The Merriman

Inspectors wroteBased on observation, interviews, record review, and policy review, the facility failed to ensure residents received timely incontinence care. This resulted in Actual Harm on 07/13/26 when Resident #6 was incontinent of urine and bowel and required staff dependence for toileting and hygiene services, went approximately 12 hours without receiving incontinence care and developed two wounds on her buttocks. This affected one resident (Resident #6) of three reviewed for incontinence. The facility census was 48. Findings Include:Review of the medical record for Resident #6 revealed an admission date 02/21/26. Diagnoses included malignant neoplasm of the unspecified part of right bronchus or lung, hypertensive heart disease with heart failure, and chronic pain and was receiving hospice services. Resident #6 was her own responsible party. [...]

Inspectors wroteBased on record review, observation, interview, manufacturer guidelines, and facility policy review, the facility failed to ensure medications were securely stored and Tuberculin solution was dated when opened for use. This deficient practice had the potential to affect all residents residing in the facility. The facility census was 48. Findings Include:1) Review of Resident #8's medical record revealed admission date 10/14/25 and hospitalization date 07/09/26 with diagnoses including but not limited to Alzheimer's Disease, type two diabetes, heart failure, high blood pressure, depression and anxiety. Review of Resident #8's Self-Administration of Medication assessment dated [DATE] revealed Resident #8 required assistance with medication administration and was not approved to be self-administering medications. Observation on 07/14/26 at 7:54 A.M. [...]

Inspectors wroteBased on observation, staff interviews, and policy review, the facility did not ensure the kitchen and equipment were clean and sanitary. This had the potential to affect all residents. Facility census was 48.

Inspectors wroteBased on observation and interview, the facility failed to maintain access to the exit door and failed to maintain access to the fire extinguisher and the fire pull station in the back hallway. This had the potential to affect all residents residing in the facility. The facility census was 48. Findings Include:Observation on 07/15/26 at 7:36 A.M. revealed in the back hallway, where rooms 17 to 22 were located, there were two beds stored end to end on the left side of the hallway up against the wall. A manual wheelchair was located at the end of the second bed directly in front of the exit door, the fire pull station and the fire extinguisher box. There was approximately two-foot distance from the end of the second bed to the exit door and the fire pull station and fire extinguisher box was to accessible. Interview on 07/15/26 at 7:45 A.M. [...]

Inspectors wroteBased on record review, review of census documentation, interview, observations, and policy review, the facility failed to ensure Resident #32's room was clean and homelike. Additionally, the facility failed to ensure reasonable care for the protection of the resident's property when Resident #11's dentures were lost during a room change. This affected two residents (#11 and #32) out of two residents reviewed for resident rights. Facility census was 48. Findings Include: 1. Record review revealed Resident #32 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, diabetes mellitus due to underlying condition with diabetic neuropathy, hyperlipidemia, and other seizures. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure ice water was offered routinely and at the frequency of resident requests for Resident #6, #12, and #30. This affected three residents (#6, #12, and #30) out of three residents reviewed for hydration. The facility also failed to ensure Resident #64 had routine meal intakes documented. This affected one resident (#64) out of four residents reviewed for dietary services. The facility census was 48. Findings Include: 1. Record review revealed Resident #64 was admitted on [DATE] with diagnoses of type I diabetes mellitus with diabetic neuropathy, chronic kidney disease stage III, protein calorie malnutrition, and hyperlipidemia. [...]

Inspectors wroteBased on observation, interviews, medical record review, and policy review, the facility failed to ensure residents had the right to a dignified existence and self-determination, when care concerns were not documented and appropriately addressed. This affected one out resident (#6) out of one resident reviewed for care conferences. Additionally, the facility failed to ensure Resident #15 received breakfast daily. This affected one (#15) of three residents reviewed for meals. The facility census was 48.

