policy review, and resident and staff interviews, the facility failed to ensure a resident's orthotic (external wearable medical device) was in place according to physician orders. This affected one (Resident #55) of one resident reviewed for orthotics. The facility census was 121.

Inspectors wroteBased on observations, record review, policy review, and staff interviews, the facility failed to ensure a resident was seen routinely for podiatry services. This affected one (Resident #97) of one resident reviewed for foot care. The facility census was 121.

Inspectors wroteBased on medical record review, observations, staff interviews, and review of facility policy, the facility failed to ensure fall interventions were in place for a resident who was at risk for falling and had a history of falls. This affected one (Resident #17) of five residents reviewed for falls. The facility census was 121 residents.

Inspectors wroteBased on medical record review, resident, physician and staff interviews, observation, and review of facility policy, the facility failed to accurately assess and provide timely ongoing monitoring of a resident with significant weight loss. This affected one (Resident #39) of 11 residents reviewed for nutrition. The facility census was 121.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure the resident's menu followed the nutritional needs of the resident. This affected one (Resident #45) of 11 residents reviewed for nutrition. The facility census was 121.

Inspectors wroteBased on observations, record reviews, policy review, staff interviews and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure proper hand hygiene and infection control procedures were followed during incontinence care and ensure staff were aware to follow enhanced barrier precautions (EBP) for a resident with an indwelling medical device. This affected two residents (#14 and #18). The facility census was 121.

Inspectors wroteBased on record review, policy review, pharmacy and staff interview, the facility failed to follow an antibiotic stewardship program and ensure antibiotics were not prescribed without adequate clinical indication. This affected two (#6 and #13) of four residents reviewed for antibiotic stewardship practices. The facility census was 121.

Inspectors wroteBased on observation, resident and staff interview, resident representative interview, medical record review, and policy review, the facility failed to provide a dignified experience when alternate communication methods were not utilized to promote and enhance a resident's quality of life. This affected one (#220) of one residents reviewed for dignity. The census was 111.

Inspectors wroteBased on medical record review, hospital documentation review, review of an incident report, review of staff training documentation, staff interview, and policy review, the facility failed to ensure residents were administered antibiotic medications and insulin as ordered and within scheduled time frames which resulted in significant medication errors. This affected two (#299 and #45) of six residents reviewed for medication administration. The census was 111.

Inspectors wroteBased on medical record review, staff interview, family interview, review of Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to ensure allegations of physical abuse were reported to Ohio Department of Health (ODH) in a timely manner. This affected two (Residents #77 and #78) of three residents reviewed for abuse. The facility census was 113 residents.

Inspectors wroteBased on medical record review, resident representative interview, staff interview, hospice staff interview, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to investigate allegations of staff to resident physical abuse. This affected two (Residents #77 and #78) of three residents reviewed for abuse. The facility census was 113 residents. Finding Include: Review of the medical record for Resident #77 revealed an admission date of 11/06/24 with diagnoses including moderate dementia with behavioral disturbance, anxiety disorder, acquired absence of kidney, and atherosclerotic heart disease. Review of the (Minimum Data Set) MDS assessment for Resident #77 dated 02/13/25 revealed the resident had severe cognitive impairment. [...]

Inspectors wroteBased on observation, staff interview, and record review the facility failed to ensure that the medication error rate was less than five percent. The facility medication error rate was 6.89 percent (%) based on 29 medication opportunities and two medication errors. This affected one (Resident #56) of three residents reviewed for medication administration. The facility census was 113 residents.

Inspectors wroteBased on staff interviews and review of daily staffing postings the facility failed to identify a licensed charge nurse in the facility for all tours of duty.

Inspectors wroteBased on review of staffing schedules and staff interview, the facility failed to ensure there was a registered nurse (RN) on duty for at least eight consecutive hours a day, seven days a week as required. This has the potential to affect all 92 residents residing in the facility. The facility census was 92.

Inspectors wroteBased on observation, record review and staff interviews, facility failed to ensure flooring was maintained in good condition affecting all 25 residents residing on the 200 hall (#5, #7, #8, #9, #11, #13, #15, #16, #19, #21, #23, #30, #39, #43, #45, #48, #49, #50, #51, #52, #57, #64, #66, #78, and #82). The facility also failed to ensure a homelike environment for one Resident (#13) of 32 residents reviewed. Facility census was 92.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Beneficiary notices were provided timely to resident and or resident representative. This affected one Resident (#139) of three reviewed for beneficiary notices. Facility census was 92.

