Wexner Heritage House

Inspectors wroteBased on medical record review, hospital document review, interview, and facility policy and procedure review, the facility failed to ensure laboratory testing and timely follow-up was completed to diagnose and treat a urinary tract infection (UTI). Actual harm occurred beginning on 12/10/25 when Resident #94 exhibited signs/symptoms of a UTI (burning) without evidence of adequate intervention. On 12/11/25 a plan for a urine culture (due to complaints of burning on urination and elevated temperature) was noted; however, the facility failed to send the urine specimen to the laboratory. On 12/16/25 (five days later) the facility recognized the urinalysis was not completed, and a urine specimen was obtained for testing. [...]

Inspectors wroteBased on observation, staff interview, and facility policy, the facility failed to ensure the dishwasher and three compartment sink was in a working order. Additionally, the facility failed to maintain the kitchen in a sanitary manner and store and prepare foods in a sanitary manner. This had the potential to affect 83 out of 85 residents residing in the facility with two residents on a nothing by mouth (NPO) diet. the facility census was 85. During observation of the kitchen area on 12/15/25 at approximately 9:40 A.M. with Regional Dietary Manager (RDM) #601, upon entering the kitchen and performing hand hygiene, the surveyor observed the paper towel dispenser at the handwashing sink was broken and nonfunctional. RDM #601 confirmed at 9:40 A.M. that the dispenser had been broken for awhile and that maintenance had not repaired it. [...]

Inspectors wroteBased on observation, resident interview, staff interview, and facility policy review, the facility failed to ensure Mantoux Tuberculosis (TB) testing and annual assessments were completed in a timely manner which had the potential to affect all 85 residents residing in the facility. Additionally, the facility failed to ensure oxygen tubing was replaced after the nasal cannula fell on the ground for Resident #105, and failed to ensure Enhanced Barrier Precautions (EBP) were followed during medication administration via a gastrostomy feeding tube for Resident #44. The facility census was 85.1. Review of the personnel file for Licensed Practical Nurse (LPN) #141 revealed a hire date of 07/08/25, however, there was no documentation verifying whether the staff actually began providing resident care on or after this date. [...]

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to follow physician orders related to obtaining daily weights. This affected Resident #01 and #10 out of five residents ordered to receive daily weights. Additionally, the facility failed to ensure that physician orders for double portions were followed, which affected Resident #18. The facility also failed to obtain a timely self-medication administration assessment for Resident #01 who was receiving tube feeding. The facility census was 85. 1. Review of the medical record for Resident #18 revealed an admission date of 06/03/25 with diagnoses of metabolic encephalopathy, type one diabetes mellitus, cognitive communication deficit, gastroesophageal reflux disease (GERD), and obesity. [...]

Inspectors wroteBased on observation, resident interview, staff interview, and facility policy, the facility failed to ensure foods were at a palatable temperature. This had the potential to affect 83 out of 85 residents in the facility with two residents receiving a nothing by mouth (NPO) diet. The facility census was 85. During interview on 12/16/2025 at 2:12 P.M., Resident #30, stated that the food was terrible, arrived cold, and lacked flavor. Review of additional interviews conducted during the survey revealed that multiple residents reported concerns regarding food being served cold. During observation related to tray service on 12/18/2025, a test tray was not observed on the meal cart at 1:18 P.M. Staff stated that the test tray was not present because it had been left in the kitchen. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure purred foods were at the appropriate consistency which had the potential to affect Residents #1, #2, #96, #53, #64 who received a pureed diet. The facility census was 85. During observation on 12/18/2025 at 11:26 A.M., the surveyor observed the pureed food preparation process with [NAME] #600. The surveyor observed the fish item intended for residents on a pureed diet and noted the consistency was stringy and not smooth. The fish was described as having separable strands when processed with broth, and the surveyor observed that the texture was not appropriate for residents prescribed a pureed diet. [...]

