Trotwood Health & Rehab LLC

Inspectors wroteBased on review of personnel files, staff interviews, and policy review, the facility failed to ensure employees were screened for history of abuse on the Ohio Abuse Registry. This had the potential to affect all residents. The facility census was 31.

Inspectors wroteBased on review of personnel files, staff interviews, and policy review, the facility failed to implement the abuse policy. This had the potential to affect all residents. The facility census was 31.

Inspectors wroteBased on personnel file review and interview, the facility failed to ensure the activity department was operated by a qualified activity professional. This had the potential to affect all residents. The facility census was 31.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to have Registered Nurse (RN) coverage as required. This had the potential to affect all residents. The facility census was 31.

Inspectors wroteBased on observation, resident and staff interview, and policy review, the facility failed to ensure food was served at the appropriate temperature. This had the potential to affect 30 of 30 residents in the facility who eat meals from the facility kitchen. The facility identified one resident (#05) who did not receive food from the kitchen. The facility census was 31.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure food was stored in a manner to prevent the potential spread of foodborne illness. The facility also failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect 30 of 30 residents who receive food from the facility kitchen. The facility identified one resident (#05) who did not receive food from the kitchen. The facility census was 31.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to accurately submit staffing data in the Payroll Based Journal (PBJ) system. This had the potential to affect all residents. The facility census was 31.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee met at least quarterly. This had the potential to affect all residents. The facility census was 31.

Inspectors wroteBased on medical record review, review of the water management logs and plan, review of personnel files, observation, staff interview, and policy review, the facility failed to ensure appropriate hand hygiene was completed while passing meal trays and medications. The facility also failed to ensure enhanced barrier precautions were implemented as appropriate, legionella prevention measures were completed, and tuberculosis tests were administered to employees as planned. This had the potential to affect all 31 residents in the facility. Findings Included: 1. Observation on 06/14/26 at 12:28 P.M., Certified Nursing Assistant (CNA) #44 began to pass trays on the 200 hall. CNA #44 delivered trays to the rooms of Residents #20, #15, #01, and #24. CNA #44 did not perform hand hygiene at any time between passing each tray. A dispenser of hand sanitizer was observed on top of the cart of trays. [...]

Inspectors wroteBased on medical record review, observations, staff interviews and policy review, the facility failed to ensure medications were stored in a sanitary and secure manner and failed to properly dispose of expired medications. This had the potential to affect 20 residents who reside on the 200-300 halls. The facility census was 31.

Inspectors wroteBased on review of the weekly menu and diet spreadsheets, observation, staff and resident interviews, and policy review, the facility failed to provide drinks per resident preference. This affected four (Resident #4, #9, #10 and #35) out of 30 residents that received food trays. The facility census was 31. Findings Included: Review of the weekly menu week one provided upon request at entrance revealed coffee was listed as a menu item at all three meals every day. Review of the diet spreadsheets for 06/14/26 breakfast and lunch revealed coffee was listed at both meals. Observations of meal service in the kitchen on 06/14/26 between 8:25 A.M. and 8:45 A.M. and tray delivery on 06/14/26 between 12:25 P.M. and 12:45 P.M. revealed there was no coffee available to serve residents. Interview on 06/14/26 at 2:20 P.M. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure residents were treated with dignity and respect. This affected one (#02) out of four residents reviewed for dignity. The facility census was 31.

Inspectors wroteBased on medical record review, resident and staff interviews, and policy review, the facility failed to ensure residents had access to personal care products. This affected one (Resident #22) of five residents sampled for dignified care. The facility census was 31.

Inspectors wroteBased on medical record review, document review, and staff interview, the facility failed to ensure residents with funds accounts had written authorizations in place. This affected two (#17 and #04) of four residents reviewed for funds. The facility identified 23 residents with current funds accounts. The facility census was 31.

Inspectors wroteBased on medical record review, document review, and staff interview, the facility failed to timely refund resident accounts. This affected one (#37) of one resident reviewed for closed funds accounts. The facility identified 23 residents with current funds accounts. The facility census was 31. Review of the medical record of Resident #37 revealed an admission date of 01/18/17. Diagnoses included paranoid schizophrenia. The resident discharged from the facility on 12/11/25. Review of the final resident trust fund check, dated 06/05/26, revealed the resident was refunded $1770.86. Interview on 06/16/26 at 10:34 A.M., Business Office Manager (BOM) #74 verified Resident #37's account was not refunded until 06/05/26. BOM #74 stated, upon starting her position, she reviewed accounts and found the account had not yet been refunded. [...]

