Inn at Northwood Village The

Based on review of the medical record, review of hospital discharge orders, and interview with staff, the facility failed to ensure hospital discharge orders were reconciled correctly for Resident #73. This affected one resident (Resident #73) of three reviewed for medication reconciliation.

Findings included:

Review of the medical record revealed Resident #73 was admitted to the facility on 01/06/20. Diagnoses included hyperkalemia, right heel pressure ulcer, hypertension, diabetes, generalized anxiety disorder, obsessive compulsive disorder, major depressive disorder, benign prostatic hyperplasia, edema, and acute kidney failure.

Review of the Health Status note dated 12/04/25 at 8:14 P.M. revealed the facility received a call from the hospital laboratory indicating Resident #73 had a critically high potassium level. The Nurse Practitioner (NP) was notified and ordered one dose of kayexalate suspension 15 grams per 60 milliliters (ml) to be given. The medication was administered and the resident was transferred to the hospital via his wife.

Review of the Health Status note dated 12/05/25 at 6:44 A.M. revealed Resident #73 was admitted to the hospital for hyperkalemia, elevated troponin levels, and chronic kidney disease.

Review of the Health Status note dated 12/07/25 at 11:46 A.M. revealed Resident #73 was readmitted to the facility via private car with his wife. Resident #73 was his baseline with no complaints, pain, discomfort or distress. The resident, his wife, and the nurse reviewed the discharge instructions and orders. The resident and wife had concerns regarding multiple medications discontinued and changed. The on-call NP was updated on the resident's condition that sent him to hospital, and ordered laboratory services including a complete blood count and basic metabolic panel on Monday or Tuesday, to discontinue the Lisinopril and Potassium, to re-start the doxycycline and have the facility NP see the resident and review information when she was in facility on Wednesday [12/10/25]. Resident #73 and his wife were aware and agreeable to all orders.

Review of the Hospital After Visit Summery dated 12/07/25 revealed Resident #73 was to stop taking the following medications: Actos 45 milligrams (mg), amlodipine 10 mg, doxycycline hyclate 100 mg, glipizide 5.0 mg, hydrochlorothiazide 25 mg, lisinopril 2.5 mg, Losartan 50 mg, metoprolol 50 mg, multivitamin 50 plus, nifedipine 60 mg and NovoLog insulin.

Review of the December 2025 through April 2026 Medication Administration Record revealed the orders for metoprolol 50 mg, Actos 45 mg, and lisinopril 2.5 mg were not discontinued for Resident #73 after he was readmitted to the facility on 12/07/25.

On 04/30/26 at 3:10 P.M. an interview with Resident Care Coordinator #200 revealed Registered Nurse #113 had reconciled the hospital discharge orders for Resident #73 however she did not discontinue some of medication for Resident #73 as ordered. She verified Resident #73 had received the metoprolol 50 mg, Actos 45 mg, and lisinopril 2.5 mg until 04/30/26. She stated the NP was notified.

This violation represents non-compliance investigated under Complaint Number OH00170035.

Based on review of the medical record and interview with staff the facility failed to ensure a comprehensive skin assessment was completed after a skin tear was obtained for Resident #82. This affected one resident (Resident #82) of three reviewed for abuse.

Findings included:

Review of the medical record revealed Resident #82 was admitted to the facility on 02/09/26. Diagnoses included vitamin D deficiency, cerebral infarction, dementia, adult failure to thrive, hypertension, atrial fibrillation, delirium, and rheumatoid arthritis. She resided on the facility's memory care unit (MCU). Resident #82 was discharged to the hospital on 03/31/26 and expired on 04/14/26 under hospice care.

Review of the Senior Living Level of Care and Service Plan dated 02/09/26 revealed Resident #82 had severely impaired cognition, required assistance with dressing, was independent with mobility, and had no skin issues.

Review of the physician's orders revealed Resident #82 had an order for Eliquis 2.5 milligrams (mg) dated 02/09/26.

