Health inspection·October 9, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, hospital record review, and interview, the facility failed to ensure Resident #39 received proper care and assistance in managing his ostomy and tube feed needs. This affected one resident (Resident #39) of three residents reviewed for dependent resident care.Findings include:Review of Resident #39's medical record revealed an admission date of 03/31/25 and a return date of 08/31/25. Resident #39's diagnoses included acute and chronic respiratory failure with hypoxia, Rett's syndrome, Todd's paralysis (post epileptic), and epileptic seizures related to external causes, not intractable, with status epilepticus.Review of Resident #39's Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status was not completed because he was rarely or never understood. Resident #39 was dependent for activity of daily living (ADL), the ability to roll from lying on his back to the left and right side and return to lying on back on the bed, and chair-to-bed-to-chair transfers. Resident #39 had a wheelchair. Resident #39 had a catheter and an ostomy. Resident #39 had medically complex conditions. Review of Resident #39's care plan revised 08/12/25 revealed Resident #39 had self-care deficits related to acute and chronic respiratory failure, seizure disorder and other diagnoses. Resident #39's needs would be met through the next review. Interventions included Resident #39 was dependent on two staff and used a mechanical lift; last check and change on last rounds on night shift.Review of Resident #39's Enteral Administration History dated 08/01/25 through 08/31/25 revealed enteral feeding tube site care, once a day, clean tube feeding site and apply split gauze to area daily was documented it was completed every day as ordered including 08/31/25. Review of Resident #39's nursing orders dated 08/05/25 revealed orders for skin checks weekly and as needed.Review of Resident #39's physician orders dated 08/05/25 revealed orders for Calmoseptine (menthol-zinc oxide) 0.44 -20.6 percent, apply to GJ (gastrojejunostomy) irritation as needed.Review of Resident #39's nursing orders dated 08/05/25 revealed orders to change colostomy skin barrier appliance (wafer) as needed for leakage or detachment.Review of Resident #39's nursing orders dated 08/05/25 revealed orders to change colostomy bag, pouch and set up as needed.Review of Resident #39's nursing orders dated 08/05/25 revealed orders to monitor stoma site and peristomal skin every shift, monitor for redness, tenderness, itching, burning, and, or swelling. Report changes to provider and document in a note, every day shift and night shift.Review of Resident #39's progress notes dated 08/26/25 through 08/31/25 did not reveal evidence Resident #39's right lower abdominal area was very red and irritated.Review of Resident #39's Treatment Administration History dated 08/26/25 revealed the weekly skin check was marked it was done but there was no evidence a weekly skin check observation was completed.Review of Resident #39's Treatment Administration History dated 08/31/25 revealed there was no evidence Resident #39's colostomy skin barrier appliance was changed due to it being detached from the ostomy. There was no evidence Resident #39's colostomy bag, pouch and set-up was changed due to it being detached from the ostomy.Review of Resident #39's Treatment Residents Affected - Few Page 1 of 10 366487 366487 10/09/2025 Tallmadge Health & Rehab Center 619 Northwest Avenue Tallmadge, OH 44278

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Administration History dated 08/05/25 through 08/31/25 did not reveal evidence Calmoseptine ointment was applied for GJ irritation.Review of the facility assignment sheets dated 08/31/25 from 7:00 A.M. through 7:00 P.M. revealed Nurse #229 was assigned to care for Resident #39.Review of Resident #39's Treatment Administration History dated 08/31/25 on day shift documented by Nurse #229 revealed Resident #39's stoma site and peristomal skin did not have redness, tenderness, itching, burning or swelling. Review of Resident #39's progress notes dated 08/31/25 at 9:35 A.M. revealed the respiratory therapist (RT) called Nurse #229 to Resident #39's room. Nurse #229 found Resident #39's tube (G-tube) was out and he needed to go to the local hospital ED for a new tube.Review of Resident #39's progress notes dated 08/31/25 at 9:35 A.M. through 08/31/25 at 10:33 A.M. did not reveal evidence Resident #39's ostomy bag was detached from his ostomy site and needed replaced. There was no evidence Resident #39's tube feeding was draining onto Resident #39 and the floor of his room.Review of Resident #39's progress notes dated 08/31/25 at 10:33 A.M. revealed Resident #39 was transported via EMS to the ED.Review of Resident #39's hospital ED progress notes dated 08/31/25 at 11:41 A.M. revealed Resident #39 arrived at the hospital ED via EMS from the facility. It