Inspectors wroteBased on medical record review, staff interviews and policy review, the facility failed to ensure baseline care plans addressed resident needs identified upon admission. This affected one (Resident #32) of three residents sampled for care planning. The facility census was 31.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure the care plan was revised for advance directives. This affected one (Resident #4) out of 16 residents reviewed for Advance Directive care planning. The facility census was 31. Findings Include:Review of the medical record revealed Resident #4 was admitted on [DATE]. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), chronic diastolic heart failure, type II Diabetes Mellitus, major depressive disorder, unspecified asthma, and generalized muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact as evidenced by Brief Interview for Mental Status score of 15. [...]

Inspectors wroteBased on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure adequate activities of daily living (ADL) care was provided. This affected one (#10) of two residents reviewed for ADL care. The facility census was 31.

Inspectors wroteBased on medical record review, observation, and resident and staff interview, the facility failed to provide the care and services to treat edema. This affected one (#10) of one resident reviewed for edema. The facility census was 31.

Inspectors wroteBased on medical record review, interviews, and policy review, the facility failed to implement orders for wound treatments. This affected one (Resident #32) out of one resident sampled for pressure injury prevention. The facility census was 31.

Inspectors wroteBased on medical record review, interviews, and policy review, the facility failed to obtain a resident reweight timely. This affected two (Resident #02 and #17) out of three residents reviewed for nutrition. The facility census was 31.

Inspectors wroteBased on medical record review, observation, interview, and policy review, the facility failed to ensure diabetic medication was administered as ordered. This affected one (Resident#3) of five residents sampled for pharmacy services. The facility census was 31.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure a comfortable environment with properly functioning equipment. This affected one (#12) of three residents reviewed for environment. The facility census was 31.

Inspectors wroteBased on record review, review of a facility self-reported incident (SRI), review of a police report, staff interview and policy review, the facility failed to ensure residents were from staff to resident physical abuse with serious injury. This resulted in Immediate Jeopardy and Actual Harm on 04/18/26 at approximately 10:40 A.M. when Dietary Aide (DA) #51 punched Resident #4 in the face. Resident #4 was admitted to the hospital with a broken jaw. This affected one (Resident #4) of three residents reviewed for abuse. The facility census was 29 residents. On 04/23/26 at 10:32 A.M., the Administrator was notified Immediate Jeopardy began on 04/18/26 at approximately 10:40 A.M. when DA #51 punched Resident #4. The Immediate Jeopardy was removed on 04/24/26 when the facility implemented the following corrective actions: [...]

Inspectors wroteBased on observation, staff and resident interviews, and review of facility policy, the facility failed to ensure air temperatures were maintained within comfortable ranges for the residents. This affected all 33 residents residing in the facility. The facility census was 33.

Inspectors wroteBased on observation, resident interview, staff interview and policy review, the facility failed to accommodate the residents who wanted to eat in the dining room. This had the potential to affect 25 residents who the facility identified as receiving meals from the kitchen and were able to eat in the dining room. The facility census was 33.

Inspectors wroteBased on record review, staff interviews, and review of personnel files, the facility failed to ensure the Activities Program was directed by a qualified Activity Director (AD). This had the potential to affect 32 residents interested in and/or actively participating in activities. The facility census was 33.

Inspectors wroteBased on observation, facility policy review and staff interview, the facility failed to ensure all essential mechanical equipment (boiler) was maintained in a functional and safe operating condition. This had the potential to affect all 33 residents residing in the facility. Findings Include: Observation of the main entrance of the facility during entrance on 12/17/25 at 8:36 A.M., revealed the air temperature felt very cool. Observation of the facility on 12/17/25 at 9:00 A.M. with Maintenance Director (MD) #06, revealed the MD #06 used a hand-held infrared thermometer and recorded temperatures in the main entrance between 51.2 and 56.5 degrees Fahrenheit (F). These areas included the main entrance of the facility, the administration offices, the resident ' s dining room, common hallways leading to the resident ' s rooms, the chapel and a common gathering room. [...]

