Health inspection·March 28, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on interview and medical record review, the facility failed to complete pressure ulcer wound care per physician orders. This affected one resident (Resident #12) out of three residents reviewed for wound care. The facility census was 48. Residents Affected - Few Findings include: Review of the medical record for Resident #12 revealed an admission date of 01/11/24 with diagnoses including osteomyelitis (infection of bone), muscle wasting and atrophy, dysphagia, pressure ulcer of the sacral region, anxiety disorder, and tracheostomy status. Review of the admission Minimum Data Set (MDS) assessment completed on 01/18/24 revealed Resident #12 had moderately impaired cognition, was always incontinent of urine, was dependent on staff for toileting and bathing, and was admitted with two unhealed, unstageable pressure ulcers. Review of the care plan dated 03/12/24 revealed Resident #12 was at high risk for altered skin integrity related to altered sensations, fragile skin, impaired mobility, incontinence, a colostomy bag for elimination, and a condom catheter. The care plan further revealed Resident #12 had actual impaired skin integrity related to an unstageable pressure ulcer on the middle of his back and sacral area. Interventions included skin assessments as ordered, medications and treatments as ordered, and wound care as ordered. Review of the physician orders revealed Resident #12 had orders for treatments including the following. • Cleanse sacrum with normal saline (NS), apply silver alginate and cover with foam dressing every day shift for wound care (Order date 01/30/2024 timed 2:27 P.M. and discontinued date 02/11/2024 timed 11:27 A.M.). • Cleanse mid back with NS, gently pack undermining with calcium alginate rope and cover with foam dressing every day shift for wound (Order date 02/02/2024 timed 4:14 P.M. and discontinued date 02/11/2024 timed 11:27 A.M.). • Page 1 of 16 366087 366087 03/28/2024 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0686 Level of Harm - Minimal harm or potential for actual harm Cleanse mid back with NS, apply collagen silver to wound bed, cover with calcium alginate and cover with foam dressing every shift for wound care (Order date 02/14/2024 timed 1:34 P.M. and discontinued date 02/26/2024 timed 7:32 P.M.). • Residents Affected - Few Cleanse sacrum with NS, apply collagen silver, apply calcium alginate and cover with foam dressing every shift for wound (Order date 02/14/2024 1:40 P.M. and discontinued date 02/21/2024 timed 8:25 A.M.). • Pack sacral wound with Dakins soaked gauze and cover with foam dressing daily and as needed every day shift (Order date 03/12/2024 at 2:08 A.M. and discontinued date 03/21/2024 timed 12:59 P.M.). • Apply wound vacuum (a device that provides vacuum-assisted closure of a wound) at 125 millimeters (mm) of mercury (Hg) continuous pressure. Apply to mid back wound. Change Tuesdays, Thursdays, and Saturdays (Order date 03/02/2024 timed 3:26 P.M. and discontinued date 03/11/2024 timed 9:48 A.M.). • Apply wound vacuum (wound vac) at 125 mmHg continuous pressure to mid back wound. Change Tuesdays, Thursdays, and Saturdays (Order date 03/12/2024 timed 2:08 A.M. and discontinued d 03/21/2024 timed 12:58 P.M.). Review of the treatment administration record (TAR), electronic medication administration record (e-MAR), and nursing progress notes from February 2024 revealed the following. • The order to cleanse sacrum with normal sale (NS), apply silver alginate and cover with foam dressing every day shift was not completed on 02/01/24, 02/02/24, or 02/06/24 with no reason provided in the eMAR notes or the progress notes. • The order to cleanse mid back with NS, gently pack undermining with calcium alginate rope and cover with foam dressing every day shift was not completed on 02/06/24 with no reason provided in the eMAR notes or the nursing progress notes. • The order to cleanse mid back with NS, apply collagen silver to wound bed, cover with calcium alginate and cover with foam dressing every shift was not completed on day shift on 02/16/24, 02/21/24, 03/23/24, or 02/24/24. Review of the eMAR notes and nursing progress notes revealed no reason the ordered wound care was not completed on these dates. 366087 Page 2 of 16 366087 03/28/2024 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0686 • Level of Harm - Minimal harm or potential for actual harm The order to cleanse sacrum with NS, apply collagen silver, apply calcium alginate and cover with foam dressing every shift was not completed on day shift, 02/16/24. Review of the eMAR notes and nursing progress notes revealed no reason the wound care was not completed on 02/16/24. Residents Affected - Few Review of the TAR, eMAR, and nursing progress notes from March 2024 revealed the following. • The order to pack sacral wound with Dakins soaked gauze and cover with foam dressing daily was not signed-off as completed on 03/14/24 or 03/15/24. There was no eMAR note or progress note revealing why the treatment was not completed. • Change the wound vac at 125 mmHg continuous pressure to Resident #12's mid back wound every Tuesday, Thursday, and Saturday. This order was not followed as evidenced by the wound vac was not changed on 03/05/24 for reason listed as other/See Nurses Note. Review of the eMAR and