Inspectors wroteBased on observation, interview, and facility policy review the facility failed to maintain safe and comfortable temperatures in Resident #36's room. This affected one (#36) of three residents reviewed for environment. The census was 85. Review of Resident #36's medical record revealed an admission date of 12/03/24. Diagnoses include type II diabetes mellitus with other specified complication, morbid obesity, unsteadiness on feet, need for assistance with personal care, lymphedema, essential (primary) hypertension, muscle weakness, chronic pain syndrome, bilateral primary osteoarthritis of hip, low back pain, and left bundle branch block. Review of Resident #36's Minimum Data Set 3.0 (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Observation on 12/15/25 at 2:20 P. [...]

Inspectors wroteBased on medical record review, interview and facility policy review, the facility failed to complete a baseline abnormal involuntary movement scale (AIMS) scale for one resident (#12) who was admitted on psychotic medication. This affected one resident (#12) of five residents reviewed for unnecessary medications. The facility census was 85. Review of the medical record for Resident #12 revealed an initial admission date of 08/22/25 with the diagnoses including but not limited to bipolar disorder, catatonic disorder, dementia with behavioral disturbances, protein calorie malnutrition, hypertension, hypothyroidism, depression, spinal stenosis, anemia, hyperlipidemia, urge incontinence, insomnia, voice and resonance disorder, constipation, adult failure to thrive and intra-abdominal and pelvic swelling, mass and lump. [...]

Inspectors wroteBased on observation, medical record review, interview and facility policy review, the facility failed to ensure routine shaving was provided for Resident #12, who was dependent on staff. This affected one resident (#12) of five residents reviewed for activities of daily living (ADL). The facility census was 85. Review of the medical record for Resident #12 revealed an initial admission date of 08/22/25 with the diagnoses including but not limited to bipolar disorder, catatonic disorder, dementia with behavioral disturbances, protein calorie malnutrition, hypertension, hypothyroidism, depression, spinal stenosis, anemia, hyperlipidemia, urge incontinence, insomnia, voice and resonance disorder, constipation, adult failure to thrive and intra-abdominal and pelvic swelling, mass and lump. [...]

Inspectors wroteBased on medical record review, and staff interview this facility failed to ensure prescribed splint orders were transcribed and implemented correctly. This affected one (Resident #75) of the two residents reviewed for splints. The facility census was 85. Review of the medical record for Resident #75 revealed an admission date of 06/02/2025. Diagnoses included cerebral palsy, contracture of the right and left hand, and muscle weakness. Review of Resident #75's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed this resident experienced long and short-term memory problems with a severely impaired cognition for daily decision-making abilities. Review of the plan of care dated 07/07/25 revealed Resident #75 was at risk for or prone to the development of contractures. [...]

Inspectors wroteBased on medical record review, observation, staff interview and policy review, the facility failed to implement interventions to prevent resident falls for Residents #20 and #94. This effected two of three residents reviewed for falls with injuries. The facility census was 85.1. Review of the medical of Resident #20 revealed she was admitted to the facility on [DATE] with diagnoses of osteoarthritis, muscle weakness, and history of falls. The resident's care plan dated 12/08/25 indicated she was at increased risk for falls. Interventions included maintaining the call light within reach. A review of the fall incident on 09/26/25 revealed the resident was found on the floor face down in her room between 4:00 A.M and 5:00 A.M. The nursing assessment noted injuries including a laceration to the left lower leg, edema to the head and eye, and pain upon touch. [...]

Inspectors wroteBased on observation, record review, staff interview, and review of facility policy, the facility failed to label oxygen tubing for Resident #09, #14, and #44. This affected three of five residents reviewed for respiratory care. The census was 85. 1. Record review of Resident #09's medical record revealed an admission date of 12/31/24. Diagnoses include chronic obstructive pulmonary disease, heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, hypertensive heart disease with heart failure, dependence on supplemental oxygen, chronic respiratory failure with hypoxia, and type II diabetes mellitus with diabetic neuropathy. Review of Resident #09's Minimum Data Set 3.0 (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09, indicating moderately impaired cognition and that Resident #09 required oxygen therapy. [...]