Review of the incident note dated 03/10/26 at 6:40 P.M. revealed the staff called for the nurse because Resident #82 was bleeding. Resident #82 was observed sitting on the commode in her bathroom, trying to take off her pajama pants and dry brief. Resident #82 was wearing a long-sleeved pajama shirt. She had blood observed on her shirt and pants and she was in her bare feet. Resident #82 stated that it was her arm and then started to talk about other things that did not make sense. She refused vital signs and was cognitively at her baseline, however she appeared to be anxious/upset and did not want the nurse to assess arm, one-on-one was effective and the resident let the nurse assess her right arm. There was a skin tear present, moderately bloody, area was gently cleansed with normal saline, five Steri-strips were applied to approximate the skin tear edges and it was covered with a dry dressing, Resident #82 was assisted by the nurse to put on a clean pair of pajamas. The resident tolerated well with tender loving care and cues. The resident's husband, Nurse Practitioner (NP), and Director of Nursing (DON) were notified.

Review of the Resident Accident/Incident report revealed on 03/10/26 at 6:40 P.M. staff called the nurse to the room of Resident #82 due to bleeding. The resident was observed on the commode trying to take her pants and brief off, she had a long sleeves pajama shirt on and was in her bare feet. She also had blood on her pants and shirt. The type of injury noted was skin tear, hematoma, swelling and she had pain three out of 10 (on a pain scale of zero to 10, zero being no pain and 10 being the worst pain). The resident refused vital signs, she was alert and oriented per her baseline, was anxious and upset, one-on-one was effective. She had a skin tear to the right outer forearm with moderate amount of blood. The area was gently cleansed with normal saline, five Steri-strips were applied. There was no measurement or comprehensive assessment of the wound noted on the report.

Review of the wound assessments revealed no documented evidence of a comprehensive wound assessment for Resident #82's skin tear and significant bruising from 03/10/26 until 03/17/26.

Review of the Home Health Care note dated 03/12/26 revealed the nurse at the facility asked the Home Health Nurse to see Resident #82 when he was at the facility visiting another resident. The facility wanted to know if the wound would be appropriate for in-house wound care. The wound of Resident #82 was assessed for appropriateness and determined the wound could be managed appropriately in house. At that time, the family meeting was occurring and the Home Health Nurse asked to speak to the residents family to educate them on the home health and the wound care process and what would occur in the assisted living facility setting. There was no description of the wound or measurements documented.

Review of the NP progress note dated 03/12/26 revealed Resident #82 was being seen today for a skin tear, hematoma and right arm pain. Nursing reported Resident #82 was grabbed by another resident causing a skin tear, hematoma and pain to the right upper extremity. The area was cleansed with normal saline, five Steri-strips were applied, and it was covered with a dry dressing. The resident was currently on Eliquis for atrial fibrillation. There were no reports of continued bleeding. Per the staff, the family was upset with the incident, came in yesterday and took her to the hospital emergency department, however there were no hospital records to be seen at this time. The resident's daughter had concerns with infection, but per the facility there were no signs or symptoms of infection, and she had been given an order for Keflex from the hospital if she did have an infection.

Review of the Wound Center note dated 03/17/26 revealed Resident #82 was being seen due to a right arm wound sustained at the nursing facility; She had a hematoma which had Steri-strips over the area. Resident #82 was on Eliquis and had mild dementia. The wound type was a traumatic wound to the right arm which measured 5.1 centimeters in length by 1.6 centimeters in width by 0.1 centimeters in depth with a large amount of sanguineous drainage. The wound bed was 95 percent eschar. The wound was debrided and had good potential to heal.