Inspectors wroteBased on observation, resident interview, staff interview and review of facility policy, the facility failed to maintain comfortable temperatures. This affected 16 (#27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, and #42) of 16 residents who resided on the 400 and 500 halls. Additionally, the facility failed to ensure residents had access to comfortable water temperatures. This affected 26 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25 and #26) residents who resided on the 100, 200 and 300 halls. The facility census was 42.

Inspectors wroteBased on observation, staff interview, review of food delivery invoices and review of facility policy, the facility failed to ensure foods were properly stored and further failed to ensure dishes were clean and sanitized in a manner to prevent foodborne illness. This had the potential to affect all 42 residents residing in the facility. The facility census was 42.

Inspectors wroteBased on observations, resident and staff interviews, and policy review, the facility failed to maintain a comfortable and home-like environment by ensuring heating/air conditioning units in resident rooms were properly functioning. This affected five (#10, #12, #35, #36, and #43) out of ten residents reviewed for complaints of air conditioning not working. The facility census was 49.

Inspectors wroteBased on medical record review and resident and staff interviews, the facility failed to ensure residents were treated with dignity and respect. This affected one (#10) out of three reviewed for dignity and respect. The facility census was 49.

Inspectors wroteBased on medication record review, staff interview, and policy review, the facility failed to ensure a resident's pain was adequately control. This affected one (#19) out of three residents reviewed for pain. The facility census was 49.

Inspectors wroteBased on medical record review, staff interviews, and policy review, the facility failed to ensure Resident #10's medications were administered as ordered and failed to ensure Resident #46's pain medication was timely reordered/available for administration. This affected two (#10 and #46) out of six residents reviewed for medication administration. The facility census was 49.

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview the facility failed to ensure the building and furnishings were in good repair. This affected Resident #43 and the 19 residents residing in the in the 300/400 hall (#2, #3, #8, #10, #11, #14, #18, #21, #23, #28, #32, #37, #39, #41, #42, #43, #44, #45, and #46). The facility census was 47 residents.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to provide a clean, homelike environment with working showers. This had the potential to affect all residents. The facility also failed to provide a clean floor for Resident #36. The facility census was 45.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to administer medications per physicians orders. There were two medication errors out of 31 opportunities resulting in a 6.45 percent (%) medication error rate. This affected two (Residents #40 and #47) of three residents reviewed for medication administration. The facility census was 45.

Inspectors wroteBased on observation, medical record review, interview, and policy review, the facility failed to ensure medications were stored in a safe manner. This affected one (Resident #19) of one resident observed for medication storage. The facility census was 45.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure a comfortable environment. This affected one (Resident #46) of three residents reviewed for comfortable temperatures. The facility census was 48.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure medications were administered as ordered. This affected one (Resident #44) of three residents reviewed for medication administration. The facility census was 48.

Inspectors wroteBased on record review, observations, staff interview, and review of facility policy, the facility failed to ensure the facility was free from medication error rate less than 5%. A total of 30 opportunities were observed with two errors observed, resulting in a 6.6% medication error rate. This affected one resident (#44) of three residents reviewed for medication administration. The facility census was 48.

Inspectors wroteBased on observation, staff and resident interviews, review of the facility census and review of facility policy, the facility failed to ensure air temperatures were maintained within comfortable ranges for residents residing on the secure behavioral unit (100 hall). This had the potential to affect 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13) residents who resided on the secure behavior unit (100 hall). The census was 49.

Inspectors wroteBased on medical record review and resident, staff and physician office staff interviews, the facility failed to provide medically-related social services by failing to provide assistance with a resident's medical appointments to an outside provider. This affected one (#21) of three residents reviewed for medical appointments. The facility census was 51.

Inspectors wroteBased on medical record review, observations, staff and pharmacist interviews and policy review, the facility failed to ensure medications were administered according to physicians orders, failed to ensure licensed nursing staff accurately documented the administration of medications in the medical record and failed to ensure medications were re-ordered/available from the pharmacy. This affected two (#52 and #21) of three reviewed for medication administration. The facility census was 51.

Inspectors wroteBased on review of nursing schedules and staff interview, the facility failed to ensure the supervision by a Registered Nurse (RN) for eight consecutive hours daily. This had the potential to affect all of the residents residing in the facility. The facility census was 52 residents.

