Taylor Springs Health Campus

Inspectors wroteBased on medical record review, interviews, policy review, review of the hospital record, and review of information from the Ohio Board of Nursing, the facility failed to ensure pressure ulcer weekly assessments, including staging, were completed per the professional standards of practice. This affected one (Resident #41) out of three residents reviewed for pressure ulcer care. The facility census was 55. Findings Included:Review of the medical record for Resident #41 revealed an admission date of 12/14/21. [...]

Inspectors wrote2. Medical record review revealed Resident #27 was admitted on [DATE] with diagnoses including anxiety disorder, depression, psychotic disorder with delusions, contractures and cerebellar stroke. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment dated 02/03/23 revealed the resident was referred to OT due to a decline in the upper extremity range of motion (ROM) and need for contracture prevention. The resident's bilateral upper extremity ROM was impaired with functional limitations present due to contracture and declining in independence with hygiene ADL's. OT to address contracture impairment and further assess and order/fabricate an orthotic device. The focus of plan of treatment was restoration, compensation and adaptation. Review of the OT Discharge summary dated [DATE] revealed the resident was discharged to the hospital. [...]

Inspectors wrote4. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified dementia, schizo-affective disorder, obsessive-compulsive disorder, generalized anxiety disorder, major depressive disorder, and obstructive sleep apnea. Review of Resident #1's physician's orders revealed she had an order to receive Melatonin 2 milligrams (mg) by mouth every night at bedtime related to insomnia. The order had been in place since 01/31/22. Review of Resident #1's active care plans revealed the resident did not have a care plan in place to address insomnia or the use of Melatonin as a sleep aid.

Inspectors wroteBased on observation, medical record review and interview, the facility failed to ensure resident rooms and equipment were clean and sanitary. This affected one resident (#27) of 19 residents sampled. The census was 44.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one resident's (#12) Minimum Data Set (MDS) assessments was coded accurately in the area of oxygen. This affected one resident (#12) of 16 sampled residents. The facility census was 44. Findings Include: 1. Review of the medical record for Resident #12 revealed an initial admission date of 12/18/24 with the last readmission of 02/07/25 with the diagnoses including but not limited to metabolic encephalopathy, pneumonitis due to inhalation of food and vomit, cerebrovascular accident with right sided hemiplegia, epilepsy, diabetes mellitus, dysphagia, anemia, age related physical debility, obesity, hypoxemia, sepsis, severe protein calorie malnutrition, hypertension, hyperlipidemia, altered mental status and acute respiratory failure with hypoxia. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an admission PASRR screen was completed accurately to reflect all known mental illness diagnoses. This affected one (Resident #26) of one residents reviewed for PASRR. The facility census was 44.

Inspectors wroteBased on observation, medical record review and interview, the facility failed to ensure comprehensive care plans were revised and accurately reflected the residents' status. This affected two residents (#27 and #34) of 19 sampled reviewed for care plans. The census was 44.

Inspectors wrote3. Medical record review revealed Resident #27 was admitted on [DATE] with diagnoses including anxiety disorder, depression, psychotic disorder with delusions, contractures and cerebellar stroke. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #27 was cognitively intact for daily-decision making, was dependent on staff for functional abilities including showering/bathing and had functional limitations of upper and lower extremities. Review of the care plan: ADL revised 03/13/25 revealed the resident required staff assistance completing all ADL tasks completely and safely. Review of the electronic Point of Care History dated January 2025 revealed Resident #27 received one bath, on 01/28/25, during the month of January 2025. [...]

Inspectors wrote2. Record review revealed Resident #42 was admitted to the facility on [DATE]. Pertinent diagnoses included: other toxic encephalopathy, unspecified atrial fibrillation, dehydration, strange and inexplicable behavior, generalized anxiety, repeated falls. Review of Resident #42's Minimum Data Set (MDS) assessment, dated 04/03/25, revealed a brief interview for mental status (BIMS) score of 5 out of 15 which signified severe cognitive impairment. Record review of care plan for Resident #42 dated 03/31/25 revealed resident was at risk for limited activity engagement due to physical impairments and that interests included sports, pets and inspirations. Record review revealed progress note dated 04/11/25 noting resident #42 had increased restlessness and anxiety. Physician order on 04/15/25 requested staff document number of times resident yelled out. [...]

Inspectors wrote3. Record review revealed Resident #42 was admitted to the facility on [DATE]. Pertinent diagnoses included: other toxic encephalopathy, unspecified atrial fibrillation, dehydration, strange and inexplicable behavior, generalized anxiety, repeated falls. Review of wound care consult for Resident #42 dated 03/22/25 (prior to resident's admission to facility) which had pressure reducing recommendations for frequent turning and minimizing elevation of head of bed. Review of care plan for Resident #42 revealed a 03/28/25 goal of skin integrity and suggestion that resident be turned and repositioned for comfort. Review of physician orders revealed order dated 03/31/25 for pressure reducing cushion for wheelchair with frequency of three times a day. [...]