was reported that Resident #39's G-tube was out and the facility was unaware when it became dislodged. The EMS staff stated when they arrived at the facility Resident #39 was covered in feed from the feeding tube and no ostomy bag was on the ostomy. The EMS staff asked the facility to place a bag on the ostomy and Resident #39 arrived at the hospital ED with an ostomy bag laid on top of the ostomy and the ostomy bag was not attached. The bag was not attached to the ostomy and gastric contents from the ostomy were leaking over Resident #39's skin, into Resident #39's diaper (incontinence brief) and on his abdominal binder. Resident #39's binder was saturated. The G-tube had brown contents leaking from the site onto the skin. Pictures were obtained by the physician. Resident #39 was bathed, given a clean incontinence brief and clean gown. A dressing was applied around the G-tube site. A new ostomy bag was placed to Resident #39's ostomy. Resident #39's skin on his right lower abdomen was extremely red and irritated. The physician checked placement of Resident #39's G-tube. The RT was notified Resident #39 had a trach. Resident #39 was covered with warm blankets. On 08/31/25 at 3:43 P.M. Resident #39 was discharged to the facility and was awake, alert and appropriate for baseline at discharge.Review of Resident #39's hospital ED physician provider notes dated 08/31/25 revealed Resident #39 had a history of multiple chronic medical problems who presented with his G-tube displaced. Resident #39 arrived via EMS with concerns for neglect at his home health care facility. On EMS arrival to Resident #39's room at the facility his feeding tube was noted to be dislodged. The timing of the dislodgement was unknown. A drain of unknown purpose was found leaking into a basin. Resident #39's ostomy bag was not in place, with leakage noted and Resident #39 was covered in feces and stomach contents. There was tube feed spillage on the floor and feces on his bed. Resident #39's room at the facility was described as being without stimulation such as toys or a television. This was a recurrent issue regarding Resident #39's care at the facility. Additional comments included Resident #39 had an ostomy with a [NAME] button in place draining yellow-green fluid onto the abdominal wall. The balloon was filled with 5 cc of fluid. There were crusties on the stoma and the ostomy site was covered by an ostomy bag without any adhesive. Liquid stool was expelled from the stoma onto the abdominal wall. Stoma site appeared irritated and there was erythematous satellite lesions surrounding the stoma on the abdomen. Review of Resident #39's hospital ED notes dated 08/31/25 revealed Resident #39's final diagnoses included candida dermatitis, leaking percutaneous endoscopic gastrostomy tube (PEG), irritant contact dermatitis associated with digestive stoma, and medical neglect of an adult by a caregiver. Start Calmoseptine (menthol-zinc oxide) 0.44-20.6 percent ointment, apply to affected areas on abdominal 366487 Page 2 of 10 366487 10/09/2025 Tallmadge Health & Rehab Center 619 Northwest Avenue Tallmadge, OH 44278

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wall twice daily for at least two weeks, and nystatin 100000 units per gram ointment, apply to red areas on abdominal wall twice daily for at least two weeks.Review of Resident #39's progress notes dated 08/31/25 at 4:20 P.M. revealed Resident #39 returned to the facility and had a new tube (G-tube) placed.Observation on 09/24/25 at 2:55 P.M. of Resident #39 revealed the door was closed to his room and there was an Enhanced Barrier Precaution sign on the door. The surveyor knocked on the door, opened the door and as the door was opened a very unpleasant, strong odor was noticed. A large puddle of greenish-yellow material was noted on the floor under Resident #39's padded wheelchair. Resident #39 was alone in the room with no staff present and was sitting in a padded wheelchair. The padded wheelchair was positioned so Resident #39 was sitting in a tilted backward position. Fresh drip marks were seen on the back of the padded wheelchair and the drips led to the puddle on the floor. A long tube could be seen that appeared to come from Resident #39's abdominal area and the long tube was attached to a small bag that was laying in a basin, and the basin was placed on the floor. The bag had a small amount of thick yellowish material in it. Tube feeding was being administered via a pump through another tube leading to Resident #39's abdomen. Nurse #430 entered Resident #39's room and stated the J-tube (jejunostomy) was used for tube feeding and the other tube was gastric contents. Nurse #430 confirmed there was a large puddle of yellowish-green material on the floor under Resident #39's wheelchair. Nurse #430 lifted Resident #39's shirt, an abdominal binder was observed and a tube could be seen under the abdominal binder but it was unclear where it