Health inspection·April 2, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure timely notification to the resident and medical practitioner regarding a change in the resident's condition and need to alter the resident's treatmet plan. This affected one resident (#98) of nine residents reviewed for notification. The facility census was 104. Findings include: Review of Resident #98's medical record revealed an admission date of 12/10/19, a re-entry date of 01/28/25 with diagnoses including cerebral infarction, neuropathy, anxiety and major depression. Review of Resident #98's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview for mental status score of 15/15 indicating the resident had intact cognition. Review of Resident #98's progress note dated 03/27/25 at 2:43 P.M. revealed the resident was having lower back pain and facility staff notified the nurse practitioner and obtained orders to get an x-ray and to give Tylenol 500 milligrams two tablets three times daily as needed for pain. Review of the lumbosacral spine x-ray completed on 03/27/25 and reported on 03/27/25 at 7:19 P.M. revealed L 2 and L 3 compression deformities were noted of an undetermined age. An interview on 03/31/25 at 12:17 P.M. with Resident #98 confirmed the resident received an x-ray on 03/27/25 but the resident had not yet heard what the results of the x-ray were. Further review of Resident #98's progress notes revealed a note written on 03/31/25 by the nurse practitioner that indicated new orders were written for lab work and Prednisone 20 milligrams daily for three days to help with pain control. No further progress notes were noted at the time of the review. Review of Resident #98's progress notes revealed she was not notified of the x-ray results from 03/27/25 and the new orders from 03/31/25 until 04/01/25 at 2:00 P.M. The progress note was entered as a late entry on 04/02/25 at 10:30 A.M. In an interview on 04/02/25 at 3:00 P.M. Unit Manager Licensed Practical Nurse (LPN) #563 confirmed Resident #98 was not notified of the x-ray results from 03/27/25 and the new orders from 03/31/25 until 04/01/25 and this information was not documented until 04/02/25 as a late entry. LPN #563 further confirmed there was no documentation of the nurse practitioner being made aware of the x-ray Page 1 of 3 366462 366462 04/02/2025 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0580 Level of Harm - Minimal harm or potential for actual harm results until 03/31/24 when the nurse practitioner documented her progress note. LPN #563 was unable to provide a reason for the delay in notification to the resident or the nurse practitioner. This deficiency represents non-compliance investigated under Complaint Number OH00163802. Residents Affected - Few 366462 Page 2 of 3 366462 04/02/2025 Canal Winchester Care Center 6800 Gender Road Canal Winchester, OH 43110

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and medical record review the facility failed to develop a comprehensive resident centered pressure ulcer prevention care plan for one resident (#107) of five reviewed for prevention of alterations in skin integrity. The facility census was 104. Findings include: Review of Resident #107's medical record revealed an admission date of 02/23/25, a discharge date of 03/12/25 and diagnoses including diverticulitis of the intestine with perforation and abscess, influenza, colostomy status, bladder disorder, rheumatoid arthritis, anxiety, unspecified disorder of psychological development and unspecified intellectual disabilities. Review of Resident #107's admission minimum data set (MDS) revealed a brief interview for mental status score of 12 indicating the resident was moderately cognitively impaired. Further review of Resident #107's MDS revealed the resident to be at risk for pressure ulcers, to be receiving a surgical wound care and to be using a pressure reducing mattress. Review of Resident #107's care plan revealed no care plan in place to prevent the development of pressure ulcers. In an interview on 04/02/25 at 12:11 P.M. MDS Coordinator Registered Nurse #533 verified the MDS indicated Resident #107 was at risk for pressure ulcers and that a care plan was not in place to prevent pressure ulcers for Resident #107. In an interview on 04/02/25 at 2:55 P.M. Certified Nursing Assistant #624 revealed she was not aware of Resident #107 having any skin impairments other that her surgical incision. This deficiency is an incidental finding discovered during the complaint investigation. 366462 Page 3 of 3