Sunrise of Findlay

Based on observation, review of the medical record, interview, and policy review, the facility failed to assess a resident after a change in condition and notify the physician and resident representative. This affected one (#19) of three residents reviewed for change in condition. The facility census was 45. Findings include: Review of the medical record for Resident #19 revealed an admission date of 10/20/24 with a diagnosis of Alzheimer's disease. Review of a cognitive assessment dated 03/19/25 revealed the resident had severe cognitive impairment. Review of a physician progress note dated 05/13/26 revealed the resident had a rectal mass diagnosed in 2021. The resident had declined any further work up or treatment and the resident representative agreed. There was no documentation the resident had rectal bleeding. Review of the nurse's progress notes dated 03/31/26 through 06/08/26 revealed no documentation of the resident bleeding. There was no documentation the resident was assessed for increased bleeding and there was no documentation the physician or family were notified of increased bleeding. Review of a handwritten statement dated 05/29/26 by Caregiver #110 revealed on 05/23/26 when providing care for Resident #19 the resident had a soiled bed pad with blood and feces on it. A copy of the statement was requested multiple times throughout the survey and was not provided by the facility. Interview on 06/09/26 at 6:08 A.M., Caregiver #108 revealed Resident #19 would have bleeding during incontinence care. Interview on 06/06/26 at 6:24 A.M., Caregiver #110 revealed over the holiday weekend on 05/23/26, 05/24/26, and 05/25/26 the resident had an increased amount of bleeding noted during incontinence care. Caregiver #110 revealed the resident had a history of bleeding on occasion during incontinence care but that weekend there was a big round spot of blood on her bed pad. Caregiver #110 revealed she reported the bleeding to the nurse. Caregiver #110 revealed the nurse told her to write a statement. Caregiver #110 revealed she wrote a statement and gave the statement to Executive Director (ED) #200. Observation on 06/09/26 at 6:37 A.M. of incontinence care for Resident #19 with Caregiver #110 and Caregiver #108 revealed the resident had bleeding from a large growth near her inner lower buttocks while staff were providing care. Interview on 06/09/26 at 9:50 A.M. Licensed Practical Nurse (LPN) #112 revealed the resident had a history of bleeding but no recent reports. LPN #112 revealed if the resident was bleeding the nurse practitioner should be notified. Interview on 06/09/26 at 11:07 A.M., Senior General Manager (SGM) #400 revealed staff should have reported concerns regarding blood in Resident #19's incontinence brief. SGM #400 revealed the caregivers could have notified using the clinical alert button and could have also verbally notified the nurse. Interview on 06/09/26 at 12:19 P.M., LPN #134 revealed Resident #19 had hemorrhoids which would bleed sometimes. LPN #134 revealed staff had reported Resident #19 had blood in her brief but thought that was not unusual. LPN #134 revealed she had not assessed the resident or asked staff any further questions regarding the amount of blood observed. LPN #134 revealed the family and physician were not notified of the bleeding because it was not unusual. Interview on 06/09/26 at 2:00 P.M., SGM #400 revealed she was unable to provide a copy of Caregiver #100's statement or other requested staff statements as they were confidential documents requiring authorization from the legal team for release of the documents. Review of the facility policy Assessing and Evaluating ResidentsBased on observation, review of the medical record, interview, and policy review, the facility failed to assess a resident after a change in condition and notify the physician and resident representative. This affected one (#19) of three residents reviewed for change in condition. The facility census was 45.

Findings include:

Review of the medical record for Resident #19 revealed an admission date of 10/20/24 with a diagnosis of Alzheimer's disease.

Review of a cognitive assessment dated 03/19/25 revealed the resident had severe cognitive impairment.

Review of a physician progress note dated 05/13/26 revealed the resident had a rectal mass diagnosed in 2021. The resident had declined any further work up or treatment and the resident representative agreed. There was no documentation the resident had rectal bleeding.

Review of the nurse's progress notes dated 03/31/26 through 06/08/26 revealed no documentation of the resident bleeding. There was no documentation the resident was assessed for increased bleeding and there was no documentation the physician or family were notified of increased bleeding.