originated. About six inches from the abdominal binder a pillow case could be seen and it was wrapped around the tube draining gastric contents. The pillowcase was saturated with greenish-yellow material. Certified Nursing Assistant (CNA) #296 stated Resident #39 was at activities and Activity Director (AD) #227 brought him back to his room and closed the door. CNA #296 stated the door to Resident #39's room should not be closed unless care was being provided. Nurse #430 stated she did not wrap a pillowcase around the tube draining gastric contents and she thought the night nurse stayed over and wrapped it. Nurse #430 stated the night nurse told her the tube was leaking, but Nurse #430 did not think the tube was leaking as much as it was and she had not checked it since around 12:00 P.M. Assistant Director of Nursing (ADON) #275 entered Resident #39's room and indicated the tube draining gastric contents was a venting drain. Resident #39 was assisted into his bed using a mechanical lift, and the wheelchair seat was wet on the left side near where the venting drain was leaking. Resident #39's pants and shirt were wet from the drainage, and his incontinence brief was soaked with the yellowish-green drainage. CNA #296 stated she wrapped Resident #39's tube with the pillowcase in the morning because it was leaking, and it was not the night nurse who wrapped it. Observation revealed Resident #39's right lower abdomen and penis were very red and irritated looking. Nurse #430 confirmed the areas were red and indicated it always looks like that. When asked if there was any treatment ordered Nurse #430 was unclear in her answer and stated he is always digging and fidgety. ADON #275 left the room to get supplies to change the venting tube tubing, returned and changed the tubing. Resident #39 was unable to be assisted back to his wheelchair due to the mechanical lift pad was wet with the yellowish-green drainage and there were no clean mechanical lift pads available.Interview on 09/24/25 at 3:26 P.M. of AD #227 revealed Resident #39 did not attend activities today (09/24/25) because in the morning around 10:30 A.M. when she went to his room to assist him to activities he needed his medication and was unable to come. AD #227 stated she tried to get him for the afternoon activity around 1:45 P.M. but his door was closed and she thought he was having care provided and AD #227 left without entering Resident #39's room. Interview on 09/24/24 at 3:45 P.M. of Nurse #430 revealed Resident #39 had a G-tube and that was the tube that was long and connected to a bag that was placed in the basin on 366487 Page 3 of 10 366487 10/09/2025 Tallmadge Health & Rehab Center 619 Northwest Avenue Tallmadge, OH 44278

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the floor, and the G-tube was leaking gastric contents onto Resident #39, his clothes, his incontinence brief, his abdominal binder, the wheelchair and the floor. Nurse #430 stated Resident #39 had a J-tube (jejunostomy tube) that was connected to the tube feeding, and he had a colostomy. Nurse #430 stated Resident #39 scratched himself and caused redness to the abdomen and penis, and there was no treatment ordered for the reddened areas.Interview on 09/25/25 at 1:23 P.M. of Nurse #229 revealed she did not remember caring for Resident #39 on 08/31/25 when his G-tube became dislodged, his ostomy bag was not attached to the ostomy site, and he was transported to the hospital.Interview on 09/25/25 at 5:15 P.M. of Nurse Practitioner (NP) #435 revealed she was not aware Resident #39 had redness of his lower abdomen and penis and was not notified the areas were red. NP #435 stated she was not surprised the areas were red because he had a G-tube and a colostomy. NP #435 stated Resident #39 had a colostomy, a trach, and a J and G tube. There was one tube inserted into Resident #39's abdomen and it had two ports. The G-tube was for gastric emptying and the J-tube was connected to tube feeding.Review of the facility policy titled Ostomy Care Procedure revised 09/19/24 included nursing personnel with demonstrated competence may provide routine ostomy site care. Changing the ostomy system included to remove and empty the used pouch, remove the wafer by gently and gradually loosening around the adhesive area, and gently cleanse the peristomal area with warm tap water and wash cloth, do not use soap. Pat the stoma and skin dry, and measure the stoma size using the measuring guide. It was important to fit the opening closely to the size of the stoma so little peristomal skin was exposed. Trace the pattern of the size of the opening on the wafer backing and cut the opening to size. Apply skin prep to the peristomal skin, remove adhesive wafer back and apply firmly to the peristomal skin. Attach the new bag to the [NAME] and close the end of the pouch with the closure device. Document per policy.Review of the facility policy titled Enteral Feeding Tube Policy