On 05/04/26 at 2:10 P.M. an interview with Registered Nurse #113 revealed she was told that Resident #82 had a skin tear on her right forearm. She went into the room to check on her and Resident #82 was sitting on the commode, she was very preoccupied with pulling her up her pants and would not let her do anything to her arm or even get close to her, but she finally got her calmed down and was able to look at her arm. She stated it was a pretty large skin tear, and it was bleeding a lot because she was on Eliquis. She stated she finally got it cleaned up and put five Steri-strips on it and a dressing. She stated she was not aware that another resident had grabbed her earlier until after everything happened, so she had not assessed her then. She stated Nursing Assistant #130 had told her that another resident had a pretty good hold on her arms and they had to forcefully remover her arm from her grip but they were not sure it if [the skin tear] had happen then or if she had hit it in the bathroom when they were trying to get her dressed, but they just noticed it after the started getting her dressed. She verified she had not performed a complete skin assessment of the wound, but indicated the resident was upset.

This violation represents non-compliance investigated under Complaint Number OH00170531.

Based on observation and staff interview, the facility failed to maintain proper infection control procedures while administering medications. This affected one resident (Resident #45), but had the potential to all residents in the facility who received medications from facility staff, except five residents (#20, #32, #36, #59 and #67) who self-administered their medications. The facility census was 81.

Findings included:

Review of the medical record revealed Resident #45 was admitted to the facility on 08/07/17. Diagnoses included osteoarthritis, chronic pain syndrome, insomnia, restless leg syndrome, edema, atrial fibrillation, anxiety disorder, chronic obstructive pulmonary disease, hypertension, major depressive disorder, and acute cholecystitis.

Review of the April 2026 physician's order revealed Resident #45 had an order for potassium chloride 20 milliequivalent once daily.

Observation of medication administration on 04/30/26 at 11:32 A.M. revealed Certified Medication Assistant (CMA) #111 was preparing medication to administer to Resident #111 and she picked up the potassium chloride 20 milliequivalent tablet with her bare hands, placed it into the pill splitter then dumped it into the medication cup to administer to Resident #45.

An interview on 04/30/26 at 11:32 A.M., CMA #111 verified she had touched the potassium tablet with her bare hands.

Based on review of the medical record, review of the facility investigation, interview, observation, and review of facility policy, the facility failed to provide adequate supervision and monitoring to Resident #2 to prevent unwanted sexual advances towards Resident #1. This affected one resident (Resident #1) of three reviewed for abuse.

Findings included:

Review of the medical record revealed Resident #2 was admitted to the facility on 04/21/25. Diagnoses included hypertension, kidney failure, anemia and hyperlipidemia.

Review of the Health Status Note dated 02/20/26 at 1:22 P.M. revealed Resident #2 was noted with inappropriate behavior while a Resident Assistant was completing his shower. The Resident Assistant stated she explained to the resident he was having inappropriate behavior and encouraged the resident to assist with shower.

Review of the Service Plan dated 04/21/26 revealed Resident #2 was mildly confused.

Further review of the medical record of Resident #2 revealed no documentation of an incident on 04/16/26 with Resident #1.

Review of the medical record revealed Resident #1 was admitted to the facility on 12/05/25. Diagnoses included anemia, insomnia, heart failure, chronic obstructive pulmonary disease, diabetes, acute kidney failure, anxiety disorder, and hypertension.

Review of the Service Plan dated 03/19/26 revealed Resident #1 was alert and oriented.

Review of the Health Status note dated 04/16/26 at 3:39 P.M. revealed the Director of Nursing (DON) spoke to Resident #1 concerning another resident entering her room. Resident #1 was to place her call light on with any concerns. It noted she spoke with the other resident [Resident #2] about entering resident rooms and her daughter was updated.

Review of the facility investigation completed by the DON dated 04/16/26 at approximately 2:00 P.M. revealed an unnamed activities staff member reported to the DON that Resident #1 was upset and reported that another resident entered her room and kissed her on the lips. The DON went to speak to the resident in the activity room, the resident did not appear to be upset or crying. Resident #1 reported Resident #2 came to her room prior to an activity so she could give him a sweater that was too small for her son, because she wanted to thank him for being helpful to her. Resident #1 stated while in her room, Resident #2 put the sweater on and then kissed her twice in the lips. Resident #1 stated she did not want to give him the wrong impression because they were just friends and he was a very naive fellow. Both residents left the room and went out to the activity and sat together. Resident #1 was educated to turn the call light on if there were any more concerns so staff could respond. It noted staff spoke to Resident #2 about not entering other resident's rooms without permission and he verbalized understanding. He was also spoken to about not kissing another resident and he verbalized understanding.