Inspectors wroteBased on observation, interview, record review, review of facility self reported incidents, review of witness statements, and policy review, the facility failed to ensure Resident #12 was free from verbal abuse. This affected one resident (#12) out of five residents reviewed for abuse. The facility census was 48. Findings Include: Review of the medical record for Resident #12 revealed an admission date of 02/21/26. Diagnoses included but were not limited to diabetes mellitus type two, psychoactive substance abuse, chronic idiopathic constipation, anxiety disorder, fibromyalgia, bipolar disorder, and abnormalities of gait and mobility. Review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Interview on 07/13/26 at 2:29 P.M. [...]

Inspectors wroteBased on observation, interview, record review, review of Self-Reported Incidents, review of witness statements, and policy review, the facility failed to ensure an allegation of abuse was reported timely. This affected one resident (#12) out of five residents reviewed for abuse. The facility census was 48. Findings Include: Review of the medical record for Resident #12 revealed an admission date of 02/21/26. Diagnoses included but were not limited to diabetes mellitus type two, psychoactive substance abuse, chronic idiopathic constipation, anxiety disorder, fibromyalgia, bipolar disorder, and abnormalities of gait and mobility. Review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Interview on 07/13/26 at 2:29 P.M. [...]

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to assess and implement smoking safety for residents. This deficient practice affected one resident (Resident #16) out of two residents reviewed for smoking safety. The facility census was 48. Findings Include:Review of Resident #16's medical record revealed admission date of 05/29/26 with diagnoses including pleural effusion, chronic obstructive pulmonary disease (COPD), high blood pressure, heart failure and cellulitis of lower leg. Review of Resident #16's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had moderately impaired cognition with a brief interview of mental status (BIMS) score of 10 out of 15 and used a wheelchair for mobility. Review of Resident #16's smoking safety assessment dated [DATE] revealed Resident #16 was assessed as a non-smoker. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure transportation was available for a dialysis dependent resident. This deficient practice affected one resident (#2) out of two residents reviewed for dialysis. The facility census was 48. Findings Include:Review of Resident #2's medical record revealed admission date of 10/30/25 with diagnoses including but not limited to end stage renal disease, renal dialysis, asthma, depression and type two diabetes. Review of Resident #2's quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #2 had moderately impaired cognition with a brief interview mental status (BIMS) score of 11 out of 15, he received dialysis and used a power wheelchair for mobility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the timely reordering of Resident #28's antianxiety medication. This affected one out of one resident's review for behavioral health services. The facility census is 48. Review of the medical record for Resident #28 revealed an admission date of 10/22/25. Diagnoses included but were not limited to panic disorder, psychoactive substance use, major depressive disorder, chronic pain, and insomnia. Review of Resident #28's quarterly Minimum Data Set (MDS) dated [DATE] revealed the residents Brief Interview for Mental Status (BIMS) score of 15 which indicated that a resident's cognitive function is intact. Review of Resident #28's care plan dated 06/09/26 revealed the resident had an alteration in mood related to depression, panic disorder, and anxiety with an intervention to administer medications as ordered. [...]

Inspectors wroteBased on record review and interview, the facility failed to schedule ordered diagnostic tests for residents. This deficient practice affected one resident (#16) out of one resident reviewed for diagnostic testing. The facility census was 48. Findings Include:Review of Resident #16's medical record revealed an admission date of 05/29/26 with diagnoses including pleural effusion, Chronic Obstructive Pulmonary Disease (COPD), high blood pressure, heart failure and cellulitis of lower leg. Review of Resident #16's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #16 had moderately impaired cognition. Review of Resident #16's physician orders revealed an order dated 07/01/26 for bilateral venous doppler and bilateral arterial doppler for lower legs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #12 was scheduled for a dental appointment as recommended after experiencing dental pain and a tooth infection. This affected one (#12) out of two residents reviewed for dental services. The facility census was 48. Review of the medical record for Resident #12 revealed an admission date 02/21/26. Diagnoses included but were not limited to diabetes mellitus type two, psychoactive substance abuse, chronic idiopathic constipation, anxiety disorder, fibromyalgia, bipolar disorder, and abnormalities of gait and mobility. Review of Resident 12's quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. [...]