Inspectors wroteBased record review, staff interview and review of facility policy, the facility failed to ensure physician ordered daily weights were collected timely, this affected one (#54) of residents reviewed for physician orders. The facility census was 85. Review of the medical record for Resident #54 revealed an admission date of 11/18/25 with diagnoses of hypocalcemia, cognitive communication deficit, atrial fibrillation, muscle weakness, chronic combined systolic and diastolic heart failure, hypertensive heart disease with heart failure, atherosclerotic heart disease of native coronary artery with angina, hyperlipidemia, and pulmonary embolism. [...]

Inspectors wroteBased on record review, interview and policy review the facility failed to ensure physician parameters were appropriately followed. This affected three (#04, #08, and #75) of six residents selected for medication regimen review. The facility census was 85. 1. Record review of Resident #04 revealed an admission date of 10/31/25 and readmission of 11/25/25. Diagnoses included but are not limited to osteomyelitis of vertebra, discitis, low back pain, complication of internal fixation device of vertebrae, bipolar disorder, Post Traumatic Stress Disorder (PTSD), depression, gout and chronic pain. [...]

Inspectors wroteBased on observation, review of manufacturer guidelines, and facility policy review the facility failed to remove expired Tubersol tuberculin solution from circulation. This deficient practice had the potential to affect new resident admissions. The facility census was 85. An observation on [DATE] at 9:51 A.M. revealed in the medication storage refrigerator located at the nurses' desk on the first hallway. Inside the refrigerator was an open half-used vial of Tubersol tuberculin solution not labeled with an open date on the storage box or on the vial. Further observation revealed another open half used vial of Tubersol tuberculin solution with an open date [DATE] located on the vial. Both vials of the Tubersol tuberculin solution had an expiration date of 10/2026. [...]

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure physician ordered urine screenings were collected timely, this affected two (Resident #36 and Resident #94) out of six reviewed for physician ordered lab results. The facility census was 85. 1. Review of the medical record for Resident #36 revealed an admission date of 12/03/24 with diagnoses including type two diabetes mellitus, depression, chronic pain syndrome, constipation, anxiety and arthritis. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 is cognitively intact, dependent on staff for personal hygiene and toilet transfers, and requires substantial to maximal assistance with bed mobility. [...]

Inspectors wroteBased on medical record review, interview and facility policy review, the facility failed ensure one resident had a physician's order for labs obtained. This affected one resident (#12) of five residents reviewed for unnecessary medications. The facility census was 85. Review of the medical record for Resident #12 revealed an initial admission date of 08/22/25 with the diagnoses including but not limited to bipolar disorder, catatonic disorder, dementia with behavioral disturbances, protein calorie malnutrition, hypertension, hypothyroidism, depression, spinal stenosis, anemia, hyperlipidemia, urge incontinence, insomnia, voice and resonance disorder, constipation, adult failure to thrive and intra-abdominal and pelvic swelling, mass and lump. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure antibiotic stewardship was followed. This affected one (Resident #36) out of four residents reviewed for antibiotic usage. The facility census was 85. Review of the medical record for Resident #36 revealed an admission date of 12/03/24 with diagnoses of type two diabetes mellitus, depression, chronic pain syndrome, constipation, anxiety and arthritis. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #36 is cognitively intact, dependent on staff for personal hygiene and toilet transfers, and requires substantial to maximal assistance with bed mobility. [...]

Inspectors wroteBased on medical record review, observation, staff interview and facility policy review, the facility failed to complete incontinence care appropriately. This affected one resident (Resident #33) observed for incontinence care. The facility census was 76.

Inspectors wroteBased on observation, interview, medical record review, and facility policy review the facility failed to maintain infection control practices by failing to perform hand hygiene during meal tray service. This affected three of three (Resident #39, #40 and #43) residents observed during meal service. This had the potential to affect all thirteen residents residing on the Yass 2 unit. The facility census was 76.