Inspectors wroteBased on medical record review, facility investigative document review, staff interview, and facility policy review, the facility failed to report an allegation of abuse to the state agency in a timely manner. This affected one (Resident #138) of two residents reviewed for abuse. The census was 92. Findings Include: Resident #138 was admitted to the facility on [DATE]. Her diagnoses were pain in left leg, morbid obesity, difficulty walking, post traumatic stress disorder, agoraphobia, insomnia, anxiety disorder, depression, chronic pain syndrome, mood disorder, and edema. Review of her minimum data set (MDS) assessment, dated 06/05/24, revealed she was cognitively intact. Review of facility Self Reported incident (SRI) number 248352, dated 06/06/24, found that Resident #138 made an abuse allegation against a staff member on 06/05/24. [...]

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to develop a comprehensive care plan to address a residents nutritional risk and significant weight loss. This affected one (#61) out of 22 residents reviewed for care plans. The facility census was 92.

Inspectors wroteBased on medical record review, review of a podiatry schedules, observations and staff, resident and resident representative interviews, the facility failed to provide a resident with timely podiatry services. This affected one (#67) of three residents reviewed for ancillary services. The facility census was 92.

Inspectors wroteBased on record review, review of video recording, staff and resident representative interviews, review of a user manual and policy review, the facility failed to ensure a resident was provided with an adequate amount of assistance while being transferred with a sit-to-stand lift. This affected one (#14) out of one residents reviewed for assistance with sit-to-stand lifts. The facility census was 92. Findings Include: Review of Resident #14's medical record revealed admission on [DATE] with diagnoses including chronic obstructive pulmonary disease, Parkinson's disease, hemiplegia, unsteadiness on feet, visual disturbances, and heart failure. Review of Resident #14's Minimum Data Set (MDS) 3.0 assessment completed on 04/04/24 indicated the resident required a wheelchair for mobility and maximum assistance for transfers. [...]

Inspectors wroteBased on medical record review, and resident and staff interviews, the facility failed to re-assess, monitor and notify the physician following a resident's significant weight loss. This affected one (#21) of three residents reviewed for nutrition. The census was 92.

Inspectors wroteBased on medical record review, observations, staff, resident and resident representative interviews and policy review, the facility failed to manage a resident's complaints of pain. This affected one (#73) of three residents reviewed for pain management. The facility census was 92.

Inspectors wroteBased on observations, staff interviews, record review and policy review, the facility failed to ensure staff implemented the medication administration policy to administer medications for one resident at a time. This affected five residents (Residents #7, #19, #23, #39 and #51) who were incidentally observed outside of the six residents formally observed for medication administration. The facility census was 92.

Inspectors wroteBased on observation, staff interview, and review of the policy for medication storage, the facility failed to ensure medications were secure from the time they were dispensed until the medications were administered. This affected one (#67) of one residents observed during the annual survey with medications left unattended at the bedside. The facility census was 92.

Inspectors wroteBased on medical record review, review of a hospice communication book/binder and staff interviews, the facility failed to ensure timely communication was occurring between hospice staff and facility staff. This affected one (#35) out of one residents reviewed for hospice care. The facility census was 92.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to implement their antibiotic stewardship program to ensure infections and antibiotics were ordered appropriately. This affected one (#42) of two residents reviewed to proper antibiotic usage. The facility census was 92.

Inspectors wroteBased on record review and staff interview, the facility failed to provide a written notice of transfer to an acute care facility to the family and/or long-term care Ombudsman. This affected two of three residents (Resident #87 and Resident #51) reviewed for discharge. The facility census was 92.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure infection control was maintained when sharps containers were not changed when full to prevent overflowing of objects which were an infection control concern. This affected four residents (#40, #59, #65 and #89) and had the potential to affect all 86 residents residing in the facility.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure a safe environment when sharps containers were not changed when full to prevent overflowing of objects which were a safety control concern. This affected four residents (#40, #59, #65 and #89) and had the potential to affect all 86 residents residing in the facility.

Inspectors wroteBased on medical record review, observation, staff and family interview, review of electronic communication, review of the fall investigations, review of the incident log, review of the education sheet, review of the hospital records, and policy review, the facility failed to ensure fall interventions were in place to prevent falls. This resulted in Actual Harm for Resident #76 when he had a fall, was sent to the hospital and suffered an acute, mildly comminuted, displaced, and angulated intra-articular fracture of the fourth proximal phalanx base (ring finger) as well as an age indeterminate fracture of the fifth metacarpal base (small finger) and a laceration to the head requiring a suture. In addition, the facility failed to ensure fall interventions were implemented, fall investigations were thorough, and the fall root cause analysis was identified. [...]

Inspectors wroteBased on medical record review, observation, staff, resident and family interview, review of the drug control sheet, and policy and procedure review, the facility failed to ensure pain was addressed, treated, and monitored appropriately after reports of pain for Residents #28 and #44, and failed to ensure pain medication was available and administered as ordered for Residents #18 and #25. Actual Harm occurred when Resident #28 experienced pain during incontinence care rated on a numeric pain scale as a nine out of 10 (zero being no pain and 10 being the worst pain), the State Tested Nurse Assistant (STNA) continued to provide the care without addressing or reporting the pain. [...]