revised 11/19/24 included licensed clinicians with demonstrated competence may administer enteral feedings and provide tube, site care. At each access of the tube for installation of fluids, nutrition, or medications, verification of placement would be conducted using the following methods: evaluate the clinical presentation of the residents including respiratory status, complaints of nausea, vomiting, feelings of fullness or excessive belching, or unusual abdominal distention. Observation of the volume and character of gastric aspirate. Do not use the tube if there was any doubt about its correct placement and contact the physician, provider for guidance. Enteral tube entrance [NAME] would be monitored daily and observed for erythema, edema, drainage including quantity, odor, appearance. Nurses should monitor the condition of the tube with each use and inform the physician if the tube becomes unusable, leaks or might need replacement. This deficiency represents non-compliance investigated under Complaint Number 2609502, 1404959, 1404954, and 1404958. 366487 Page 4 of 10 366487 10/09/2025 Tallmadge Health & Rehab Center 619 Northwest Avenue Tallmadge, OH 44278

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, policy review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer program to ensure necessary and timely interventions were initiated for Resident #96 who was identified to have skin breakdown in the hospital just prior to admission. The facility also failed to timely identify changes in skin integrity and implement necessary wound care to promote wound healing and prevent infection.Actual harm occurred on 07/31/25 when Resident #96, who was dependent on staff for activities of daily living, was transferred to the hospital due to a change in condition. The resident was subsequently assessed by hospital staff to have an unstageable sacral wound with a significant amount of purulence in the tissue consistent with a necrotizing soft tissue infection. Hospital staff also documented the resident had a pressure injury to the right buttock, a pressure injury to the right heel (assessed to be black), a pressure injury to the upper posterior right leg (assessed to be a suspected deep tissue pressure injury). Prior to the hospital identification and assessment, there was no evidence the facility had knowledge of these areas or an active treatment plan in place to prevent, monitor and promote healing. This affected one resident (#96) of three residents reviewed for wound/pressure ulcers.Findings include:Review of Resident #96's medical record revealed an After Visit Summary for a hospital stay from 06/30/25 through 07/08/25 that reflected Resident #96 had a coccyx (active) pressure injury (identified on 07/05/25). On 07/06/25 the coccyx pressure area was non-blanchable (skin discoloration that did not fade or turn white when pressed, indicating bleeding under the skin rather than increased blood flow. This type of discoloration was a significant clinical sign that required immediate medical attention, as it could signal developing pressure injuries), had erythema (abnormal redness of the skin, caused by dilation and irritation of the superficial capillaries), sloughing (sloughing in pressure injuries referred to the presence of dead tissue, appearing as yellow, tan, gray, or green stringy material that covered the wound bed. This tissue consisted of protein fibers and dead skin cells and impeded healing by obscuring the wounds true depth and staging) and was pink. The peri-wound was blanchable, had erythema and was fragile. The hospital record noted treatment to the coccyx pressure area included cleansing, a moisture barrier ointment and foam dressing. Review of Resident #96's closed medical record revealed an admission date of 07/08/25 with diagnoses including malignant neoplasm of the ascending colon, secondary neoplasm of the liver and intrahepatic bile duct, severe protein calorie malnutrition and type two diabetes mellitus with diabetic polyneuropathy. On 07/31/25 Resident #96 was transported to the hospital emergency department (ED), admitted to the hospital and did not return to the facility. Review of Resident #96's facility admission Observation dated 07/08/25 at 6:19 P.M. documented Resident #96 had no alterations in skin. The admission observation failed to include identification of the pressure injury to the resident's coccyx identified on 07/05/25 during the resident's hospitalization or treatment that was in place to the area. Resident #96's Braden Scale assessment dated [DATE] revealed the resident was at high risk for developing pressure ulcers, injuries.Review of Resident #96's care plan dated 07/08/25 included Resident #96 was at risk for pressure ulcers related to his diagnoses. The goal developed was for Resident #96's skin to remain intact. Interventions included to conduct a systematic skin inspection weekly and as needed (pay particular attention to the bony prominences) and report signs of skin breakdown (sore, tender, red, or broken areas). The plan of care failed to include evidence of the pressure injury to the resident's coccyx identified on 07/05/25 during the resident's hospitalization or evidence ongoing treatment was in place to the area. Review of Resident #96's Weekly Observation dated 07/08/25 revealed there were no skin issues noted. Review of Residents Affected - Few 366487 Page 5 of 10 366487 10/09/2025 Tallmadge Health & Rehab Center 619 Northwest Avenue Tallmadge, OH 44278