Inspectors wroteBased on closed record review, hospital record review, policy review and interview the facility failed to implement a comprehensive, resident centered plan for the prevention and treatment of pressure ulcers. Actual Harm occurred on 09/03/25 when Resident #86, who had resided in the facility less than 30 days, was cognitively impaired and required staff assistance with activities of daily living, was assessed to have an unstageable pressure ulcer to the sacrum with necrosis requiring debridement. Resident #86 had been admitted to the facility on [DATE] with a skin alteration to the coccyx that the facility failed to complete a comprehensive wound assessment of, failed to provide appropriate/adequate interventions for and failed to ensure the facility wound physician and wound nurse were timely notified of to prevent the deterioration of the alteration to an unstageable pressure ulcer. [...]

Inspectors wroteBased on closed record review, self-reported incident review, facility investigation review, interviews, and policy review, the facility failed to complete a thorough investigation regarding an alleged sexual assault of Resident #85. This affected one (Resident #85) of three residents reviewed for abuse. The facility census was 84. Findings Include: Review of the closed medical record revealed Resident #85 was admitted on [DATE] with diagnoses that included a urinary tract infection, Parkinson ' s disease, fibromyalgia, and dystonia. The resident was discharged on 09/05/25. The hospital Discharge summary dated [DATE] revealed Resident #85 had a fall and was treated for a urinary tract infection. An admission summary dated [DATE] at 9:00 P.M. [...]

Inspectors wroteBased on closed record review, interview, and policy review, the facility failed to complete treatments, provide medications and obtain laboratory testing as ordered by the physician. This affected one (#86) of three residents reviewed for condition change. The facility census was 84.

Inspectors wroteBased on closed record review, interview, and policy review, the facility failed to ensure laboratory testing was completed per physician order. This affected one (#86) of three residents reviewed for condition change. The facility census was 84.

Inspectors wroteBased on observation, record review, review of wound notes, facility policy review and interview, the facility failed to assess, monitor, and implement a comprehensive and individualized prevention program to prevent the development of avoidable pressure ulcers and failed to ensure adequate interventions were in place to prevent new pressure injuries for Resident #61. Additionally, the facility failed to comprehensively assess, monitor and implement a treatment for Resident #80's unstageable (full-thickness skin and muscle loss, with slough or eschar obstructing the wound bed making it impossible to determine the true depth of the ulcer.) pressure ulcer on admission to the facility for more than two days. [...]

Inspectors wroteBased on observation, medical record review and interviews, the facility failed to ensure Resident #29 and #71 was treated in a dignified manner. This affected two residents (#29 and #71) of three residents reviewed for dignity. The facility census was 72. Findings Include: 1. Review of the medical record for Resident #29 revealed an initial admission date of 06/02/25 with the diagnoses including but not limited to encounter for surgical aftercare following surgery on the digestive system, infarction of spleen, activated protein C resistance, extranodal marginal zone B-cell lymphoma of mucosa associated lymphoid tissue, asthma, chronic kidney disease, hypertension, edema, atrial fibrillation, gout, sarcoidosis, hyerplipidemia, benign prostatic hyperplasia with lower urinary tract symptoms, presence of urogenital implants and other diseases of spleen. [...]

Inspectors wroteBased on observation, medical record review, interview and facility policy review, the facility failed to notify Resident #61's primary care physician of an unstageable deep tissue injury (DTI) (Persistent non-blanchable deep red, maroon or purple discoloration, intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). This affected one resident (#61) of three residents reviewed for pressure ulcers. The facility census was 72. Findings Include: [...]

Inspectors wroteBased on closed medical record review, interview and facility policy review, the facility to ensure the required information was provided to the receiving provider and the transfer was documented in the resident's medical record. This affected one resident (#42) of three residents reviewed for transfers. The facility census was 72. Findings Include: Review of the closed medical record for Resident #42 revealed an initial admission date of 12/02/22 with the diagnoses including but not limited to dementia with behavioral disturbances, symbolic dysfunctions, abnormal posture, violent behavior, repeated falls, diabetes mellitus, hypertension, hyperlipidemia, osteoporosis, overactive bladder, obesity and depression. The resident was discharged to an acute care hospital on [DATE]. [...]