Inspectors wroteBased on record review, observations, interviews, and facility policy review, the facility failed to ensure infection control was maintained during transport of soiled linens and failed to ensure hand hygiene during incontinence care and Enhanced Barrier Precautions were implemented appropriately. This affected one resident (#16) out of one resident reviewed for wound care and affected one resident (#6) out of one resident reviewed for incontinence care. The facility census was 48. Findings Include: 1. Review of Resident #16's medical record revealed admission date of 05/29/26 with diagnoses including but not limited to cellulitis of lower leg, pleural effusion, high blood pressure, and heart failure. [...]

Inspectors wroteBased on observation, interviews and policy review, the facility failed to ensure adequate and appropriate utensils were provided for resident meals. This affected seven residents (#1, #3, #13, #14, #19, #43, and #44) of seven residents reviewed for appropriate eating utensils being provided with meals. This had the potential to affect all 45 residents who received meals from the kitchen. The facility census was 45.

Inspectors wroteBased on medical record review, hospital record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized skin management program to prevent incidents of neglect for Resident #20 and Resident #46. This resulted in Immediate Jeopardy and Actual Harm beginning on 10/21/25 after the facility failed to ensure Resident #46, a severely cognitively impaired resident who was dependent on staff for care, received timely and proper treat to prevent a significant deterioration to a wound to the resident's left lateral foot, resulting in the resident being transferred to the emergency department (ED) where he was admitted and treated with intravenous (IV) medications for severe sepsis. [...]

Inspectors wroteBased on review of personnel files and interview, the facility failed to conduct background checks on all employees prior to hire, failed to conduct a review of the Nurse Aide Registry (NAR) for all employees prior to hire, failed to conduct a review of the abuse registry for all employees prior to hire, failed to conduct professional or personal reference checks for all employees prior to hire, and failed to maintain the background check log in a complete and accurate manner. This had the potential to affect all 45 residents residing in the facility.

Inspectors wroteBased on record reviews, observations, interviews, review of personnel files, review of facility self-reported incident (SRIs), and facility policy review, the facility failed to be administrated in a manner that uses its resources effectively and efficiently to ensure resident safety, prevent neglect, as evidenced by the failure to provide proper wound care and ensure physician oversight for Residents #20 and #46, failure to conduct required pre-employment criminal background checks, Nurse Aise Registry (NAR) checks, abuse registry checks, and personal and professional background checks, failure to maintain an accurate background check log; failure to thoroughly investigate allegations of abuse, neglect, and misappropriation involving Residents #37, #41, and #50; and failure to maintain a safe environment free from illicit drugs, placing Residents #6, #7, and #12 at risk. [...]

Inspectors wroteBased on observation, interview, work request review and facility policy review, the facility failed to ensure all areas of the facility were in good repair. This had the potential to affect all 45 residents residing in the facility.

Inspectors wroteBased on resident record reviews, resident interview, staff interviews, review of facility self-reported incidents (SRIs), review of police reports, review of facility investigations, review of Substance Abuse and Mental Health Services Administration (SAMHSA) publication titled Treatment of Stimulant Use Disorders, review of Centers for Disease Control and Prevention (CDC) publication titled Stimulant Guide, review of the Smoking/Alcohol/Non-Prescribed Drugs Agreement, review of the behavior contract and facility policy review, the facility failed to provide an environment that was safe and free from drugs and alcohol as well as have an effective substance abuse program. This affected four residents (#6, #7, #12 and #41) of four residents reviewed for drug use. The facility census was 45.

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to ensure the call light was within reach for Resident #20. This affected one resident (#20) of three residents reviewed for call light accessibility. The facility identified five residents (#20, #24, #27, #45 and #57) who were unable to self-ambulate. The facility census was 45.

Inspectors wroteBased on record review, review of a self-reported incident (SRI), interview and review of facility policy, the facility failed to ensure Resident #1 was free of misappropriation. This affected one (Resident #1) of five residents reviewed for misappropriation. The facility census was 45.