Inspectors wroteBased on observation, medical record review, and interviews, the facility failed to obtain a physician order and monitor a non-invasive ventilation device (Bi-pap) for Resident #37. This affected one resident (#37) of four residents reviewed for respiratory care. The facility census was 44. Findings Include: Review of the medical record for Resident #37 revealed an initial admission date of 02/08/25 with the diagnoses including but not limited to metabolic encephalopathy, acute respiratory failure with hypoxia, cerebral infarct, atherosclerotic heart disease, obesity, obstructive and reflux uropathy, retention of urine, diabetes mellitus, obstructive sleep apnea, hypertension, low back pain, benign prostatic hyperplasia, pulmonary embolism, contusion of spleen and encounter for surgical aftercare. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure one resident's (#29) antihypertensive medication (medication used to lower the blood pressure) per the physician ordered parameters. This affected one resident (#29) of five residents reviewed for unnecessary medications. The facility census was 44. Findings Include: Review of the medical record for Resident #29 revealed an initial admission date of 03/22/22 with the diagnoses including but not limited to dysphagia, aphasia, dysarthria, atrial septal defect, asthma, atrial fibrillation, hypertensive urgency, hypertensive heart disease with heart failure, obesity, heart failure and hyperlipidemia. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. [...]

Inspectors wroteBased on observation, medical record review, interviews, and facility policy review, the facility failed to ensure one resident (#29) received emergent and/or routine dental care. This affected one resident (#29) of two residents reviewed for dental services. The facility census was 44. Findings Include: Review of the medical record for Resident #29 revealed an initial admission date of 03/22/22 with the diagnoses including but not limited to dysphagia, aphasia, dysarthria, atrial septal defect, asthma, atrial fibrillation, hypertensive urgency, hypertensive heart disease with heart failure, obesity, heart failure and hyperlipidemia. Review of the plan of care dated 03/23/22 revealed the resident had potential for oral/dental health problems related to two broken teeth and resident reports difficulty chewing. [...]

Inspectors wroteBased on medical record review, infection control log review, policy review and interview, the facility failed to administer antibiotics as ordered. This affected one resident (#27) of five residents sampled for unnecessary medications. The census was 44.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure a resident who was dependent on staff for eating received timely meal assistance. This affected one resident (#44) of 10 residents who required assistance at meals. The facility census was 48.

Inspectors wroteBased on interview, record review, facility self-reported incident (SRI) review, and facility policy review the facility failed to timely report an allegation of abuse by Resident #3 to the executive director and state agency in a timely manner. This affected one resident (#3) of three residents reviewed for abuse. The facility census was 45.

Inspectors wroteBased on closed medical record review, emergency room record review, facility policy review and interview, the facility failed to develop and implement an individualized, effective and comprehensive pain management program for Resident #10 who experienced pain following a fall. Actual harm occurred on 02/25/24 at 7:30 A.M. when Resident #10 sustained a fall with swelling and complaints of pain (rated an eight on a scale of one to 10) to her left wrist. The resident was provided one dose of pain medication (at 8:16 A.M) which was noted to be ineffective following the incident but was not provided any other pain medication, pain management or transferred to the emergency room until 02/25/24 at approximately 2:00 P.M. (over six hours later). The resident was assessed to have a closed fracture of distal ends of left radius and ulna (wrist). [...]

Inspectors wroteBased on closed record review, staff interview, and emergency room discharge instructions, the facility failed to provide care for a broken left wrist for one (Resident #10) of three residents reviewed for accidents. The facility census was 45.

Inspectors wroteBased on closed medical record review and staff interviews, the facility failed to administer medication as ordered by the physician for one ( Resident #10) out of three residents reviewed for medication. The facility census was 45.

Inspectors wroteBased on closed medical record review and interviews, the facility failed to maintain an accurate medical record for a controlled drug for one ( Resident #10) out of three residents reviewed for medication. The facility census was 45.

Inspectors wroteBased on review of call lights response reports, review of concern logs, interviews, and observation the facility failed to ensure sufficient staffing to provide care and services to residents. This affected three residents (#11, #20, and #52) of four residents interviewed with the potential to affect all 50 residents.

Inspectors wroteBased on medical record review, review of shower schedule, review of shower sheets, review of concern log, review of resident council minutes, interviews, and policy review the facility failed to ensure dependent residents received showers per preference. This affected two residents (#20, #52) of three reviewed for showers.

Inspectors wroteBased on observations, staff interviews, and facility policy review the facility failed to properly store and date opened food items and failed to have dietary staff secure loose hair in a hair restraint during food preparation. This had the potential to affect all 50 residents in the facility. The facility census was 50.