nurses progress notes revealed no reason was provided for the wound vac dressing not being changed on this date, which was a Tuesday. • The order to apply a wound vac at 125 mmHg continuous pressure to Resident #12's mid back wound and change Tuesdays, Thursdays, and Saturdays was not completed on Thursday, 03/14/24. Review of the eMAR and nursing progress notes revealed no reason given for the wound vac change to be omitted. Interview on 03/27/24 at 2:42 P.M. with Resident #12 revealed that up until the past week or so, he was not always getting his dressings changed like he was supposed to because the nurses told him they were short-staffed and they would get to it later, but sometimes they did not have the time to come back. Interview on 03/28/24 at 1:30 P.M. with the Director of Nursing (DON) indicated there was no ability to confirm whether the ordered wound treatments were performed on the dates they were not signed-off, including the treatments to the sacral wound on 02/01/24, 02/02/24, or 02/06/24, 02/16/24, 03/14/24 and 03/15/24. Treatments to the mid-back wound on 02/06/24, 02/16/24, 02/21/24, 03/23/24, and 02/24/24, and changing of the wound vac on 03/05/24 and 03/14/24. Review of the undated facility policy titled Medication Administration (GENERAL) revealed once treatments and medications were administered, the person administering the medication or treatment was responsible for initialing in the appropriate space provided under the date and time to indicate the treatment was administered. Review of the undated facility policy titled Pressure Ulcer Prevention and Risk Identification revealed treatments and interventions for skin pressure areas would be implemented as indicated by the physician. This deficiency represents non-compliance investigated under Complaint Number OH00151617. 366087 Page 3 of 16 366087 03/28/2024 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interviews, record review, and facility policy review the facility failed to ensure timely and appropriate incontinence care was provided for Resident #36 and Resident #38. This affected two of three residents who were reviewed for incontinence care. The facility census was 48. Findings include: 1. Review of the Medical Record for Resident #36 revealed an admission date of 12/23/21. Diagnoses included atrial fibrillation, muscle wasting and atrophy, type two diabetes mellitus, moderate protein-calorie malnutrition, adult failure to thrive, and systolic (congestive) heart failure. Review of the quarterly Minimum Data Set (MDS) assessment completed on 03/08/24 revealed Resident #36 had intact cognition, was dependent for toileting, always incontinent of urine, was at risk for the development of pressure ulcers, and had no skin issues at the time of the assessment. Review of the latest assessment titled CHS Skin assessment weekly/return/ER/LOA, dated 03/21/24, revealed Resident #36 had intact skin. Review of the Care Plan dated 03/08/24 revealed Resident #36 had an alteration in activities of daily living (ADL) performance and participation related to her listed diagnoses. Interventions included providing perineal care with each incontinent episode, providing preventative skin care, and monitoring for any skin breakdown. Review of the toileting hygiene and bladder continence tasks documented in the electronic medical record revealed no record of bladder continence or toileting hygiene on 03/04/24, 03/05/24, 03/09/24, 03/12/24, 03/18/24, 03/19/24, 03/21/24, 03/22/24, or 03/26/24. One instance of bladder continence check and toileting hygiene on 02/29/24, 03/01/24 through 03/03/24, 03/06/24 through 03/08/24, 03/11/24, 03/13/24, 03/14/24, 03/16/24 through 03/20/24, and 03/24/24. Two instances of bladder continence checks and toileting hygiene on 02/28/24, 03/10/24, 03/15/24, 03/23/24, and 03/27/24. Review of the intake and output forms for 02/27/24 revealed no written documentation of urine output or incontinence care for Resident #38 on 02/27/24 or 03/27/24. There were no other paper intake or output forms filled out between 03/01/24 and 03/27/24. Observation on 03/27/24 at 10:30 A.M. of Resident #36 receiving incontinence care from State Tested Nurse Aide (STNA) #148 revealed mild redness and an open area to the left buttock with a scant amount of blood noted on the incontinence brief, as well as on the washcloth, as STNA #148 was cleaning the area. Interview on 03/27/24 at 10:40 A.M. with Resident #36 revealed she was only able to feel she was wet when her brief was overly saturated with urine. Further interview revealed the reddened, open area on her bottom was new and she got open areas occasionally from wearing wet briefs. Resident #36 stated staff typically did not check her for incontinence during the night unless she activated her call light because she felt she was soaked. Resident #36 added that staff sometimes turned her call light off indicating they would return, and then she was left waiting for the next shift to come in and change her. During the interview, Resident #36 also stated whether she got checked and changed 366087 Page 4 of 16 366087 03/28/2024 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few regularly for incontinence during the days shifts depended on which staff were working. She stated some staff just came in to reposition her and never checked to see if she was wet. Interview on 