Review of a handwritten statement dated 05/29/26 by Caregiver #110 revealed on 05/23/26 when providing care for Resident #19 the resident had a soiled bed pad with blood and feces on it. A copy of the statement was requested multiple times throughout the survey and was not provided by the facility.

Interview on 06/09/26 at 6:08 A.M., Caregiver #108 revealed Resident #19 would have bleeding during incontinence care.

Interview on 06/06/26 at 6:24 A.M., Caregiver #110 revealed over the holiday weekend on 05/23/26, 05/24/26, and 05/25/26 the resident had an increased amount of bleeding noted during incontinence care. Caregiver #110 revealed the resident had a history of bleeding on occasion during incontinence care but that weekend there was a big round spot of blood on her bed pad. Caregiver #110 revealed she reported the bleeding to the nurse. Caregiver #110 revealed the nurse told her to write a statement. Caregiver #110 revealed she wrote a statement and gave the statement to Executive Director (ED) #200.

Observation on 06/09/26 at 6:37 A.M. of incontinence care for Resident #19 with Caregiver #110 and Caregiver #108 revealed the resident had bleeding from a large growth near her inner lower buttocks while staff were providing care.

Interview on 06/09/26 at 9:50 A.M. Licensed Practical Nurse (LPN) #112 revealed the resident had a history of bleeding but no recent reports. LPN #112 revealed if the resident was bleeding the nurse practitioner should be notified.

Interview on 06/09/26 at 11:07 A.M., Senior General Manager (SGM) #400 revealed staff should have reported concerns regarding blood in Resident #19's incontinence brief. SGM #400 revealed the caregivers could have notified using the clinical alert button and could have also verbally notified the nurse.

Interview on 06/09/26 at 12:19 P.M., LPN #134 revealed Resident #19 had hemorrhoids which would bleed sometimes. LPN #134 revealed staff had reported Resident #19 had blood in her brief but thought that was not unusual. LPN #134 revealed she had not assessed the resident or asked staff any further questions regarding the amount of blood observed. LPN #134 revealed the family and physician were not notified of the bleeding because it was not unusual.

Interview on 06/09/26 at 2:00 P.M., SGM #400 revealed she was unable to provide a copy of Caregiver #100's statement or other requested staff statements as they were confidential documents requiring authorization from the legal team for release of the documents.

Review of the facility policy Assessing and Evaluating Residents

Based on observation, staff interview, and review of the menu and recipe, the facility failed to ensure residents on a modified texture diet received all components of the meal. This affected three (#14, #26, and #42) of three residents reviewed for modified texture diets. The facility census was 42.

Findings include:

1. Review of the medical record for Resident #14 revealed an admission date of 05/16/23 with diagnoses of dementia and hypertension. Further review revealed a physician's order dated 09/19/23 for Resident #14 to receive a mechanical soft diet.

2. Review of the medical record for Resident #26 revealed an admission date of 06/17/22 with a diagnosis of dysphagia. Further review revealed a physician's order dated 04/26/24 for Resident #26 to receive a mechanical soft diet.

3. Review of the medical record for Resident #42 revealed an admission date of 06/11/18 with a diagnosis of Alzheimer's disease. Further review revealed a physician's order dated 10/25/24 for Resident #42 to receive a mechanical soft diet.

Interview on 11/20/24 at 11:14 A.M. with Dining Services Coordinator (DSC) #200 revealed Resident #14, Resident #26, and Resident #42 were on mechanical soft diets. DSC #200 stated the regular meal was barbecue chicken thighs and the menu for residents on a mechanical soft diet was a chicken slider.

Observation on 11/20/24 at 11:25 A.M. revealed DSC #200 plating ground chicken and grilled vegetables for Resident #14 and Resident #42. No bun was provided with the meal to make a slider sandwich. DSC #200 covered the plates with aluminum foil and placed them in the transport cart.

Observation on 11/20/24 at 12:25 P.M. revealed DSC #200 plating ground chicken and chopped broccoli for Resident #26. No bun was provided with the meal to make a slider.

Interview on 11/20/24 at approximately 3:30 P.M. with DSC #200 confirmed she did not provide buns for Resident #14, Resident #26, and Resident #42 because she did not have slider buns available. DSC #200 stated she had only hamburger-sized buns and confirmed she did not provide an alternative option for the carbohydrate (bread) portion of the meal.