F 0686 Level of Harm - Actual harm Residents Affected - Few Resident #96's Observations dated 07/08/25 through 07/31/25 did not reveal evidence additional Weekly Observations were completed. In addition, review of the Observations dated 07/08/25 through 07/31/25 revealed no evidence Assistant Director of Nursing (ADON) #275 had completed a skin assessment during this time.Review of Resident #96's physician orders dated 07/08/25 revealed pressure reducing/reduction orders to float heels when in bed as tolerated, every shift (day shift and night shift). Provide pressure reducing cushion to chair and document cushion in place in the chair. Provide pressure reducing mattress to the bed and document that mattress was in place. Turn and reposition in bed as tolerated every shift, every day shift and night shift. Review of Resident #96's medical record including progress notes, General Administration Records, Treatment Administration Records, Medication Administration Records and Point of Care aide charting dated 07/08/25 through 07/31/25 revealed no documented evidence Resident #96 was turned and repositioned when he was in bed. In addition, there was no documented evidence of pressure reducing cushion was placed on his chair, a pressure reducing mattress was on his bed or his heels were floated when he was in bed.Review of a facility Wound Summary Report dated 07/08/25 through 07/31/25 revealed it did not include Resident #96 had any type of wounds/pressure ulcers.Review of Resident #96's Wound Management records dated 07/08/25 through 07/31/25 revealed no evidence Resident #96 had any type of wounds/pressure ulcers.Review of Resident #96's shower sheets dated 07/11/25, 07/14/25, 07/16/25, 07/18/25, 07/22/21, 07/25/25 and 07/28/25 revealed no documented evidence of any type of pressure ulcers, or any reddened or open areas to the resident's coccyx. Review of Resident #96's admission Minimum Data Set assessment dated [DATE] revealed Resident #96 was cognitively intact. The assessment revealed Resident #96 was dependent (on staff) for toileting hygiene, lower body dressing and the ability to move from lying on the back to sitting on the side of the bed. Resident #96 required substantial to maximal (staff) assistance with bathing, upper body dressing, and the ability to roll from lying on his back to the left and right side and return to lying on his back. Resident #96 was occasionally incontinent of urine and always incontinent of bowel. The assessment revealed Resident #96 was at risk of developing pressure ulcers, injuries. Review of Resident #96's physician orders dated 07/16/25 revealed PATH (skilled nursing documentation) observation to be completed every shift, twice a day. Review of Resident #96's PATH observation documentation dated 07/16/25 through 07/30/25 revealed observations were not completed two times a day as ordered. There was no PATH documentation on 07/19/25 or 07/20/25. On 07/21/25 there was one PATH observation. There were no PATH observations documented on 07/23/25, 07/24/25, 07/25/25, 07/27/25, 07/28/25, or 07/29/25. On 07/26/25 and 07/30/25 there was only one PATH observation documented.Review of Resident #96's PATH observations from 07/16/25 through 07/30/25 revealed the nurses documented Resident #96's skin was intact and he did not have an order for a dressing. However, review of Resident #96's Point of Care History dated 07/16/25 at 1:43 P.M., documented by State Tested Nursing Assistant (STNA) #295, revealed Resident #96 had an open area on his buttock and a dressing on his buttock. On 07/19/25 at 9:55 A.M. STNA #295 documented Resident #96 had an open area on his buttock and a dressing on his buttock. On 07/28/25 at 10:13 A.M. and 07/30/25 at 9:09 A.M., STNA #295 documented Resident #96 had a dressing on his buttock. Resident #96's Occupational Therapy Treatment Encounter Note dated 07/23/25 revealed Resident #96 complained of coccyx pain and nursing was aware. Resident #96 had poor tolerance for sitting in a wheelchair, had slouched posture with hips very close to the edge of the seat. Resident #96 reported it was due to pain of the coccyx and Resident #96 refused to stay in the chair following the session and was assisted to his bed. The note was signed by Occupational Therapist (OT) #410 on 07/23/25 at 12:54 P.M. Review of Resident #96's progress notes dated 07/22/25 at 12:13 P.M. through 07/24/25 revealed no written evidence Resident #96 was 366487 Page 6 of 10 366487 10/09/2025 Tallmadge Health & Rehab Center 619 Northwest Avenue Tallmadge, OH 44278