03/27/24 at 10:57 A.M. with STNA #148 confirmed Resident #36 should be checked for incontinence every two hours and changed as needed. She further confirmed the open area on Resident #36's left buttock. During the interview, STNA #148 revealed new skin concerns should be reported to the nurse and documented on the skin sheet, but added she had not been assigned this hall recently and assumed the nurse already knew about the open area on Resident #36's left buttock. Interview on 03/28/24 at 12:32 P.M. with the Director of Nursing (DON) revealed residents who required repositioning and incontinence care should be observed every two hours and checked for incontinence. An additional interview with the DON on 03/28/24 at 2:45 P.M. revealed since the end of February 2024 staff on the East wing documented incontinence care in the electronic medical record except for 03/27/24 and 03/28/24, which were documented on paper intake and output forms and the column under voids and incontinence care was blank for 03/28/24. Review of the undated facility policy titled Incontinence Care revealed the facility would provide incontinence care to maintain skin integrity and provide comfort and self esteem for the residents. Further review revealed reddened areas or skin breakdown noted during incontinence care was to be reported to the nurse. 2. Review of the Medical Record for Resident #38 revealed an admission date of 06/29/19. Diagnoses included amyotrophic lateral sclerosis (ALS), dysphagia, lack of coordination, muscle wasting and atrophy, protein-calorie malnutrition, and a stage four pressure ulcer of sacral region. Review of the quarterly Minimum Data Set (MDS) assessment completed on 01/16/24 revealed Resident #38 had severely impaired cognition, was dependent for toileting, always incontinent of bowel and bladder, received tube feedings, and had an unhealed stage four pressure ulcer. Review of the Care Plan dated 01/16/24 revealed Resident #38 had an alteration in activities of daily living (ADL) performance and participation related to her listed diagnoses. Interventions included providing perineal care with each incontinent episode, providing preventative skin care, and monitoring for any skin breakdown. Further review of the medical record revealed Resident #38 was not in the facility from 03/18/24 through 03/22/24. Review of the toileting hygiene and bladder continence tasks documented in the electronic medical record revealed no record of bladder continence or toileting hygiene on 03/03/24, 03/04/24, 03/05/24, 03/08/24, 03/09/24, 03/12/2403/16/24, or 03/17/24. One instance of bladder continence check and toileting hygiene on 02/29/24, 03/01/24 through 03/03/24, 03/06/24, 03/07/24, 03/11/24 through 03/15/24, and 03/24/24. Two instances of bladder continence checks and toileting hygiene on 02/28/24, 03/10/24, 03/23/24, and 03/27/24. Review of the written intake and output forms for 02/27/24 revealed no documentation of urine output or incontinence care for Resident #38 on 02/27/24. Review also revealed one void and incontinence care on night shift on 03/27/24. There were no other paper documentation forms between 02/27/24 366087 Page 5 of 16 366087 03/28/2024 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0690 through 03/27/24. Level of Harm - Minimal harm or potential for actual harm Interview on 03/28/24 at 12:32 P.M. with the Director of Nursing (DON) revealed residents who required repositioning and incontinence care should be observed every two hours and checked for incontinence. Residents Affected - Few An additional interview with the DON on 03/28/24 at 2:45 P.M. confirmed since the end of February 2024 staff on the East wing documented the incontinence care in the electronic medical record except for 03/27/24 and 03/28/24, which were documented on paper intake and output forms and the column under voids and incontinence care was blank for 03/28/24. Review of the undated facility policy titled Incontinence Care revealed the facility would provide incontinence care to maintain skin integrity and provide comfort and self-esteem for the residents. This deficiency represents non-compliance investigated under Complaint Number OH00151901, OH00151617, and OH00151630. 366087 Page 6 of 16 366087 03/28/2024 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with staff and residents, record review, policy review, and review of the the the payroll-based journal (PBJ) staffing report, the facility failed to have sufficient staffing to meet the needs of the residents. This affected Residents #12, #36, and #38 and had the potential to affect all residents. The census was 48. Findings include: 1. Review of the PBJ staffing report from fiscal year (FY) quarter one (10/01/23 through 12/31/23) revealed the facility had a one star staffing rating and excessively low weekend staffing. Observation upon entrance to the facility on [DATE] at 1:51 P.M. revealed no staff members in the hallways or at the nurses' station on the [NAME] wing (skilled unit) and the call light on for room [ROOM NUMBER]. Further observation revealed two housekeepers wheeling their carts down the first hall of the [NAME] wing, but no nursing staff were observed in the [NAME] wing. No nursing staff was observed in the front hall of the [NAME] wing until 2:01 P.M. when they responded to the call light in room [ROOM NUMBER]. Random