Review of the menu spreadsheet revealed the regular texture meal received barbecue chicken, pasta salad, and grilled vegetables. Further review revealed the mechanical soft texture meal received barbecue chicken slider, no pasta salad, and grilled vegetables.

Review of the recipe for barbecue chicken sliders revealed a hamburger slider bun was required for the sandwich.

Based on observation, interview, and record review, the facility failed to serve food in a clean and sanitary manner. This had the potential to affect all residents. The facility census was 42. Findings include: Observations on 11/20/24 beginning at 11:59 A.M. of the kitchenette revealed an uncovered tray with slices of pie on top of the transport chart. Care Manager (CM) #201 did not switch gloves after touching contaminated items including the saran wrap covering sandwiches transported from the main kitchen to the kitchenette, touching serving spoon handles, lids on steam pans, lid to pasta salad then picked up two ready-made sandwiches by hand with the contaminated gloves and continued to serve the lunch meal with utensils. Two residents were served ready-made sandwiches during the observation. Interview on 11/20/24 at 12:01 P.M. with CM #201 verified that pies were transported uncovered from the main kitchen to the kitchenette and would be served to residents for dessert. Interview on 11/20/24 at 12:11 P.M. with CM #201 verified that gloves were not changed after touching contaminated items then serving ready-made food with her gloves. Review of the 09/15/1999 policy titled, HandwashingBased on observation, interview, and record review, the facility failed to serve food in a clean and sanitary manner. This had the potential to affect all residents. The facility census was 42.

Findings include:

Observations on 11/20/24 beginning at 11:59 A.M. of the kitchenette revealed an uncovered tray with slices of pie on top of the transport chart. Care Manager (CM) #201 did not switch gloves after touching contaminated items including the saran wrap covering sandwiches transported from the main kitchen to the kitchenette, touching serving spoon handles, lids on steam pans, lid to pasta salad then picked up two ready-made sandwiches by hand with the contaminated gloves and continued to serve the lunch meal with utensils. Two residents were served ready-made sandwiches during the observation.

Interview on 11/20/24 at 12:01 P.M. with CM #201 verified that pies were transported uncovered from the main kitchen to the kitchenette and would be served to residents for dessert.

Interview on 11/20/24 at 12:11 P.M. with CM #201 verified that gloves were not changed after touching contaminated items then serving ready-made food with her gloves.

Review of the 09/15/1999 policy titled, Handwashing

Based on observation, staff interview, and review of facility recipe, the facility failed to ensure vegetables were served at the appropriate texture for residents on a mechanical soft diet. This affected two (#14 and #42) of three residents reviewed for modified texture diets. The facility census was 42.

Findings include:

1. Review of the medical record for Resident #14 revealed an admission date of 05/16/23 with diagnoses of dementia and hypertension. Further review revealed a physician's order dated 09/19/23 for Resident #14 to receive a mechanical soft diet.

2. Review of the medical record for Resident #42 revealed an admission date of 06/11/18 with a diagnosis of Alzheimer's disease. Further review revealed a physician's order dated 10/25/24 for Resident #42 to receive a mechanical soft diet.

Interview on 11/20/24 at 11:14 A.M. with Dining Services Coordinator (DSC) #200 revealed Resident #14 and Resident #42 were on mechanical soft diets.

Observation on 11/20/24 at 11:25 A.M. revealed DSC #200 plating ground chicken and grilled vegetables for Resident #14 and Resident #42. Further observation of the grilled vegetables revealed long slices of red and green bell peppers, long slices of red onions, long slices of zucchini and yellow squash, and mushrooms.

Interview on 11/20/24 at approximately 11:40 A.M. with DSC #200 revealed she reviewed the menu for residents on a mechanical soft diet and confirmed the grilled vegetables required the same preparation for residents on a regular texture diet and residents on a mechanical soft texture diet. DSC #200 confirmed she was surprised the large pieces of vegetables were appropriate for a mechanical soft diet and verified the menu did not say the vegetables should be prepared any differently.