Inspectors wroteBased on observation, medical record review, interview and facility policy review, the facility failed to residents with indwelling medical devices utilized enhanced barrier precautions (EBP) as required. This affected one resident (#39) of three residents reviewed for incontinence. The facility census was 72. Findings Include: Review of the medical record for Resident #39 revealed an initial admission date of 07/26/22 with the latest readmission of 02/10/23 with the diagnoses including but not limited to dementia with behavioral disturbances, dysphagia, chronic pulmonary edema, adult failure to thrive, hepatic failure, gastrostomy status, pressure ulcer of sacral region stage IV, disorders of lung, hypertension, depression, hyperlipidemia and osteoarthritis. [...]

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure weekly skin assessments were accurate and completed as well as treatment orders being in place and timely for two ( Resident #21 and #41) out of three residents reviewed for skin breakdown. The facility census was 85.

Inspectors wroteBased on medical record review, facility investigation report review, staff interview, and facility policy review, the facility failed to report an allegation of resident abuse to the State agency as required. This affected one resident (#46) of two resident investigative reports reviewed. The census was 83. Findings Include: [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, interviews, and facility investigation review, this facility failed to ensure a resident with a Do Not Resuscitate Comfort Care (DNRCC) code status did not receive life saving measures or cardiopulmonary resuscitation (CPR) after a cardiac arrest. This affected one (Resident #3) of the one resident reviewed for appropriate code status. The facility census was 96.

Inspectors wroteBased on medical record review, hospital documents review, staff interview, and facility policy review, this facility failed to obtained ordered urine samples for testing due to cloudy urine. This affected one (Resident #196) of the five resident reviewed for care and treatment to prevent hospitalization. The facility census was 96.

Inspectors wroteBased on medical record review, interview, observations, and facility policy review, this facility failed to maintain infection control measures while completing catheter care. This affected one (Resident #196) of the one resident observed for catheter care. The facility census was 96.

Inspectors wroteBased on observation and interview the facility failed to ensure the kitchen's hood filters were free from grease and dust. This had the potential to affect all 91 residents who consumed food from the kitchen. The facility identified two residents (#46 and #48) who ate nothing by mouth. The facility census was 93.

Inspectors wroteBased on record review, observation, resident/ responsible party interview, staff interview, and policy review, the facility failed to ensure residents who were dependent on staff for personal care received the assistance needed for bathing and other personal hygiene related care. This affected seven (Resident #4, #20, #42, #82, #245, #248, and #253) of nine residents reviewed for activities of daily living (ADL's).

Inspectors wrote2. On 02/26/24 at 2:47 P.M., an observation of Resident #253's room noted there was an intravenous (IV) bag (500 milliliters) of 0.9% Sodium Chloride and tubing hanging from an IV pole against the wall across from his bed. The IV tubing still had the IV catheter attached at the end of it and the IV catheter was exposed and noted to have dried blood in it. The resident's Power of Attorney (POA), who was in the room at the time of the observation, revealed the resident was given IV fluids about three days ago and the IV bag and tubing had been hanging there since then. He indicated there was blood still in the end of the tubing in the IV catheter. A review of Resident #253's medical record revealed he was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive care plans for Resident #30, Resident #59, and Resident #82. This affected three residents (#30, #59, #82) of 27 residents reviewed for comprehensive care plans.

Inspectors wroteBased on interview, record review, and policy review the facility failed to sufficiently identify and provide activities of interest to Resident #3, specifically on the weekend. This affected one resident (#3) of one resident reviewed for activities. The facility census was 93.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure Resident #4's weights were monitored and addressed timely related to cardio-pulmonary complications and failed to ensure Resident #245's surgical wound and anemia was monitored and properly treated. This affected two residents (Resident #4 and Resident #245) of three residents reviewed for quality of care.

Inspectors wroteBased on record review, review of the facility's 802 matrix, review of the wound physician's wound evaluations, staff interview, and policy review, the facility failed to ensure a resident's wound on his buttocks was properly assessed and classified to identify it as a pressure ulcer as indicated by the wound physician and not moisture associated skin dermatitis as indicated by the facility's wound nurse. This affected one (Resident #249) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow occupational therapy recommendations and physician orders for splints. This affected two residents (#3 and #42) of four residents reviewed for position and mobility. The facility census was 93.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure padded side rails were implemented as ordered for Resident #46 with a history of epilepsy. This affected one resident (Resident #46) of six residents reviewed for accident hazards. The facility census was 93.