observations throughout the afternoon on 03/26/24 revealed the nurse assigned to the [NAME] wing and the nurse assigned to the East (LTC - long-term care unit) wing were also passing medications to residents in the Assisted Living section of the facility. Interview on 03/26/24 at 3:35 P.M. with Licensed practical nurse (LPN) #113 revealed she was the nurse assigned to the East wing (LTC), and she was also responsible for half of the Assisted Living (AL) residents in the 300 hall, and the nurse on the [NAME] wing took care of residents on the other half of the AL hall. Further interview revealed there were supposed to be two aides working the East wing, but she often found herself working with only one aide. LPN #113 verbalized difficulty getting work assignments completed due to most of the residents on the unit required two staff to assist with bed mobility, transfers, and assistance with activities of daily living (ADLs). LPN #113 further stated due to a call-off on 03/18/24, a test ready state tested nurse aide (STNA) was the only STNA assigned the East wing independently, although he had not yet completed orientation. Interview on 03/26/24 at 3:40 P.M. with STNA #118 revealed she was concerned about the number of residents requiring the assistance of two staff and mechanical lifts and that it was rare there was another STNA assigned on the unit with her and she often had to pull the nurse away from passing medications to help with care that required two staff. Interview on 03/26/24 at 3:4 5 P.M. with STNA #110 revealed the facility was often short-staffed and there were many residents that required the assistance of two staff for care. STNA #110 further stated even if two STNAs were on duty, the acuity of some of the residents took time away from the ability to assist other residents and answer call lights timely. Interview on 03/26/24 at 5:11 P.M. with Registered Nurse (RN) #138 revealed she was working the East Wing with only one STNA due to a call-off. An additional interview on 03/27/24 at 8:33 A.M. confirmed she was assigned to the East wing, as well as half of the AL. 366087 Page 7 of 16 366087 03/28/2024 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the list of residents requiring a mechanical lift and/or two-person assistance with transfers revealed 21 of the 48 residents residing in the facility required assistance of two staff for all transfers. 2. Interview on 03/27/24 at 2:42 P.M. with Resident #12 revealed that up until the past week or so, he was not always getting his dressings changed like he was supposed to because the nurses told him they were short-staffed and would get to it later, but sometimes they did not have time to come back. He further stated he didn't think he was getting all his medications like he was supposed to, and he wouldn't know what was missing since it was mixed and went into his feeding tube, but he knows he missed a dose of Methadone and the medication that helped him feel less anxious. During the interview, Resident #12 verbalized he was very scared something bad could happen to him because there was not a lot of staff, and it took a long time to get someone to answer his call light. He stated on 03/25/24 he had his light on for over an hour during day shift because he needed repositioned for comfort, stating the discomfort lasted for a couple hours. Resident #12 stated he feared what could happen if he had a medical emergency and staff did not respond timely. Review of the medical record for Resident #12 revealed an admission date of 01/11/24 with diagnoses including osteomyelitis, muscle wasting and atrophy, dysphagia, pressure ulcer of the sacral region, anxiety disorder, and tracheostomy status. Review of the admission Minimum Data Set (MDS) assessment completed on 01/18/24 revealed Resident #12 had moderately impaired cognition, was always incontinent of urine and was dependent on staff for toileting and bathing. The MDS also revealed Resident #12 was admitted with two unhealed, unstageable pressure ulcers and was on a scheduled pain medication regimen. Review of the care plan dated 03/12/24 revealed Resident #12 was high risk for altered skin integrity related to altered sensations, fragile skin, impaired mobility, incontinence, a colostomy bag for elimination, and a condom catheter. Resident #12 had actual impaired skin integrity related to an unstageable pressure ulcer on the middle of his back and sacral area. Interventions included skin assessments as ordered, medications and treatments as ordered, and wound care as ordered. Resident #12 had an alteration in cardiac function related to heart failure, hyperlipidemia, and hypertension. Resident #12 had an alteration in health maintenance related to gastroesophageal reflux disease (GERD), respiratory failure, and chronic obstructive pulmonary disease (COPD). Interventions included administering medications as ordered. According to the care plan, Resident #12 also required antidepressant medication for major depressive disorder. The facility was to administer the antidepressant medication per physician's order and notify the physician of any changes. Review of the physician orders revealed Resident #12 had orders for medications and treatments, including: - Lovenox Injection Solution Inject 40 milligrams (mg) subcutaneously in the morning for prevention of deep vein thrombosis (DVT), dated 02/12/24. - Vericiguat Oral Tablet (Vericiguat), give 10 mg via percutaneous endoscopic gastrostomy (PEG) tube in the mornings related to heart failure, dated 01/11/24. - Brovana Inhalation Nebulization Solution 15 micrograms (mcg)/2 milliliters (ml) 1 unit inhale orally via nebulizer two times a day related to acute and chronic respiratory failure with hypoxia, dated 01/11/24. 