Health inspection·July 17, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on staff interview, observation, record review, and policy review, the facility failed to notify a resident representative of a new skin condition. This affected one (#15) of five residents reviewed for a change in condition. The facility census was 73.Review of the medical record for Resident #15 revealed an admission date of 01/11/22 with diagnoses of dementia, anxiety, anemia, and Type II diabetes mellitus.Review of the quarterly Minimum Data Set (MDS) assessment, completed 06/06/25, revealed Resident #15 had impaired cognition and required substantial/maximal assistance for bed mobility and was dependent for transfers.Review of Resident #15's electronic medical record (EMR) from 06/01/25 through 07/17/25 at 9:30 A.M. revealed no documentation regarding a bruise or new skin concern to Resident #15's face or neck. Additional review revealed no evidence Resident #15's representative was notified of a new skin condition on Resident #15's neck.Interview on 07/17/25 at 9:14 A.M. with Certified Nursing Assistant (CNA) #103 revealed she observed a change in condition to Resident #15 wherein bruising was noted to Resident #15's left neck and right jawline. CNA #103 stated she documented it in the CNA charting and it was also charted by the CNA on the previous shift.Observation on 07/17/25 at approximately 9:30 A.M., with Registered Nurse (RN) #202, of Resident #15 revealed a red area to Resident #15's neck on the left side of the front of her neck, halfway between the shoulder and jaw. Concurrent interview with RN #202 confirmed he did not document his assessment of the area on Resident #15's neck. RN #202 stated he was alerted to the new skin area on Resident #15 by the previous shift's nurse but could not clarify when he first became aware of the area. RN #202 confirmed he did not notify Resident #15's representative about the new skin area. Interview on 07/17/25 at 11:02 A.M. with the Administrator and RN Clinical Support (RNCS) #501 revealed the facility conducted an investigation into the new area on Resident #15's skin after the surveyor identified the lack of documentation in the EMR. RNCS #501 stated Resident #15's bruise was initially identified on 07/12/25 by Licensed Practical Nurse (LPN) #206 and reported to RN #202 to follow up on. RNCS #501 confirmed an assessment of the bruise was not documented and Resident #15's representative was not notified. RNCS #501 confirmed resident representatives should be notified when a new skin condition was identified. Review of the policy, Notification of Change in Condition, dated 05/10/16, revealed the resident's representative should be notified if there was an accident resulting in injury, a significant change in the resident's condition, or if there was a need to alter treatment significantly. Further review revealed documentation of notification should be recorded in the resident's electronic health record.This deficiency represents non-compliance investigated under Complaint Number 2561896. Page 1 of 3 365541 365541 07/17/2025 Heritage The 2820 Greenacre Dr Findlay, OH 45840

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on staff interview, record review, observation, and policy review, the facility failed to ensure timely assessments of a new skin condition. This affected one (#15) of five residents reviewed for change in condition. The facility census was 73.Findings include:Review of the medical record for Resident #15 revealed an admission date of 01/11/22 with diagnoses of dementia, anxiety, anemia, and type 2 diabetes mellitus.Review of the quarterly Minimum Data Set (MDS) assessment, completed 06/06/25, revealed Resident #15 had impaired cognition and required substantial/maximal assistance for bed mobility and was dependent for transfers.Review of Resident #15's Profile in the electronic medical record (EMR) revealed she required a mechanical lift for transfers since 06/10/22.Review of Resident #15's electronic medical record (EMR) dated 06/01/25 through 07/17/25 at 9:30 A.M. revealed no documentation regarding a bruise or new skin concern to Resident #15's face or neck.Review of the late entry Incident Report, initiated 07/17/25 at 11:08 A.M., revealed Resident #15 had a bruise to her left neck suspected to be caused by a mechanical lift sling.Interview on 07/17/25 at 9:14 A.M. with Certified Nursing Assistant (CNA) #103 revealed she observed a change in condition to Resident #15 wherein bruising was noted to Resident #15's left neck and right jawline. CNA #103 stated she documented it in the CNA charting and it was also charted by the CNA on the previous shift.Observation on 07/17/25 at approximately 9:30 A.M., with RN #202, of Resident #15 revealed a red area to Resident #15's neck on the left side of the front of her neck, halfway between the shoulder and jaw. Concurrent interview with RN #202 confirmed he did not document his assessment of the area on Resident #15's neck. Further, RN #202 denied any knowledge of a mark on Resident #15's jawline. RN #202 stated he was alerted to the new skin area on Resident #15 by the previous shift's nurse but could not clarify when he became aware of the area. RN #202 stated he did not create an Event in the EMR because he assumed the nurse on the previous shift would have initiated the Event. Additionally, RN #202 stated the Event in the EMR system created a prompt for staff to assess the area on each shift to monitor the new condition. RN #202 stated he was not prompted to complete and document an assessment of the area and confirmed he did not document any assessment of Resident #15's new skin condition.Interview on 07/17/25 at 11:02 A.M. with the Administrator and RN Clinical Support (RNCS) #501 revealed the facility conducted an investigation into the new area on Resident #15's skin after the surveyor identified the lack of documentation in the EMR. RNCS #501 stated Resident #15's bruise was initially identified on 07/12/25 by LPN #206 and reported to RN #202 to follow up on. RNCS #501 confirmed an assessment of the bruise was not documented. Concurrent review of a written statement obtained by RNCS #501 from RN #202 on 07/17/25 revealed RN #202 assessed Resident #15's bruise on 07/12/25 and RN #202 did not find the bruise suspicious as Resident #15 was transferred via mechanical lift and RN #202 had seen the lift sling rub against Resident #15's neck. Further review of the statement revealed RN #202 did not document an assessment of the bruise or suspected cause of the bruise.Observation on 07/17/25 at 11:55 A.M. revealed RN #202 measuring and assessing Resident #15's bruise. Concurrent interview with RN #202 confirmed it was left of center on her neck and halfway between her shoulder and jaw. RN #202 measured the area with a ruler, determining a width of two centimeters and a height of 0.7 centimeters. The coloring was brownish with yellowing around the edges. The edges were irregular and undefined. RN #202 stated the area had the appearance of an aging bruise. Further observation of Resident #15 revealed a scab on her left jaw. RN #202 stated it appeared to be an area Resident #15 picked. An attempted interview with Resident #15 at the time of the observation was unsuccessful.Follow-up interview on 07/17/25 at approximately 12:30 P.M. with the Administrator and RNCS #501 confirmed Resident #15's medical record contained no evidence of an assessment of a new bruise between Residents Affected - Few 365541 Page 2 of 3 365541 07/17/2025 Heritage The 2820 Greenacre Dr Findlay, OH 45840

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 07/12/25 and 07/17/25 until a late entry Incident Report was initiated on 07/17/25 at 11:08 A.M. RNCS #501 stated the facility policy allowed for back-dating documentation up to two weeks. Review of the facility policy titled, Bruise, Rash, Lesion, Skin Tear, Laceration Assessment Guidelines, dated 05/10/16, revealed an identified skin alteration occurring after admission should be followed by completing a Bruise incident in the EMR along with a progress note. Continued monitoring of the wound should be completed.This was an incidental finding identified during the Complaint Survey completed 07/17/25. 365541 Page 3 of 3