Inspectors wroteBased on observations, resident and staff interviews, and review of facility policy, the facility failed to ensure a clean, safe, comfortable environment for all residents. This affected 32(#01, #02, #03, #05, #06, #08, #09, #10, #12, #17, #18, #19, #22, #23, #27, #29, #30, #31, #32, #35, #36, #37, #41, #42, #44, #46, #47, #49, #50, #51, #53, and #54) of the 52 residents observed for environment. The facility census was 52.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and policy review, the facility failed to ensure residents did not have access to knives, razors, and smoking materials and smokers were supervised while smoking. This affected Residents #50, #29, #48 and #107. The facility identified 28 Residents (#01, #03, #04, #07, #09, #16, #18, #19, #20, #21, #22, #24, #27, #30, #31, #34, #35, #37, #38, #40, #41, #42, #44, #48, #50, #51, #53, and #54) who smoked. The facility census was 52.

Inspectors wroteBased on observation, staff interview, and review of the dishwasher manual, the facility failed to ensure the dishwasher was functioning to clean and sanitize dishes appropriately. This had the potential to affect 51 of 52 residents in the facility. The facility identified one resident (#15) who did not receive food from the kitchen. The facility census was 52.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure residents with wounds and indwelling medical devices were placed in enhanced barrier precautions (EBP). This affected five (#14, #15, #16, #28, and #33) of five residents reviewed for EBP. The facility census was 52 residents.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were offered pneumococcal and influenza vaccinations. This affected five (Resident #2, #5, #16, #33, and #47) of five residents reviewed for vaccinations. The facility census was 52 residents.

Inspectors wroteBased on record review, observation, staff interview, and review of facility policy, the facility failed to ensure residents were provided with dignity and respect. This affected two (#17 and #33) residents of the five residents reviewed for dignity and respect. The facility census was 52.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure the physician was notified of a resident's weight loss. This affected one (Resident #40) of two residents reviewed for nutrition. The facility census was 52.

Inspectors wroteBased on medical record review, staff and Guardian interview, observations, review of emergency room (ER) records, review of witness statements, review of Self-Reported Incidents (SRI's) and review of the facility policy, the facility failed to provide adequate supervision to prevent resident-to-resident sexual abuse. This affected two (#29 and #43) of the ten residents reviewed for abuse. The facility census was 52 residents.

Inspectors wroteBased on observations, record review, resident interview, staff interviews, review of witness statements and policy review, the facility failed to timely implement their abuse policy during allegations of staff-to-resident verbal abuse. This affected one (#18) of the 10 residents sampled for abuse. The facility census was 52.

Inspectors wroteBased on record review, staff interview, observation, review of witness statements, review of the facility policy, and review of Self-Reported Incident (SRI), the facility failed to thoroughly investigate allegations of sexual abuse. This affected one (#29) of the ten residents reviewed for abuse. The facility census was 52.

Inspectors wroteBased on resident interviews, staff interviews, review of the medical record, and policy review, the facility failed to hold quarterly care conferences with residents and/or resident's representatives. This affected three (#29, #49 and #51) of the three residents sampled for care conferences. The facility census was 52.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to provide services to maintain resident vision. This affected one (Resident #46) of eight residents sampled for vision services. The facility census was 52 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure dietary supplements were administered per the physician's order. This affected one (#106) of two residents reviewed for nutrition. The facility census was 52.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure residents received medications as ordered. This affected one (#39) of four residents reviewed for pain. The facility census was 52.

Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to obtain radiology services per physician's order. This affected one (Resident #107) of one reviewed for constipation. The facility census was 52 residents.

Inspectors wroteBased on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents received follow up care to dental visits. This affected two (Residents #46 and #49) of three residents sampled for dental care. The facility census was 52 residents.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure resident records adequately reflected resident status. This affected one (Resident #107) of one resident reviewed for constipation. The facility census was 52 residents.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure residents had functioning call lights. This affect three (Residents #2, #47, #53) of three residents reviewed for call lights. The facility census was 52 residents.

Inspectors wroteBased on observations and staff interviews, the facility failed to provide a comfortable, clean, and homelike environment by not ensuring comfortable air temperatures on 100 Hall. This had the potential to affect 11 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11) residents residing on the 100 Hall. Additionally, the facility failed to ensure the facility was free of pervasive odors on 500 Hall. This had the potential to affect 10 (#46, #47, #48, #49, #50, #51, #52, #53, #54, and #55) residents residing on the 500 Hall. The facility census was 55.

Inspectors wroteBased on record review observations, staff and resident interviews, and policy review, the facility failed to ensure the call light was within a resident's reach. This affected one (#47) out of three residents reviewed for call lights. The facility census was 55.