366087 Page 8 of 16 366087 03/28/2024 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0725 - Methadone oral tablet 5 mg, give three tablets by mouth two times a day for pain, dated 01/15/24. Level of Harm - Minimal harm or potential for actual harm - Cleanse sacrum with normal sale (NS), apply silver alginate and cover with foam dressing every day shift for wound care (Order date- 01/30/2024 timed 2:27 P.M., discontinue (D/C) date- 02/11/2024 timed 11:27 A.M.). Residents Affected - Many - Cleanse mid back with NS, gently pack undermining with calcium alginate rope and cover with foam dressing every day shift for wound (Order date- 02/02/2024 timed 4:14 P.M., D/C date- 02/11/2024 timed 11:27 A.M.). - Cleanse mid back with NS, apply collagen silver to wound bed, cover with calcium alginate and cover with foam dressing every shift for wound care (Order date- 02/14/2024 timed 1:34 P.M., D/C date 02/26/2024 timed 7:32 P.M.). - Cleanse sacrum with NS, apply collagen silver, apply calcium alginate and cover with foam dressing every shift for wound (Order date- 02/14/2024 timed 1:40 P.M., D/C date- 02/21/2024 timed 8:25 A.M.). - Duloxetine hydrochloride (HCl) oral capsule delayed Release particles, give 20 mg via PEG-Tube in the morning related to major depressive disorder, dated 03/12/2024. - Vericiguat oral tablet, give 2.5 mg via PEG-Tube in the morning related to heart failure, dated 03/12/2024. - Pack sacral wound with Dakins soaked gauze and cover with foam dressing daily and as needed every day shift (Order date- 03/12/2024 timed 2:08 A.M., D/C date- 03/21/2024 timed 12:59 P.M.). - Apply wound vacuum (wound vac - a device that provides vacuum-assisted closure of a wound) at 125 millimeters (mm) of mercury (Hg) continuous pressure. Apply to mid back wound. Change Tuesdays, Thursdays, and Saturdays (Order date- 03/02/2024 timed 3:26 P.M., D/C date- 03/11/2024 timed 9:48 A.M.) - Apply wound vac at 125 mmHg continuous pressure to mid back wound. Change Tuesdays, Thursdays, and Saturdays (Order date- 03/12/2024 timed 2:08 A.M., D/C date- 03/21/2024 timed 12:58 P.M.). Review of the medication treatment record (MAR), the treatment administration record (TAR), the electronic medication administration record (eMAR) notes, and nursing progress notes from February 2024 revealed the following: - Lovenox 40 mg subcutaneously in the morning for prevention of deep vein thrombosis was not given. Review of the eMAR notes and progress notes revealed no reason for the omission. - Vericiguat 10 mg via PEG tube in the mornings related to heart failure was held on 02/11/24 and was not administered on 02/12/24 for reason listed as Other. Review of the eMAR notes and progress notes revealed no reason for the medication not being administered on 02/11/24 or 02/12/24. - Brovana Inhalation Nebulization Solution 15 micrograms (mcg)/2 milliliters (ml) 1 unit inhale orally via nebulizer two times a day related to acute and chronic respiratory failure with hypoxia was held on day shift 02/15/24. Review of the eMAR notes and nursing progress notes revealed no reason the medication was being held. 366087 Page 9 of 16 366087 03/28/2024 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many - Methadone oral tablets, 15 mg twice daily was not given the morning of 02/26/24. Review of the eMAR notes and nursing progress notes revealed no reason the medication was omitted the morning of 02/26/24. - The order to cleanse sacrum with normal sale (NS), apply silver alginate and cover with foam dressing every day shift was not completed on 02/01/24, 02/02/24, or 02/06/24 with no reason provided in the eMAR notes or the progress notes. - The order to cleanse mid back with NS, gently pack undermining with calcium alginate rope and cover with foam dressing every day shift was not completed on 02/06/24 with no reason provided in the eMAR notes or the nursing progress notes. - The order to cleanse mid back with NS, apply collagen silver to wound bed, cover with calcium alginate and cover with foam dressing every shift was not completed on day shift on 02/16/24, 02/21/24, 03/23/24, or 02/24/24. Review of the eMAR notes and nursing progress notes revealed no reason the ordered wound care was not completed on these dates. - The order to cleanse sacrum with NS, apply collagen silver, apply calcium alginate and cover with foam dressing every shift was not completed on day shift, 02/16/24. Review of the eMAR notes and nursing progress notes revealed no reason the wound care was not completed on 02/16/24. Review of the MAR, TAR, eMAR notes, and nursing progress notes from March 2024 revealed the following: - Duloxetine HCL 20 mg via PEG-tube every morning for major depressive disorder was held on 03/14/24, 03/19/24, 03/20/24, and 03/23/24 with no reason provided. Review of the eMAR notes and nursing progress notes revealed no reason Duloxetine was held on these dates - The order to pack sacral wound with Dakins soaked gauze and cover with foam dressing