F 0686 Level of Harm - Actual harm Residents Affected - Few having pain in his coccyx during therapy or evidence interventions were attempted related to the pain or to determine the source of the pain.Review of a transportation schedule revealed Resident #96 was transported by the facility to a physician appointment on 07/31/25 at 11:00 A.M.However, review of the corresponding nursing progress note dated 07/31/25 revealed no documentation was completed on this date related to the resident leaving to go to the appointment, the resident's condition at the time he left and/or the resident's status. There was no additional entry/documentation to reflect the resident was transferred from the physician appointment to the emergency room and subsequently admitted to the hospital and/or why. Review of Resident #96's ED to Hospital admission paperwork dated 07/31/25 included Resident #96's arrival time was 07/31/25 at 11:27 A.M. Resident #96 had an appointment at the hospital cancer center, was unresponsive and hypoxic and was transported to the ED. A nasal trumpet (a soft flexible tube inserted into a nostril to keep the airway open) was placed and Resident #96 was put on a non-rebreather mask (delivers high concentrations of oxygen to patients who are experiencing severe respiratory distress but do not require mechanical ventilation) and his oxygen saturations began to increase. Resident #96 was minimally responsive on arrival. Resident #96's reason for the visit included hypoxia, sepsis, an unstageable pressure injury of the sacral region, a wound of the sacral region, initial encounter, a wound of the sacral region subsequent encounter. Further review of the hospital record revealed on 07/05/25 at 8:00 A.M. an unstageable pressure injury of the coccyx was first assessed. On 07/08/25 at 9:20 A.M. Resident #96 was assessed to have a Deep Tissue pressure injury to the right buttock (active) which was first assessed on this date. On 07/08/25 at 9:20 A.M. Resident #96 had a Deep Tissue Pressure Injury of the right heel. On 08/01/25 at 8:00 A.M. Resident #96 had a right, upper posterior leg Deep Tissue Injury. Review of a hospital operative note dated 08/05/25 revealed Resident #96 had an unstageable sacral wound. Resident #96 had an excisional debridement (skin subcutaneous tissue muscle fascia) necrotizing soft tissue infection of the sacrum and measurements included length of 11.0 centimeters (cm) with a width of 16 cm. There was a significant amount of purulence in the tissue consistent with a necrotizing soft tissue infection. The postoperative diagnosis was necrotizing soft tissue infection of the sacrum.Review of Resident #96's After Visit Summary for a hospital visit dated 07/31/25 through 08/17/25 included Resident #96 had a wound identified on 07/05/25 as a pressure injury to the coccyx (active). On 08/01/25 at 3:50 P.M. the coccyx was documented to be necrotic. The area was cleansed and a foam dressing was applied. The number of days the wound had been present was listed as 28. Resident #96 had a pressure injury of the right buttock (active) identified on 07/08/25. The number of days listed that the pressure injury was present was 25. A pressure injury of the right heel (active) was identified on 07/08/25. On 08/01/25 at 1:26 P.M. the right heel was assessed and was described as black. The treatment was site care. Number of days present was 25. An upper posterior right leg pressure injury (active) was identified on 08/01/25 at 1:27 P.M. The upper posterior right leg pressure injury was described as purple (a purple or maroon color in a pressure injury, also known as a suspected deep tissue pressure injury indicated damage to the underlying soft tissue even if the skin was intact). The treatment was site care. The number of days was one.Interview on 09/24/25 at 11:55 A.M. with Resident #96's spouse (Wife #425) revealed she thought Resident #96 had a sore starting on his backside when he was admitted to the facility and he had a bed sore on his heel. Wife #425 stated someone at the hospital gave her a white bottle with medication that needed put on Resident #96's sores, and she gave the medication to a nurse at the facility and told her it needed put on the sores. Wife #425 could not remember what nurse at the facility she gave the medication to and did not know the name of the medication in the white bottle. On 07/31/25 Resident #96 had an appointment at the hospital to see 366487 Page 7 of 10 366487 10/09/2025 Tallmadge Health & Rehab Center 619 Northwest Avenue Tallmadge, OH 44278