Inspectors wroteBased on medical record review, observation, interview, and review of the Centers for Medicare and Medicaid (CMS) Census and Condition form 672, the facility failed to ensure sufficient levels of staff to meet the total care needs of all residents. This had the potential to affect all 84 residents residing in the facility.

Inspectors wroteBased on staff interview and review of the personnel records, the facility failed to ensure State Tested Nurse Assistant's (STNA) received performance evaluations. This had the potential to affect all 84 residents residing in the facility.

Inspectors wroteBased on review of the facility policy, observations, staff interviews, and record review, the facility failed to follow the planned menu on two different occasions. This affected all residents residing on all units, except for Resident #71 who was identified as consuming nothing by mouth. The facility census was 84.

Inspectors wroteBased on observations, record review, resident and staff interviews, and review of the facility's policy, the facility failed to keep the kitchen clean and failed to check expiration dates of food in Resident #62's refrigerator resulting in her eating expired food. This affected one (Resident #62) of three resident refrigerators observed and had the potential to affect all residents except Resident #71 who was identified as receiving no food from the kitchen. The facility census was 84.

Inspectors wroteBased on review of the facility's policy, observations, staff interview, and record review the facility failed to follow a Legionella prevention plan, maintain infection control during wound care for Resident #189, and to ensure laundry was appropriately separated for Resident #17 who had an active COVID-19 infection. This had the potential to affect all 84 residents residing in the facility.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to maintain kitchen equipment in an operating condition. This had the potential to affect all residents but one resident (#71) identified as eating nothing by mouth. The facility census was 84.

Inspectors wroteBased on staff interview and review of the resident fund documentation, the facility failed to obtain authorization to manage funds and maintain witnessed authorizations for residents. This affected four residents (#17, #19, #32, and #37) out of five residents reviewed for funds. The facility census was 84.

Inspectors wroteBased on medical record review, observation, staff, resident, and family interview, review of the hospice documentation, and policy and procedure review, the facility failed to ensure dependent residents received assistance with daily care. This affected one resident (#60) reviewed for oral care, three residents (#25, #76 and #87) reviewed for showers, one resident (#42) reviewed for shaving, and one resident (#28) reviewed for meals out of seven residents reviewed residents reviewed for activities of daily living. The facility census was 84. Findings Include: 1. Review of the medical record for Resident #60 revealed an admission date of 06/17/22 and a readmission date of 07/30/22. [...]

Inspectors wroteBased on medical record review, observation, staff and resident interview, and review of the facility activity calendar, the facility failed to ensure activities were available to residents in isolation for COVID-19 infection, ensure group activities were available to residents, and to ensure assistance to activities was provided for residents who were unable to attend activities independently. This directly affected three residents (#13, #21, and #36) out of 26 residents reviewed for activities during the annual survey with the potential to affect 23 additional residents (#02, #08, #09, #11, #13, #15, #17, #19, #20, #26, #28, #31, #35, #40, #41, #42, #46, #49, #50, #55, #59, #64, and #69) who resided on the B unit. The facility census was 84.

Inspectors wroteBased on medical record review, observation, staff and resident interview, review of the facility investigations, and policy and procedure review, the facility failed to ensure Resident #44's wound was monitored routinely and the dressing was changed as ordered, failed to ensure Resident #62's wound cause was comprehensively investigated and the wound dressing was changed as ordered, failed to ensure Resident #189 had an order for a wound dressing, failed to ensure appropriate positioning for Resident #19, and failed to ensure Resident #28 had geri-sleeves on as ordered. This affected five residents (#19, #28, #44, #62, and #189) out of 22 residents reviewed for quality of care. The facility identified 23 residents with non-pressure skin impairment. The facility census was 84. Findings Include: 1. [...]

Inspectors wroteBased on medical record review, observation, staff, resident, and responsible party interview, and policy review, the facility failed to ensure fluids were available and provided for residents #05 and #40 and the facility failed to provide nutritional interventions, monitor weight and intake, and provide tube feeding as ordered for Resident #05, #31, #60, #62, #71, and #76. This effected two residents (#05 and #40) out of six residents reviewed for hydration and six residents (#05, #31, #60, #62, #71, and #76) out of seven residents reviewed for nutrition. The facility census was 84.

Inspectors wroteBased on review of Medscape prescribing information, staff interviews, and record reviews, the facility failed to ensure the appropriate monitoring of abnormal behaviors, failed to ensure medications were used for the appropriate indication, and failed to ensure medications were held as ordered by the physician when vital signs were outside the ordered parameters. This affected four residents (#5, #28, #49, and #73) of the 26 residents whose records were reviewed during the annual survey. The facility census was 84.