daily was not signed-off as completed on 03/14/24 or 03/15/24. There was no eMAR note or progress note revealing why the treatment was not completed. - Change the wound vac at 125 mmHg continuous pressure to Resident #12's mid back wound every Tuesday, Thursday, and Saturday. This order was not followed as evidenced by the wound vac was not changed on 03/05/24 for reason listed as other/See Nurses Note. Review of the eMAR and nurses progress notes revealed no reason was provided for the wound vac dressing not being changed on this date, which was a Tuesday. - The order to apply a wound vac at 125 mmHg continuous pressure to Resident #12's mid back wound and change Tuesdays, Thursdays, and Saturdays was not completed on Thursday, 03/14/24. Review of the eMAR and nursing progress notes revealed no reason given for the wound vac change to be omitted. Interview on 03/28/24 at 1:30 P.M. with the Director of Nursing (DON) confirmed there was no reason for the Lovenox, Brovana, or Duloxetine being held or omitted in February 2024 and March 2024. Regarding the Vericiguat that was held on 02/11/24 and omitted with reason Other on 02/12/24, the DON said it was probably not yet delivered from the pharmacy due to it being a high-cost medication with no alternatives. The DON further revealed no ability to confirm whether the ordered wound treatments were performed on the dates they were not signed-off, including treatments to the sacral wound on 02/01/24, 02/02/24, or 02/06/24, 02/16/24, 03/14/24 and 03/15/24; treatments to the mid-back wound on 366087 Page 10 of 16 366087 03/28/2024 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0725 02/06/24, 02/16/24, 02/21/24, 03/23/24, and 02/24/24, and Level of Harm - Minimal harm or potential for actual harm changing of the wound vac on 03/05/24 and 03/14/24. Residents Affected - Many Review of the undated facility policy titled Medication Administration (GENERAL) revealed once treatments and medications were administered, the person administering the medication or treatment was responsible for initialing in the appropriate space provided under the date and time to indicate the treatment was administered. The policy further revealed if a medication was not administered, the reason should be provided and if two or more consecutive doses are withheld, the physician was to be notified. Review of the undated facility policy titled Pressure Ulcer Prevention and Risk Identification revealed treatments and interventions for skin pressure areas would be implemented as indicated by the physician. 3. Interview on 03/27/24 at 10:40 A.M. with Resident #36 revealed staff took a long time to respond to her call light, citing up to an hour or so on occasion. She further revealed staff occasionally turned her call light off, told her they would be back, and then she was left waiting for the next shift to come in and change her. During the interview, Resident #36 revealed she was only able to feel she was wet when her incontinence brief was overly saturated with urine; otherwise, she was unable to tell if she was wet. Further interview revealed she had a new open area on her left buttock, and she got open areas occasionally from wearing wet briefs. Resident #36 stated staff typically did not check her for incontinence during the night unless she activated her call light once she felt that she was soaked. During the interview, Resident #36 also stated there was not always staff to check to see if she was incontinent during day shifts. Review of the Medical Record for Resident #36 revealed an admission date of 12/23/21. Diagnoses included atrial fibrillation, muscle wasting and atrophy, type two diabetes mellitus, moderate protein-calorie malnutrition, adult failure to thrive, and systolic (congestive) heart failure. Review of the quarterly Minimum Data Set (MDS) assessment completed on 03/08/24 revealed Resident #36 had intact cognition, was dependent for toileting, always incontinent of urine, was at risk for the development of pressure ulcers, and had no skin issues at the time of the assessment. Review of the latest assessment titled CHS Skin assessment weekly/return/ER/LOA, dated 03/21/24, revealed Resident #36 had intact skin. Review of the Care Plan dated 03/08/24 revealed Resident #36 had an alteration in activities of daily living (ADL) performance and participation related to her listed diagnoses. Interventions included providing perineal care with each incontinent episode, providing preventative skin care, and monitoring for any skin breakdown. Review of the toileting hygiene and bladder continence tasks documented in the electronic medical record revealed no record of bladder continence or toileting hygiene on 03/04/24, 03/05/24, 03/09/24, 03/12/24, 03/18/24, 03/19/24, 03/21/24, 03/22/24, or 03/26/24. One instance of bladder continence check and toileting hygiene on 02/29/24, 03/01/24 through 03/03/24, 03/06/24 through 03/08/24, 03/11/24, 03/13/24, 03/14/24, 03/16/24 through 03/20/24, and 03/24/24. Two instances of bladder continence checks and toileting hygiene on 02/28/24, 03/10/24, 03/15/24, 03/23/24, and 03/27/24. 