F 0686 Level of Harm - Actual harm Residents Affected - Few an oncologist, but when he got there he was in a bad state, unresponsive, and he was taken to the ED. Wife #425 stated when Resident #96 was re-admitted to the hospital on [DATE] he had a deep wound on his backside, he needed surgery, and the surgeon told her it was one of the worst wounds he had seen. The wound was very deep and going into his spine. Wife #425 indicated she asked Resident #96 more than once if his wounds were being treated and she told the nurse the wounds were not being treated. Wife #425 stated Resident #96 was not changed timely and layed in feces for hours. One time Wife #425 stated she charged down to the nurse's station and was told they would be right in, but they did not come in. Wife #425 stated she told the social worker and she made sure Resident #96's incontinence brief was changed. Wife #425 stated Resident #96 had a lot of different aides and none took care of him consistently.Interview on 09/24/25 at 4:13 P.M. with OT #410 revealed she gave Resident #96 a shower, but did not remember details of any abnormal skin areas. OT #410 revealed Resident #96 was very frail and thin and did not spend much time out of bed.Interview on 09/24/25 at 5:06 P.M. of Nurse #247 revealed she did not remember Resident #96.Interview on 09/25/25 at 11:32 A.M. with the Director of Nursing (DON) revealed she was unaware Resident #96 had any wounds when he was admitted to the facility or during his stay at the facility. Interview on 09/25/25 at 11:33 A.M. with Assistant Director of Nursing (ADON) #275 revealed after residents were admitted to the facility a Team review of the resident was completed. The Team reviewed paperwork and made sure everything on the discharge summary was addressed and followed up if everything was not addressed. ADON #275 stated she did not remember Resident #96 having any wounds and when she evaluated him, she denied any awareness of wounds.During an interview on 09/25/25 at 12:03 P.M. with Regional Director of Operations (RDO) #400, RDO #400 reviewed Resident #96's hospital paperwork (prior to admission) and verified the resident had a non-blanchable area on his coccyx. RDO #400 stated the coccyx area healed before Resident #96 was admitted to the facility, and Resident #96 did not have any pressure injuries when he was admitted to the facility. RDO #400 stated the nurses documented Resident #96 did not have any open areas of the skin while he resided at the facility.Interview on 09/28/25 at 2:57 P.M. with Certified Nursing Assistant (CNA) #253 revealed she took care of Resident #96 during the resident's stay and he had a reddened area right at the top of his tailbone that was approximately an inch in diameter. CNA #253 stated she could not remember if it had any other colors in it. Resident #96 had an abdominal (ABD) dressing covering the area on his tailbone. CNA #253 indicated sometimes the dressing came off when it was soiled and she always notified the nurses when this happened, and the nurse would put another dressing over the tailbone. CNA #253 stated the aides tell the nurses when residents including Resident #96 had open areas on their skin. CNA #253 indicated Resident #96 complained of pain, but she could not remember how severe the pain was. During the interview, CNA #253 stated residents including Resident #96 did not get turned and repositioned every two hours like they were supposed to by the staff, and she did not know why.Interview on 09/25/25 at 12:52 P.M. with Nurse #247 revealed she reviewed Resident #96's medical record after her conversation with the surveyor on 09/24/25 at 5:06 P.M. Nurse #247 then revealed she had admitted Resident #96 to the facility on [DATE]. The nurse revealed Resident #96 was admitted on [DATE] and he did not have skin issues or wound treatment orders when he was admitted . Nurse #247 revealed she was again working on 07/31/25 when Resident #96 was transported to his physician appointment, but she did not remember details of Resident #96 leaving for his appointment. Nurse #247 confirmed there was no evidence in Resident #96's progress notes that he left the faciity on [DATE] for an appointment, did not return, or was admitted to the hospital. Nurse #247 stated she could not remember why she did not document any of those things.Interview on 09/29/25 at 10:42 A.M. with CNA #273 revealed on 07/31/25 she transported Resident #96 to his 366487 Page 8 of 10 366487 10/09/2025 Tallmadge Health & Rehab Center 619 Northwest Avenue Tallmadge, OH 44278