Inspectors wroteBased on record review, interviews, and observations, the facility failed to timely order and initiate treatment for urinary tract infections (UTI's) for Resident #63 and failed to timely order and initiate appropriate treatments for Residents #22's catheter and Resident #82's nephrostomy tube. This affected three residents (Resident #22, #63, and #82) of three residents reviewed for catheter and urinary tract infections. The facility census was 93.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to develop and implement a comprehensive, effective and individualized nutritional program to ensure nutritional recommendations were addressed timely, nutritional interventions were implemented as ordered, and/or to recognize and address significant/severe resident weight loss. This affected four residents (#19, #22, #23, and #59) of seven residents reviewed for nutrition. The facility census was 93.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident #59 was capable of completing his own tracheostomy care and that tracheostomy care was completed as ordered. This affected one resident (Resident #59) out of one resident reviewed for tracheostomy care.

Inspectors wroteBased on record review, staff interview, and resident interview, the facility failed to ensure their contracted pharmacy provided pharmaceutical services to ensure medications were available for administration as ordered by the physician. This affected one resident (Resident #85) of two residents reviewed for antibiotic use. The facility census was 93.

Inspectors wroteBased on observation, record review, review of drug manufacturer's instructions, staff interview, and policy review, the facility failed to ensure their medication error rate did not exceed 5 percent (%). The facility had two medication errors out of 35 opportunities resulting in a medication error rate of 5.71%. This affected two residents (#248 and #397) of four residents reviewed for medication administration. The facility census was 93.

Inspectors wroteBased on interview, observation, and record review the facility failed to dispose of expired medication for Resident #47. This affected one resident (#47) of four residents reviewed for medication administration. The facility census was 93.

Inspectors wroteBased on observation, interview, medical record review, review of tray tickets, and review of diet descriptions the facility failed to ensure Resident #3 was served a puree diet as ordered. This affected one resident (#3) of nine residents reviewed for food/nutrition. The facility identified nine residents ( #59, #3, #31, #50, #250, #254, #27, #263, #23) ordered a pureed diet. The facility census was 93.

Inspectors wroteBased on observation, interview, and medical record review the facility failed to ensure food allergens were not served to Resident #261, and failed to ensure Resident #1, who had a physician identified lactose intolerance, was not served lactose containing foods. This affected two residents (#261 and #1) of nine residents reviewed for food/nutrition. The facility census was 93.

Inspectors wroteBased on observations, staff interview, medical record review, and policy review the facility failed to provide thickened liquids as ordered for one resident (#19). This affected one resident (#19) of nine residents reviewed for food/nutrition. The facility identified six residents (#3, #50, #19, #55, #263 and #42) who required thickened liquids. The facility census was 93.

Inspectors wroteBased on record review, staff interview, and resident interview, the facility failed to ensure resident records were complete and accurate regarding medications received and the proper location of wounds. This affected three residents (Resident #30, #46, and #85) of 25 residents reviewed for complete and accurate records. The facility census was 93.

Inspectors wroteBased on medical record review, observation, interview, and facility policy review, thhe facility failed to maintain infection control during Resident #60's dressing change, failed to ensure Resident #380's Foley catheter bag remained off the floor, failed to ensure proper hand hygiene with personal care and meal service, and failed to properly wear personal protecitve equipement related to prevention of COVID-19 transmission. This had the potential to affect all 80 residents residing at the facility at this time.