Inspectors wroteBased on record reviews, interviews, facility self-reported incident (SRI) reviews and facility policy review, the facility failed to timely investigate and report the results of the investigations to the State agency within five business days as required related to an allegation of physical abuse for Resident #41 and an allegation of misappropriation for Resident #50. This affected two residents (#41 and #50) of four residents reviewed for facility SRIs. The facility census was 45.

Inspectors wroteBased on record reviews, interviews, review of self-reported incidents (SRIs) and review of the facility policy, the facility failed to thoroughly investigate allegations of abuse, neglect and misappropriation. This affected three residents (#37, #41 and #50) out of 29 residents reviewed for abuse, neglect and misappropriation. The facility census was 45.

Inspectors wroteBased on medical record review, review of a discharge notice, interview, and review of the facility policy, the facility failed to provide evidence of an appropriate discharge, including completing a discharge summary or recapitulation of stay and documenting the details of the discharge in the medical record for Resident #56. This affected one resident (#56) of one resident reviewed for discharge. The facility census was 45.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure pressure ulcer treatments were completed as ordered for resident #5. This affected one resident (#5) of three residents reviewed for pressure ulcers. The facility census was 45.

Inspectors wroteBased on record review, observation, interview and review of the facility policy, the facility failed to maintain a safe smoking environment for Resident #13. This affected one resident (#13) of two residents reviewed for smoking. The facility census was 45.

Inspectors wroteBased on record review and interview, the facility failed to provide evidence of timely Foley catheter care for Resident #5. This affected one resident (#5) out of three reviewed for activities of daily living (ADL). The facility census was 45.

Inspectors wroteBased on resident record review, resident interview, staff interviews, facility investigation, and facility policy review, the facility failed to ensure pain medication was available as needed. This affected one resident (#7) of one resident reviewed for pain management. The facility census was 45.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure wound care was overseen by a physician. This affected two residents (#20 and #46) of seven reviewed for wound management. The facility identified 11 current residents (#5, #10, #12, #17, #20, #25, #32, #37, #38, #39 and #45) with wounds. The facility census was 45.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #13 received medications as ordered. This affected one resident (#13) of eight residents reviewed for medication administration. The facility census was 45.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure medications were properly stored. This affected one resident (#38) of three reviewed for proper medication storage. The facility census was 45.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to maintain proper infection control practices while providing wound care for Resident #12. This affected one resident (#12) of two residents observed for wound care. The facility census was 45.

Inspectors wroteBased on observations and interviews with staff the facility failed to label and date food and failed to ensure dietary staff wore hair restraints. This had the potential to affect all 49 residents who received food from the kitchen. The census was 49.

Inspectors wroteBased on closed record reviews and interview, the facility failed to ensure resident medical records contained all required discharging information and appropriate information was communicated to the receiving facility. This affected two residents (Resident #55, and Resident #65) of three residents reviewed for discharge planning. The census was 49.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure there was sufficient dietary staff for timely meal service. This had the potential to affect all residents who received meals from the kitchen. The facility did not identify any residents who did not eat by mouth. The facility census was 53.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all 53 residents receiving meals from the kitchen, as the facility identified no residents who did not eat by mouth The facility census was 53.

Inspectors wroteBased on observation, interview and review of facility policy the facility did not maintain clean bathing and shower rooms for all residents excluding 20 residents (Resident #2, # 3 #7, #8, #9, #12, #15, #17, #19, #21, #22, #23, #24, #25, #26, #28, #32, #33, #35 and #46) the facility identified as not using the bathing and shower rooms. The facility census was 53.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the correct serving size of mechanical soft meat was served to Resident #5, #14, #25, #32, #35 and #156. This affected six residents (#5, #14, #25, #32, #35, and #156) of seven residents (#5, #9, #14, #25, #32, #35, and #156) the facility identified as receiving a mechanical soft diet excluding Resident #9 who had a physician order for mechanical soft diet with pureed meats only. The facility census was 53.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility did not ensure Resident #5 had properly sized clothing to maintain his right to dignity. This affected one resident (Resident #5) out of 21 residents reviewed for dignity. The facility census was 53.