F 0686 Level of Harm - Actual harm Residents Affected - Few appointment. CNA #273 stated she did not know Resident #96 very well but thought he seemed like his normal self. The CNA revealed it was raining and an employee at the Oncology Center assisted Resident #96 into the building. CNA #273 indicated she contacted the Oncology Center to check on Resident #96 and was told he was taken to the ED.During an interview on 09/29/25 at 11:17 A.M. Nurse #420 revealed wound treatments were not completed timely and sometimes not at all. Nurse #420 indicated Resident #96 had a wound, but she did not know the details because she was not assigned to care for him. Nurse #420 did not reveal how she knew Resident #96 had a wound. The nurse revealed there was a lack of education for the nurses and many of the nurses were more interested in socializing with each other rather than taking care of the residents. Nurse #420 stated she brought her concerns regarding wound treatments not completed timely to the Administrator and Director of Nursing but got nowhere. Nurse #420 stated she was told by other nurses that she was taking too long when she admitted residents and did not need to do a full skin assessment for each admission.Interview on 09/29/25 at 12:07 P.M. with the DON revealed PATH observations should be completed one time a day, and she had orders written for two times a day so that the PATH observation would be completed at least one time a day. The DON confirmed Resident #96's PATH observations were not completed at least one time a day from 07/08/25 through 07/30/25. The DON confirmed Resident #96 did not have Weekly Observations completed for skin evaluation and stated it was not required to have Weekly Observations of skin. The DON confirmed Resident #96's medical record including progress notes, General Administration Records, Treatment Administration Records, Medication Administration Records and Point of Care aide charting dated 07/08/25 through 07/31/25 revealed no documented evidence Resident #96 was turned and repositioned when he was in bed. In addition, there was no documented evidence of pressure reducing cushion was placed on his chair, a pressure reducing mattress was on his bed or his heels were floated when he was in bed. The DON stated she did not know why there was no evidence these things were completed because there were orders in Resident #96's record, and she believed staff were completing these things. When told Resident #96 had documentation in the Point of Care aide charting on 07/16/25, 07/19/25, 07/28/25 and 07/30/25 that Resident #96 had open areas and dressings on his buttock the DON stated she would look into it. Interview on 09/29/25 at 2:49 P.M. with CNA #296 revealed she took care of Resident #96 while he resided at the facility. The CNA revealed Resident #96 did not like the aides to do much for him and stayed in his bed a lot. CNA #296 stated Resident #96 had a red area on his butt and the aides put cream on it. CNA #296 indicated she always told the nurses about Resident #96's red area and was told to apply cream. CNA #296 stated Resident #96 had the red area on his buttock, but she did not remember if he had a skin issue on the heel. CNA #296 stated we always report to the nurses when we see something.Interview on 09/29/25 at 3:08 P.M. with the Administrator revealed if a resident was admitted to the hospital, she feels like there should be documentation they left and came back (included in the medical record). During the interview, the Administrator revealed Resident #96's wife mentioned the resident did not get his incontinence brief changed timely and told the social worker who made sure he was changed right away. The Administrator denied Resident #96's hospital discharge instructions had treatment orders (even though the hospital after summary included the use of a moisture barrier ointment and a foam dressing). The Administrator stated she would expect nurses to obtain a treatment order if they observed Resident #96's wound.Interview on 09/29/25 at 4:00 P.M. with RDO #400 and the DON confirmed Resident #96's Point of Care History dated 07/16/25 at 1:43 P.M. documented Resident #96 had an open area on his buttock and a dressing on his buttock. On 07/19/25 at 9:55 A.M. Resident #96 had an open area on his buttock and a dressing on his buttock. On 07/28/25 at 10:13 A.M. and 07/30/25 at 9:09 A.M. Resident #96 had a dressing on his buttock. RDO 366487 Page 9 of 10 366487 10/09/2025 Tallmadge Health & Rehab Center 619 Northwest Avenue Tallmadge, OH 44278

F 0686 Level of Harm - Actual harm Residents Affected - Few #400 stated the open areas and dressings were only documented by one aide, and felt the aide could have made a mistake. RDO #400 stated the nurses documented there were no skin issues. Review of the facility policy titled Pressure Injury Prevention and Treatment Policy revised 09/18/23 included residents admitted with existing pressure injuries would receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. New pressure injuries would not develop unless the individual's clinical condition demonstrated they were unavoidable. Pressure injuries identified would be assessed initially and at least weekly thereafter, until closed. All assessments would include location and stage, size, exudate, pain, wound bed, appearance of surrounding tissue and any evidence of infection. Pressure injuries identified would be documented and orders obtained from providers for treatment.This deficiency represents non-compliance Complaint Number 2624905, 2609502, 1404959, 1404954, and 1404955. 366487 Page 10 of 10