Inspectors wroteBased on medical record review, observations, staff and resident interviews, and policy review, the facility failed implement their smoking policy to ensure a resident who smokes was assessed upon admission. Additionally, the facility failed to provide adequate interventions and/or supervision to ensure resident's smoking materials were properly secured per the facility smoking policy. This affected two (#51 and #46) out of three residents reviewed for smoking. The facility census was 55.

Inspectors wroteBased on medical record reviews, staff interviews, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected two (#23 and #47) residents out of the three residents reviewed for medications administered as ordered. The facility census was 55.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure resident's medications were administered as ordered resulting in two medication errors out of 30 opportunities or a 6.66 percent (%) medication error rate. This affected one (#53) out of two residents observed for medication administration. The facility census was 55.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to obtain laboratory work as ordered. This affected one (#65) out of the three residents reviewed for nutrition. The facility census was 55.

Inspectors wroteBased on record review, observations, staff and resident interviews, and policy review, the facility failed to ensure the call light system was functioning properly. This affected two (#23 and #47) out of the three residents reviewed for call lights not functioning properly. The facility census was 55.

Inspectors wroteBased on medical record review, staff interviews, and policy review, the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being at risk for elopements did not elope from the facility. This affected one (#26) out of three residents reviewed for elopement. The facility census was 58.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure proper disposal of medications after a resident was discharged from the facility. This affected one (#60) out of three residents reviewed for medication disposition after discharge from the facility. The facility census was 58.

Inspectors wroteBased on record review, observations, staff and resident interviews, and facility policy review, the facility failed to ensure a resident's call light was functioning properly. This affected one (#02) out of the three residents reviewed for call lights. The facility census was 58.

Inspectors wroteBased on observations, resident and staff interviews and review of Resident Council Meeting minutes, the facility failed to ensure the 200 Hall shower was in good working condition for resident use. This affected one (#31) out of the residents reviewed for functioning shower and also had the potential to affect nine (#26, #28, #30, #31, #32, #33, #34, #35 and #36) residents who reside on the 200 hallway that utilize the shower room. Additionally, the facility failed to ensure the roof did not leak onto the resident hallway on the 500 hall. This had the potential to affect 10 (#55, #56, #57, #58, #59, #60, #61, #62, #63 and #64) residents who reside on the 500 hallway where the room was leaking. The facility census was 50.

Inspectors wroteBased on medical record reviews, staff interview, and policy review, the facility failed to administer medications as ordered. This affected three (#31, #37, and #42) out of the three residents reviewed for medication administration. The facility census was 50.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the facility failed to ensure portable space heaters were not used in resident accessible areas. This had the potential to affect all residents residing in the facility with the exception of two facility-identified residents (#33 and #44) who did not leave their rooms. The facility census was 47.

Inspectors wroteBased on medical record review, hospital documentation review, staff interview, and review of facility policies, the facility failed to follow facility procedures for leave of absences (LOAs), failed to implement interventions and provide education to residents and family members to reduce falls and incidents while on LOAs, and failed to investigate causative factors and determine a root cause analysis of repeated fall incidents while on LOA from the facility. This resulted in actual harm when Resident #100 left the facility for LOAs with family and had repeated fall incidents and injuries during the LOAs. Resident #100 was seen in the emergency room on multiple occasions for fractures and dislocation of the left hip and fracture of the left femur which required hospitalization and surgical intervention. This affected one (#100) of two residents reviewed for falls. The census was 40.

Inspectors wroteBased on employee personnel record review, staff interview, and policy review, the facility failed to test employees for tuberculosis per the facility policy. This affected five (State Tested Nurse Aide (STNA) #104, STNA #131, STNA #128, Licensed Practical Nurse (LPN) #156, and LPN #162) of five employee personnel records reviewed. This had the potential to affect all 50 residents. The census was 50.

Inspectors wroteBased on medical record review, staff and family interviews, and review of facility policy and procedures, the facility failed to ensure nutritional interventions were initiated and sustained to prevent unplanned weight loss for one (#52) of three residents reviewed for weight loss. This resulted in actual harm for Resident #52 who experienced a severe unplanned weight loss of 25.9 percent (%) in less than a one-month period of time. The facility census was 51 residents.