Inspectors wroteBased on review of the facility policy, observations, resident and staff interviews, and review of the mealtimes, the facility failed to serve meals according to the planned times and at regular mealtimes. This affected all but the 24 residents residing on Unit A. The facility census was 84.

Inspectors wroteBased on observations, resident representative interview, and staff interview, the facility failed to ensure the memory care unit furniture was maintained in a safe, sanitary, comfortable, and functional manner and failed to maintain clean refrigerators for Resident #19 and Resident #28. This had the potential to affected the 13 residents residing in the memory care unit and affected two (Resident #19 and Resident #28) of three resident refrigerators observed. The facility census was 84.

Inspectors wroteBased on observation, medical record review, staff interview, review of the Resident [NAME] of Rights, and policy and procedure review, the facility failed to ensure privacy was maintained and residents were treated with dignity and respect during incontinence care. This affected one resident (#60) out of seven residents reviewed for pressure ulcers. The census was 84. Findings Include: Review of the medical record for Resident #60 revealed an admission date of 06/17/22 and a readmission date of 07/30/22. Diagnoses included dysphagia, adult failure to thrive, severe protein calorie malnutrition, chronic kidney disease stage four, anorexia, depression, pneumonia, shortness of breath, falls, malignant bladder cancer, and the need for assistance with personal care. [...]

Inspectors wroteBased on medical record review and staff and family interview, the facility failed to ensure the resident representatives and the physician were notified of falls. This affected two residents (#25 and #76) out of seven residents reviewed for falls. The facility census was 84.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure all relevant mental disorders were listed on the resident Preadmission Screening and Resident Review (PASARR). This affected one resident (#76) out of two residents reviewed for PASARR. The facility census was 84.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident baseline care plans were completed upon admission to the facility. This affected two residents (#28 and #42) out of 26 residents reviewed for care plans. The facility census was 84.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure comprehensive care plans reflected the resident assessments. This affected three residents (#28, #40, and #42) out of 26 residents reviewed for care planning. The facility census was 84.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure timely review and revision of care planned interventions. This affected one resident (#19) out of seven residents reviewed for falls. The facility census was 84.

Inspectors wroteBased on medical record review, observation, staff interview, the facility failed to ensure physician ordered pressure ulcer interventions were implemented. This affected one resident (#28) out of six residents reviewed for pressure ulcers. The facility census was 84.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure timely follow-up of therapy recommendations to prevent the potential worsening of a residents contracture. This affected one resident (#42) out of two residents reviewed for range of motion. The facility census was 84.

Inspectors wroteBased on medical record review, observation, interview, and policy review, the facility failed to ensure residents received timely physician ordered incontinence care and timely treatment was implemented for a resident with a urinary tract infection (UTI). This affected two residents (#16 and #28) out of five residents reviewed for bowel and bladder incontinence and UTI. The facility census was 84.

Inspectors wroteBased on medical record review, staff interview, and policy and procedure review, the facility failed to ensure documentation of appropriate dialysis port monitoring and communication between the facility and dialysis. This affected one resident (#22) out of one resident reviewed for dialysis. The facility identified two residents (#22 and #61) who received dialysis services. The census was 84. Findings Include: Review of the medical record for Resident #22 revealed an admission date of 10/28/22 and the diagnoses of end stage renal disease (ESRD), non compliance with renal dialysis, diabetes type two, morbid obesity, need for assistance with personal care, high blood pressure, and adult failure to thrive. [...]

Inspectors wroteBased on staff interview, review of the Medscape prescribing information, and record review, the facility failed to ensure there was an appropriate diagnosis for the use of the antipsychotic medication Seroquel for Resident #76. This affected one (Resident #76) of five residents reviewed for unnecessary medication. The facility census was 84.

Inspectors wroteBased on medical record review, review of the facility policy, observation, and staff interview, the facility failed to ensure the medication error rate was less than five percent. There were ten medication errors out of 35 opportunities observed, resulting in 28.57% (percent) medication error rate. This affected one (#31) of three residents observed for medication administration. The facility census was 84.

Inspectors wroteBased on record review, review of the facility policy, and staff interviews, the facility failed to ensure an adequate system was in place for the timely review and reporting of laboratory and diagnostic results to the physician. This affected two (Resident #16 and #40) of six residents reviewed for laboratory services. The facility census was 84.

Inspectors wroteBased on staff interview, observations, and review of medical records, the facility failed to ensure the resident's medical records were accurate. This affected two (#25 and #62) of 24 resident records reviewed in the annual survey. The facility census was 84.

Inspectors wroteBased on resident representative interview, staff interviews, observations, review of the facility policy, and record review, the facility failed to ensure Resident #38's room was free from pests and maintained in a manner to prevent pests. This affected one (Resident #38) of four residents reviewed for physical environment. The facility census was 84.