Inspectors wroteBased on record review, and interviews the facility failed to develop person-centered care plans to identify triggers of Post Traumatic Stress Disorder (PTSD) for Resident #10 and Resident #29. This affected two residents (#10 and #29) of 21 residents reviewed for care plans. The facility identified three residents (#10, #29, and #37) with PTSD. The facility census was 53.

Inspectors wroteBased on observations, record review, and interview the facility failed to ensure Resident #21 wore a hand splint according to physician order. This affected one resident (Resident #21) of one resident reviewed for splint devices. The facility identified three residents (#6, #12 and #21) with orders for hand splints. The facility census was 53.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure Resident #5 and Resident #29 were free from potential accident hazards related to smoking. This affected two residents (#5 and #29) of four residents reviewed for accidents/hazards. The facility identified 29 residents (#4, #5, #6, #10, #11, #13, #15, #16, #17, #18, #21, #23, #29, #31, #32, #34, #38, #40, #41, #43, #44, #45, #46, #48, #49, #50, #51, #56, #156) as smokers. The facility census was 53.

Inspectors wroteBased on observations, interviews, record review, facility policy review , and review of manufacturer's user guide, the facility failed to ensure Resident #21's head strap for the BiPAP ( bilevel positive airway pressure) machine was clean and sanitary and failed to ensure Resident #34's oxygen tubing was dated. This affected two residents (#21 and #34) out of two residents reviewed for respiratory care. The facility census was 53.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all insulin medications were accurately labeled to ensure safe administration of medications. This affected three residents (Resident #3, #15 and 36) of nine residents reviewed for medication storage. The census was 53.

Inspectors wroteBased on observation, record review and interview the facility did not ensure Resident #9 received pureed food to meet individual needs. This affected one resident (Resident #9) of five residents reviewed for food/nutrition. The facility identified one resident (#9) as receiving pureed food texture. The facility census was 53.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, interview, and policy review, the facility failed to provide necessary intervention, including a bed of appropriate size for Resident #56 to prevent a fall with injury during personal care. Actual harm occurred on 12/16/24 when Resident #56, who was dependent on staff for incontinence care and personal hygiene sustained a fall out of bed while staff were providing incontinence care, resulting in a distal fracture to the end of her right femur and a closed distal fracture to the end of her left femur. The facility identified the resident needed a king bariatric bed rather than a queen (bed) as the root cause of the fall. This affected one resident (#56) of three residents reviewed for accidents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure palatable food temperatures were consistently served to residents. This finding had the potential to affect all 55 residents who reside in the facility and were provided meals from the kitchen.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the menus and spreadsheets were followed as planned. This finding affected Residents #9, #13, #27 and #44 and had the potential to affect all 55 residents residing in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Residents #9 and #44's mighty shake nutritional supplements were provided as ordered. This finding affected two (Residents #9 and #44) of four residents reviewed for meals.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #27's medication was available and administered as ordered. This finding affected one (Resident #27) of four residents reviewed for medication administration.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a mediation error rate of 5% or less. A total of 26 medications were administered with two errors for a medication error rate of 7.69%. This finding affected two (Residents #27 and #53) of four residents reviewed for medication administration.

Inspectors wroteBased on staff interview, observation and review of facility documents, the facility failed to maintain a sanitary kitchen. This had the potential to affect all of the residents residing in the facility with the exception of Resident #18. The facility census was 45 residents.

Inspectors wroteBased on medical record review, review of a notification of termination of services letter to a physician, review of a notification letter to residents of the change in the Medical Director and rounding physician, review of notification letter to residents of their transfer of physician, review of doctor election form, review of eLicense.ohio.gov website, staff interview, physician interview, Ombudsman interview, resident interview, and review of facility policies, the facility failed to discuss the need for alternative physician services with residents and honor the resident's right to maintain their physician of their choice. This affected and/or had the potential to affect seven residents (#5, #12, #13, #15, #25, #34, and #41) of seven residents who had been receiving services from Physician #1 but were required by the facility to change to a new physician or Physician #2. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure their Quality Assurance and Performance Improvement (QAPI) program committee thoroughly evaluated, identified areas in need of improvement, and corrected deficient practice. This affected three of three residents reviewed for choice of physician (#15, #42 and #24) and one (#43) of three residents reviewed for accuracy of documentation. The facility census was 49.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain complete medical records in residents medical charts. This had the potential to affect all 48 residents residing at the facility. The facility census was 48.