Inspectors wroteBased on record review, observation, resident interview, staff interview, review of the Activity Director (AD) job description, and review of the facility activity calendar, the facility failed to ensure the activities program was implemented as scheduled. This affected five (Residents #13, #16, #34, #56, #57) and had the potential to affect all the residents in the facility with the exception of the following 29 facility-identified (Residents #2, #3, #4, #5, #8, #9, #10, #11, #12, #13, #17, #21, #24, #25, #27, #29, #31, #32, #36, #37, #38, #40, #41, #43, #45, #46, #48, #50, #51) who did not participate in activities. The facility census was 51.

Inspectors wroteBased on review of activity calendar, review of personnel files, staff interview, and review of job description, the facility failed to ensure the services of a qualified Activity Director (AD). This had the potential to affect all residents residing in the facility with the exception of the 29 residents (#2, #3, #4, #5, #8, #9, #10, #11, #12, #13, #17, #21, #24, #25, #27, #29, #31, #32, #36, #37, #38, #40, #41, #43, #45, #46, #48, #50, #51) identified by the facility as not participating in activities. The facility census was 51.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were available for administration as ordered by the physician. This affected one (Resident #14) of four residents reviewed for medications. The facility census was 51 residents.

Inspectors wroteBased on record review, observation, staff, family, and Wound Physician (WP) #315 interviews, review of facility policy, review of wound physician notes, and review of guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to implement interventions/treatments to prevent the development of pressure ulcers and/or aid in the healing of existing pressure ulcers as ordered by the physician. This resulted in Actual Harm when Resident #35 was found to have avoidable pressure ulcers which were first identified as a stage III pressure ulcer on his right heel on 09/21/22 and an avoidable unstageable pressure ulcer in the palm of his left hand discovered at the time of the survey on 11/02/22. This affected one resident (#35) of two residents reviewed for pressure ulcers. The census was 48.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a Registered Nurse (RN) worked at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 48 residents residing in the facility.

Inspectors wroteBased on resident and staff interviews, medical record review and policy review, the facility failed to conduct quarterly care conferences. This affected four (Residents #08, #09, #27, and #40) out of the four residents sampled for care conferences. Facility census was 48.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to maintain evidence the Quality Assessment and Assurance (QAA) committee held quarterly Quality Assurance and Process Improvement (QAPI) meetings. This had the potential to affect all 48 residents in the facility.

Inspectors wroteBased on observation, resident interview, and staff interviews, the facility failed to ensure the dining room was available for accommodate resident preferences. This affected two (Residents #09 and #40) of three residents reviewed for accommodations of needs. The facility's census was 48.

Inspectors wroteBased on medical record review, staff and family interviews, and review of facility policy, the facility failed to notify a resident's representative and resident's physician when resident had a change in condition. This affected one (Resident #35) of the three residents reviewed for notifications. The facility's census was 48.

Inspectors wroteBased on medical record review, staff interview, review of facilities Self-Reported Incidents (SRIs) and policy review, the facility failed to timely report an allegation of sexual abuse to the state agency. This impacted one (Resident #26) of three residents reviewed for abuse. The facility census was 48.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure a resident and/or resident's representative were notified of the facility's bed hold policy upon being transferred to the hospital. This impacted one (Resident #26) of two residents reviewed for hospitalization. Facility census was 48.

Inspectors wroteBased on medical record review, staff interview, observations, and review of the Resident Assessment Instrument (RAI) version 3.0, the facility failed to develop a significant change Minimum Data Set (MDS) when indicated. This affected three (Residents #1, #34, and #35) of three residents reviewed for MDS completion. The facility census was 48.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure a new Preadmission Screening and Resident Review (PASARR) was completed following a psychiatric hospitalization. This affected two (Residents #26 and #34) of five residents reviewed for PASARR. The facility census was 48.

Inspectors wroteBased on observation, record review, and interviews the facility failed to provide therapeutic activities to meet the needs and preferences of the resident population. This affected two (Residents #09 and #40) out of two residents reviewed for activities. The facility census was 48.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to implement physician orders following a pharmacy medication review. This affected one (Resident #31) of five residents reviewed for unnecessary medications. The facility census was 48.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete laboratory (lab) orders per pharmacy recommendations and physician's orders. This affected one (Resident #8) of one resident reviewed for lab orders. The facility's census was 48.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a clean and sanitary environment. This affected two (Residents #46 and #35) of three residents reviewed for environment. The facility census was 48.