Inspectors wroteBased on staff interview, resident interview, observations, and facility policy review, the facility failed to serve food at an appetizing temperature. This affected Resident #24 with the potential to affect all 24 residents residing on the [NAME] Avenue hall (Resident #17, #24, #26, #28, #30, #31, #34, #35, #36, #38 #40, #49, #50, #51 #57, #60, #68, #73, #229, #427, #428, #429, #430, and #432). Findings Include: Review of the facility census, revealed Resident #17, #24, #26, #28, #30, #31, #34, #35, #36, #38 #40, #49, #50, #51 #57, #60, #68, #73, #229, #427, #428, #429, #430, and #432 resided on [NAME] Avenue hall. Observation on 02/28/22 at 12:38 P.M. revealed the lunch meal trays arrived to [NAME] Avenue hall and the door to insulated cart with the trays was left open until it was closed at 12:54 P.M. [...]

Inspectors wroteBased on staff interview, resident interview, medical record review, and facility policy review, the facility failed to provide proper assistance with toileting to ensure Resident #24 was treated with respect and dignity at all times. This affected one resident (Resident #24) of two residents reviewed for dignity.

Inspectors wroteBased on record review, resident and staff interviews, review of care conference notes, and facility policy review, the facility failed to conduct quarterly care conferences for Resident #36. This affected one resident (Resident #36) of one resident reviewed for care conferences.

Inspectors wroteBased on staff interview, resident interview, observations, and facility policy review, the facility failed to promote and facilitate resident self-determination through support of resident choice of meals. This affected one resident (Resident #427) of three residents reviewed for choices.

Inspectors wroteBased on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to obtain a physicians signature and authorization of Resident #60's preferred code status. This affected one resident (Resident #60) of one resident reviewed for advance directives.

Inspectors wroteBased on interview, observation, medical record review, and facility policy review, the facility failed to ensure Resident #36 received assistance to be bathed according to schedule. This affected one resident (Resident #36) of four residents reviewed for activities of daily living (ADL's).

Inspectors wrote2. Review of the medical record for Resident #36 revealed an admission date on 07/14/21. Medical diagnoses included cerebral infarction (stroke), chronic viral Hepatitis C, dyspnea (shortness of breath), localized edema, type II Diabetes Mellitus with diabetic chronic kidney disease, blindness in unspecified eye, morbid obesity, muscle weakness, long term use of insulin, dependence on renal dialysis, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the plan of care dated 07/15/21 revealed Resident #36 was at risk for signs and symptoms of hypo/hyperglycemia and diabetic complications related to diagnosis of Type II Diabetes Mellitus with neuropathy. Resident #36 was prone to elevated blood sugar in the evening and low blood sugar in the morning. Interventions included administer diabetic medication as ordered. [...]

Inspectors wroteBased on medical record review, resident and staff interviews, and review of facility policy, the facility failed to schedule an ophthalmology consult appointment timely for Resident #36. This affected one resident (Resident #36) of one resident reviewed for ancillary services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #27's interventions to promote wound healing and prevent pressure ulcer development were in place at all times. This affected one resident (Resident #27) of seven residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #37's interventions were implemented to reduce the resident's risk of contracture and skin break down related to left sided weakness. This affected one resident (Resident #37) of one resident reviewed for limited range of motion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow ordered fall prevention measures for Resident #30. This affected one resident (Resident #30) of six residents reviewed for falls.

Inspectors wroteBased on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to ensure Resident #24 received appropriate treatment and services to maintain or restore bowel and bladder function. This affected one resident (Resident #24) of one resident reviewed for bowel and bladder incontinence.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to timely address Resident #67's weight loss. This affected one resident (Resident #67) of four residents reviewed for nutrition.

Inspectors wroteBased on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to administer Resident #60's oxygen per physician orders. This affected one resident (Resident #60) of three residents reviewed for respiratory care.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure a rational was provided for a denial of Resident #2's pharmacy recommendations. This affected one resident (Resident #2) of five residents reviewed for drug regimen review.

Inspectors wroteBased on staff interview, medical record review, and facility policy review, the facility failed to decrease Resident #60's psychotropic medication per pharmacy and physician recommendations. This affected one resident (Resident #60) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on staff interview, resident interview, observations, medical record review, and facility policy review, the facility failed to assist Resident #60 in obtaining urgent dental care. This affected one (Resident #60) of four residents reviewed for dental care.