Inspectors wroteBased on record review and interviews, the facility failed to ensure registered nurse coverage at least eight hours per day, seven days per week. This finding had the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure their Quality Assurance and Performance Improvement (QAPI) program committee thoroughly evaluated, identified areas in need of improvement, and data related to the issues was being monitored to determine if the plan of correction was being implemented as written and corrections were being sustained, and to determine if revisions were necessary. This had the potential to affect eight residents (Residents #3, #18, #22, #23, #26, #28, #43, and #48) who were receiving wound care treatments. The facility census was 49.

Inspectors wroteBased on observation, interview, medical record review, and review of facility policy, the facility failed to ensure wound care was completed as ordered, treatments provided were rendered according to appropriate standards of care to decrease the risk of infection, and the record accurately reflected care that was provided. This affected one resident (#26) out of three residents reviewed for wound care. The facility census was 49.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #44's pressure ulcer wound care was completed as ordered and failed to ensure the accuracy of Resident #44's medical record. This finding affected one (Resident #44) of one resident reviewed for pressure wounds.

Inspectors wroteBased on interview, medical record review, and policy review the facility failed to ensure a complete and accurate medical record for one resident (#43) of three residents reviewed for wound care. The facility census was 49.

Inspectors wroteBased on record review and interview the facility failed to implement a safe discharge including the provision of medications for Resident #49. This affected one (Resident #49) of three residents reviewed for discharge planning and implementation. The census was 46.

Inspectors wroteBased on review of a facility Legionella water management plan documentation, staff interview, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to fully implement a complete water management program to prevent the growth of Legionella bacteria. This had the potential to affect all 47 residents residing in the facility. The census was 47.

Inspectors wroteBased on observation, staff interview, interview with a water service representative, review of an emergency water supply contract, and review of water company recommendations, the facility failed to ensure an adequate usable emergency water source was available for use in the event of a service disruption. This had the potential to affect all 47 residents residing in the facility. The facility census was 47.

Inspectors wroteBased on observation, interview, record review, and review of facility policy on wound care, the facility failed to obtain diagnostic testing as ordered to identify and treat a possible infection of Resident #31's Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure ulcer of the sacrum. Actual harm occurred on 02/06/23 when Resident #31 was sent to the emergency room and admitted to the hospital for an infection of the sacral wound. This affected one (Resident #31) of two residents reviewed for pressure ulcers. The census was 41.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure that the kitchen was clean and sanitary and dish washing protocols were followed to ensure dishes were sanitized. This had the potential to affect 39 of 41 residents receiving food from the kitchen. Resident #31 received no food by mouth (NPO). The facility census was 41.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure staff followed proper infection control procedures when entering and exiting COVID-19 isolation rooms and failed to ensure proper infection control procedures were used during wound care for Resident #26. This affected nine residents (#9, #14, #23, #26, #29, #137, #139, #237, and #287). The census was 41.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure a clean and well-maintained environment. This affected five residents (#13, #27, #28, #138, and #238) rooms of 41 resident occupied rooms and two common areas. This had the potential to affect all 41 residents that resided in the facility.

Inspectors wroteBased on observations, interviews and record review, the facility failed to treat residents with respect and dignity at all times. This affected three residents (#19, #26, #27) out of six residents reviewed for dignity. The facility census was 41.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provided adequate feeding assistance to Resident #16. This affected one (#16) of three residents reviewed for activities of daily living. The census was 41.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen tubing was dated when changed and that a physician's order was in place for oxygen use for Resident #12. This affected one (Resident #12) of one reviewed for oxygen use. The census was 41.

Inspectors wroteBased on observations, interview and record review, the facility failed to honor resident preferences regarding menu choices. This affected three residents (#3, #4, and #6) of three residents reviewed for choices. The facility census was 41.