Interview on 11/20/24 at approximately 3:30 P.M. with DSC #200, and concurrent review of the recipe for grilled vegetables, revealed instructions for mechanically altered diets. Guidance included cutting up soft vegetables to less than 1/2 inch size or to mince or mash soft vegetables, depending on the diet order. DSC #200 stated she was not aware the recipe included instructions for preparing the vegetables for residents on a mechanical soft diet.

Based on record review, staff interview, review of written statements, and review of the hospital records, the facility failed to ensure the medical record contained information regarding a change in condition. This affected one (#13) of three residents reviewed for a change in condition. Additionally, the facility failed to notify the resident representative upon a change in condition with subsequent transportation to the Emergency Department. This affected two (#11 and #13) of three residents reviewed for changes in condition. The facility census was 42.

Findings include:

1. Review of the medical record for Resident #13 revealed an admission date of 01/13/22 and a discharge to another facility on 12/26/23 with diagnoses of dementia and Alzheimer's disease.

Review of the Service Evaluation and Health Assessment (SEHA) dated 07/25/23 revealed Resident #13 was alert to person, was forgetful and confused, and had limited recall abilities.

Review of the progress notes from 12/01/23 through 12/26/23 revealed no evidence Resident #13 had a change in condition or was transported to the Emergency Department on 12/08/23.

Interviews on 02/27/24 between 12:46 P.M. and approximately 2:15 P.M. with the Executive Director (ED) revealed she became aware Resident #13 had a change in condition and was transported to the Emergency Department on approximately 01/12/24 by Resident #13's son.

Further interview with the ED revealed the facility learned, through their investigation, Resident #13 had a change in condition after approximately 10:30 P.M. on 12/08/23 when no nurses were in the facility. Interviews with the Care Managers revealed they noticed a change in condition and contacted the Director of Nursing (DON) for direction. The DON advised staff to send Resident #13 to the Emergency Department for evaluation.

Further interview with the ED revealed the DON was on medical leave for a fracture on 12/08/23, and when the ED interviewed the DON, she did not recall the telephone conversations with the aides.

The ED stated Resident #13 returned from the hospital without any discharge paperwork.

The ED confirmed Resident #13's medical record contained no documentation regarding Resident #13's change in condition or transportation to the Emergency Department on 12/08/23. The ED further confirmed the facility could provide no evidence Resident #13's representative was notified regarding her change in condition or transportation to the Emergency Department.

Review of the witness statement written by Care Manager #100 on 01/22/24 revealed she noticed a change in condition for Resident #13, including facial drooping and slurred speech, and staff contacted the DON who advised them to call an emergency ambulance.

Review of the witness statement written by Care Manager #101 dated 01/19/24 revealed she worked with Resident #13 before she was sent to the ED. Care Manager #101's statement revealed Resident #13 had slurred speech and the left side of her face began to droop. Care Manager #101 contacted the DON who advised Care Manager #101 to call an emergency ambulance for Resident #13.

Review of the staff schedule revealed nurses were scheduled from 5:45 A.M. to 2:15 P.M. and from 1:45 P.M. to 10:15 P.M. daily.

Review of the hospital discharge records for Resident #13 revealed she arrived at the Emergency Department on 12/08/23 at 11:24 P.M. and discharged back to the facility on 12/09/23 at 1:00 A.M.

Review of the Resident Agreement for Resident #13 dated 01/13/22, revealed the facility would attempt to contact the resident's responsible party if the resident required emergency services.

2. Review of the medical record for Resident #11 revealed an admission date of 06/24/23 with a readmission date of 12/13/23. Diagnoses included dementia, irritability and anger, and hearing loss.

Review of the SEHA dated 10/25/23 revealed Resident #11 had impaired cognition.

Review of a progress note dated 12/13/13 at 11:42 A.M. revealed Resident #11 had a change in condition and was sent to the Emergency Department.

Interview on 02/27/24 at 12:46 P.M. with the ED confirmed the medical record for Resident #11 did not show Resident #11's representative was notified of Resident #11's change in condition and transportation to the Emergency Department.

Review of the Resident Agreement for Resident #11 dated 06/22/22, revealed the facility would attempt to contact the resident's responsible party if the resident required emergency services.

This violation represents non-compliance investigated under Complaint Number OH00150846.