Inspectors wroteBased on observations, resident and staff interview, medical record review, and facility policy review, the facility failed to provide adequate accommodations for a resident to elevate his legs when he was out of bed as ordered. This affected one resident (#42) of two reviewed for environment. The facility census was 50.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to provide a written notice of transfer to a resident upon being transferred to the hospital. This affected one (#44) of one resident reviewed for hospitalization. The facility census was 50. Findings Include: Review of the closed medical record for former Resident #44 revealed an admission date on [DATE]. The resident expired on [DATE]. Medical diagnoses included unspecified dementia, congestive heart failure (CHF), pleural effusion, morbid obesity, schizophrenia, depression, muscle weakness, dysphagia, and encephalopathy (a brain disease). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44's cognition was not assessed. However, per staff assessment, Resident #44 had moderately impaired cognition. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to provide a written bed hold notice to a resident upon being transferred to the hospital. This affected one (#44) of one resident reviewed for hospitalization. The facility census was 50. Findings Include: Review of the closed medical record for former Resident #44 revealed an admission date on [DATE]. The resident expired on [DATE]. Medical diagnoses included unspecified dementia, congestive heart failure (CHF), pleural effusion, morbid obesity, schizophrenia, depression, muscle weakness, dysphagia, and encephalopathy (a brain disease). Review of Resident #44's payer source revealed the resident had Medicaid. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44's cognition was not assessed. [...]

Inspectors wroteBased on staff interview, document review, and policy review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) for Resident #1 when she had a new diagnosis of schizophrenia and Resident #8 when they did not have a correct mental health diagnosis. This affected two residents (#1 and #8) of two residents reviewed for PASARR. The facility census was 50.

Inspectors wroteBased on staff interview, document review, and policy review the facility failed to notify the state mental health authority for Resident #1 when she had a new diagnosis of schizophrenia and Resident #8 when had a new mental health diagnoses of vascular dementia, major depressive disorder, and psychotic disorder with delusions. This affected two residents (#1 and #8) of two residents reviewed for mental health screening. The facility census was 50.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person centered dental care plan. This affected one resident (#6) of two residents reviewed for dental care. The facility census was 50.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to appropriately assess and monitor pressures ulcers. This affected one resident (#152) of four residents reviewed for pressure ulcers. The census was 50. Findings Include: Record review revealed Resident #152 was admitted to the facility on [DATE]. Her diagnoses were encounter for surgical aftercare following surgery of the skin and subcutaneous tissue, fibromyalgia, cervical disc degeneration, rheumatoid arthritis, urinary tract infection, morbid obesity, lymphedema, pressure ulcer of sacral region, depression, anxiety disorder, type II diabetes, hypothyroidism, overactive bladder, hyperlipidemia, bacteremia, rectal abscess, age related physical debility, weakness, and sepsis. Review of her Minimum Data Set (MDS) assessment, dated 02/16/23, revealed she was cognitively intact. [...]

Inspectors wroteBased on resident and staff interview, observation, and record review the facility failed to store drugs in locked compartments when staff left an inhaler and nasal spray in a resident's room. This affected one resident (#1) of five residents reviewed for medications. The facility census was 50. Findings Include: Record review of Resident #1 revealed an admission date of 01/28/22 with pertinent diagnoses of: schizoaffective disorder depressive type 9/27/22, chronic obstructive pulmonary disease, asthma, hypertensive heart disease with heart failure, heart failure, obsessive-compulsive disorder, unspecified dementia, generalized anxiety disorder, hypertension, other sleep disorders, and functional urinary incontinence. [...]

Inspectors wroteBased on observation, interview, policy review, and record review the facility failed to provide emergency dental care. This affected one resident (#6) of two residents reviewed for dental services. The facility census was 50.

Inspectors wroteBased on medical record review, staff interview, review of the hospice binder, and review of the hospice contract, the facility failed to ensure continuity of care for a resident receiving hospice services when hospice progress notes were not readily available to facility staff caring for a resident. This affected one resident (#35) of one resident reviewed for hospice services. The facility census was 50. Findings Include: Review of the medical record for Resident #35 revealed an admission date on 02/01/22. Medical diagnoses included encephalopathy (a brain disease), unspecified dementia, unspecified psychosis, developmental disorder of scholastic skills, and other forms of scute ischemic heart disease. Review of the physician orders dated March 2023 revealed Resident #35 had the following order dated 02/11/23: [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to adequately follow antibiotic stewardship procedures prior to the ordering and administering of antibiotics. This affected one resident (#33) of two residents reviewed for antibiotic use. The census was 50. Findings Include: Record review revealed Resident #33 was admitted to the facility on [DATE]. Her diagnoses were encephalopathy, sepsis, enterocolitis due to CDiff, acute respiratory failure, shock, pneumonia, dementia, acute posthemorrhagic anemia, hyperlipidemia, hyperosmolality and hypernatremia, acute kidney failure, major depressive disorder, insomnia, melena, hematemesis, hypertension, altered mental status, and elevated white blood cell count. Review of Minimum Data Set (MDS) assessment, dated 02/12/23, revealed she had a significant cognitive impairment. [...]