366087 Page 11 of 16 366087 03/28/2024 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the intake and output forms for 02/27/24 revealed no written documentation of urine output or incontinence care for Resident #38 on 02/27/24 or 03/27/24. There were no other paper intake or output forms filled out between 03/01/24 and 03/27/24 to review. Observation on 03/27/24 at 10:30 A.M. of Resident #36 receiving incontinence care from State Tested Nurse Aide (STNA) #148 revealed mild redness and an open area to the left buttock with a scant amount of blood noted on the brief, as well as on the washcloth, as STNA #148 was cleaning the area. Interview on 03/27/24 at 10:57 A.M. with STNA #148 confirmed Resident #36 should be checked for incontinence every two hours and changed as needed. STNA #148 further confirmed the open area on Resident #36's left buttock. Interview on 03/28/24 at 12:32 P.M. with the Director of Nursing (DON) revealed residents who required repositioning and incontinence care should be observed every two hours and checked for incontinence. An additional interview with the DON on 03/28/24 at 2:45 P.M. confirmed staff on the East wing documented the incontinence care in the electronic medical record since the end of February 2024, except for 03/27/24 and 03/28/24, which were documented on paper intake and output forms and the column under voids and incontinence care was blank for 03/28/24 at the time of the interview. Review of the undated facility policy titled Incontinence Care revealed the facility would provide incontinence care to maintain skin integrity and provide comfort and self esteem for the residents. Further review revealed reddened areas or skin breakdown noted during incontinence care was to be reported to the nurse. 4. Review of the Medical Record for Resident #38 revealed an admission date of 06/29/19. Diagnoses included amyotrophic lateral sclerosis (ALS), dysphagia, lack of coordination, muscle wasting and atrophy, need for assistance with personal care, protein-calorie malnutrition, and a stage four pressure ulcer of sacral region. Review of the quarterly Minimum Data Set (MDS) assessment completed on 01/16/24 revealed Resident #38 had severely impaired cognition, was dependent for toileting, always incontinent of bowel and bladder, received tube feedings, and had an unhealed stage four pressure ulcer. Review of the Care Plan dated 01/16/24 revealed Resident #38 had an alteration in activities of daily living (ADL) performance and participation related to her listed diagnoses. Interventions included providing perineal care with each incontinent episode, providing preventative skin care, and monitoring for any skin breakdown. Review of the medical record revealed Resident #38 was not in the facility from 03/18/24 through 03/22/24. Review of the toileting hygiene and bladder continence tasks documented in the electronic medical record revealed the following no record of bladder continence or toileting hygiene on 03/03/24, 03/04/24, 03/05/24, 03/08/24, 03/09/24, 03/12/2403/16/24, or 03/17/24. One instance of bladder continence check and toileting hygiene on 02/29/24, 03/01/24 through 03/03/24, 03/06/24, 03/07/24, 03/11/24 through 03/15/24, and 03/24/24. Two instances of bladder continence checks and toileting hygiene on 02/28/24, 03/10/24, 03/23/24, and 03/27/24. 366087 Page 12 of 16 366087 03/28/2024 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the written intake and output forms for 02/27/24 revealed no documentation of urine output or incontinence care for Resident #38 on 02/27/24. Review also revealed one void and incontinence care on night shift on 03/27/24. There were no other paper documentation forms between 02/27/24 through 03/27/24. Interview on 03/28/24 at 12:32 P.M. with the Director of Nursing (DON) revealed residents who required repositioning and incontinence care should be observed every two hours and checked for incontinence. An additional interview with the DON on 03/28/24 at 2:45 P.M. confirmed staff on the East wing documented the incontinence care in the electronic medical record since the end of February 2024, except for 03/27/24 and 03/28/24, which were documented on paper intake and output forms and the column under voids and incontinence care was blank for 03/28/24. Review of the undated facility policy titled Incontinence Care revealed the facility would provide incontinence care to maintain skin integrity and provide comfort and self-esteem for the residents. This deficiency represents non-compliance investigated under Complaint Number OH00151901, OH00151617, and OH00151630. 366087 Page 13 of 16 366087 03/28/2024 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on record review and interviews, the facility failed to ensure registered nurse coverage at least eight hours per day, seven days per week. This had the potential to affect all 48 residents residing in the facility. Residents Affected - Many Findings include: Review of the staffing schedules from 03/03/24 to 03/09/24 with Human Resources (HR) #158 revealed no evidence of registered nurse (RN) coverage on 03/09/24 for at least eight hours as required. Interview on 03/28/24 at 11:58 A.M. with HR #158 confirmed the facility did not have RN coverage of at least eight hours on 03/09/24. At the time of the interview, the Administrator was also present and verified there was no RN coverage in the building for at least eight consecutive hours. This deficiency represents non-compliance investigated unde Complaint Number OH00151901, OH00151617, and OH00151630. 366087 Page 14 of 16 366087 03/28/2024 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on medical record review and interview, the facility failed to maintain accurate medical records for Resident #1 and Resident #12. This affected two residents (#1 and #12) of six residents reviewed for documentation of medications and wound care treatments. The facility census was 48. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 01/12/24 with diagnoses including acute and chronic respiratory failure with hypoxia, need for assistance with personal care, chronic obstructive pulmonary disease, type two diabetes mellitus, pneumonia, and hypertension. Review of the admission Minimum Data Set (MDS) assessment completed on 01/18/24 revealed Resident #1 had intact cognition, was incontinent of urine, dependent for toileting, and had no unhealed pressure ulcers. Review of the assessment titled Skin Grid Pressure 3.0 - V2 dated 01/23/24 revealed a new pressure area of the left buttock described as a shallow circular area composed of friable granular tissue. Review of physician orders revealed an order dated 02/13/24 to cleanse the open area to the left buttock with wound cleanser, apply alginate, cover with foam dressing, and change daily and as needed every day shift until healed. Further review of the physician orders revealed orders dated 02/13/24 to turn and reposition Resident #1 every shift and to apply Nystatin topical cream 100,000 units per gram (gm) to Resident #1's bilateral labial folds topically every shift for irritation. Review of the Treatment Administration Record (TAR) revealed no indication the ordered wound care to Resident #1's left buttock was completed on 02/16/24, 02/21/24,02/23/24, or 02/24/24. Further review of the TAR revealed no documentation that Resident #1 was turned or repositioned on day shift on 02/21/24, 02/23/24, or 02/24/24 or that she received Nystatin cream on 02/15/24, 02/21/24, 02/23/24, or 02/24/24 during the day shift. Interview on 03/27/24 at 1:55 P.M. with Resident #1 revealed no concerns related to receiving ordered medications or treatments as ordered. Interview on 03/28/24 at 1:30 P.M. with the Director of Nursing (DON) confirmed no documentation was on the TAR for the wound care to Resident #1's left buttock on 02/16/24, 02/21/24,02/23/24, and 02/24/24; no documented evidence Resident #1 was turned or repositioned on 02/21/24, 02/23/24, and 02/24/24; and no documentation Nystatin cream was applied on day shift of 02/15/24, 02/21/24, 02/23/24, or 02/24/24. The DON further revealed the cream was kept at Resident #1's bedside and was applied during incontinence care by the STNAs, but the nurse forgot to document it was completed. Review of the undated facility policy titled Medication Administration (GENERAL) revealed once treatments and medications were administered, the person administering the medication or treatment was responsible for initialing in the appropriate space provided under the date and time to indicate the treatment was administered. 366087 Page 15 of 16 366087 03/28/2024 Vista Center, The 100 Vista Drive Lisbon, OH 44432

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the medical record for Resident #12 revealed an admission date of 01/11/24 with diagnoses including osteomyelitis, muscle wasting and atrophy, dysphagia, pressure ulcer of the sacral region, anxiety disorder, and tracheostomy status. Review of the admission Minimum Data Set (MDS) assessment completed on 01/18/24 revealed Resident #12 had moderately impaired cognition. Further review of the MDS revealed Resident #12 was admitted with two unhealed, unstageable pressure ulcers and was on a scheduled pain medication regimen. Review of the care plan dated 03/12/24 revealed Resident #12 was high risk for altered skin integrity related to altered sensations, fragile skin, impaired mobility, incontinence, a colostomy bag for elimination, and a condom catheter. The care plan further revealed Resident #12 had actual impaired skin integrity related to an unstageable pressure ulcer on the middle of his back and sacral area. Interventions included skin assessments as ordered, medications and treatments as ordered, and wound care as ordered. Review of the physician orders revealed an order dated 02/22/24 for Resident #12 to have a wound vacuum (wound vac - a device that provides vacuum-assisted closure of a wound) set at 125 millimeters (mm) of mercury (Hg) of continuous pressure to be bridged from the mid back wound to the sacral wound. The order further noted the wound vac dressing was to be changed every Tuesday, Thursday, and Saturday. Review of the Treatment Administration Record (TAR) revealed no documentation that the wound vac was applied until 02/27/28. Interview on 03/28/24 at 1:30 P.M. with the Director of Nursing (DON) revealed the wound vac arrived at the facility the evening of 02/23/24 and she came into the facility and applied the wound vac onto Resident #12's mid-back and sacral wounds on 02/24/24. The DON said she forgot to sign-off that she performed this wound treatment on 02/24/24. Review of the undated facility policy titled Medication Administration (GENERAL) revealed once treatments and medications were administered, the person administering the medication or treatment was responsible for initialing in the appropriate space provided under the date and time to indicate the treatment was administered. 366087 Page 16 of 16