Review of the Psychiatric Evaluation dated 04/22/26 revealed Resident #1 stated another resident in the facility was contributing to her anxiety, but reported feeling safe in the facility.

Observation and interview on 04/30/26 at 8:15 A.M. revealed Resident #2 was standing at the table of Resident #1 in the dining room while she was eating. He was standing to the left of her chair. Resident #2's identity was confirmed by Business Office Manager (BOM) #103.

On 04/30/26 at 8:30 A.M. an interview with Resident #1 revealed Resident #2 would talk to her all the time and follow her back to her room to make sure she did not fall, which she thought was really nice of him. She stated he had been, touchy, feely a few times and she just told him to stop. She stated about two weeks ago she had him come to her room because she had a shirt for him that was too small for her son, so she told Resident #2 he could have it because he was always doing nice things for her. She stated he came into her room, shut the door, grabbed her, and kissed her on the lips twice. She stated she told him to stop and get out of her room and he did leave. She stated she told the DON immediately. She stated he continued to follow her back to her room after that, so several of her friends started walking with her to and from the dining room. She stated she did not ask them too, but they knew she was upset about the whole situation, so they were being nice and walking with her. She stated he was still following her around, so the DON finally told him to stop bothering her, but he started doing it again a few days ago. She stated she did not think he understood what he was doing.

On 04/30/26 at 10:00 A.M. an interview with Nursing Assistant #109 revealed Resident #2 had kissed Resident #1 and was a little too friendly with her and Resident #1 did not like the attention and did not want to be that type of friend with him. Nursing Assistant #109 stated they were told to keep an eye on them and redirect Resident #2 if needed and Resident #1 was to let them know if she became uncomfortable with his attention.

On 04/30/26 at 10:07 A.M. an interview with Nursing Assistant #100 revealed she had not witnessed the kiss, but was working when it happened. She stated Resident #2 was in Resident #1's room before an activity and he had kissed or tried to kiss Resident #1 a couple times and Resident #1 was pretty upset about it. She stated Resident #1 told her they were just friends and she did not want anything romantic with him. She stated she believed Resident #2 had a crush on Resident #1. She stated they were instructed to keep him away from Resident #1 as much as possible. She also stated Resident #1 was having her friends escort her to and from the dining room, but was told by the DON that it was not necessary.

On 04/30/26 at 10:10 A.M. an interview with the DON revealed Resident #1 had been in the nail salon, told the staff what had happened, and the staff had notified her. She stated Resident #1 could not remember the exact time the incident occurred, so she looked at the video footage, and it was prior to the activity that day. She stated Resident #1 had asked Resident #2 to come to her room because she had a sweater that was too small for her son and Resident #2 was always doing things for her, so she wanted to give it to him to be nice. She stated Resident #1 told her that Resident #2 put the sweater on in her room, had kissed her twice on the lips as a thank you for the sweater, but she was uncomfortable with it. She told Resident #1 to let the staff know if she was uncomfortable with anything Resident #2 was doing. She stated there had not been any other incident until today. She stated they did an internal investigation and Resident #1's daughter was notified. She stated it was not reported to the Ohio Department of Health because she did not believe it was a reportable incident. She stated the staff were instructed to watch for her call light and to intervene if Resident #2 got touchy with Resident #1, but he could talk to her in the dining room because the dining room was monitored by staff during meals. She stated Resident #1 was fine with the plan they had in place.

On 04/30/26 at 10:50 A.M. an interview with Nursing Assistant #110 revealed Resident #2 would not leave Resident #1 alone. She stated Resident #2 would stare at Resident #1 all the time. She stated she was here the day he kissed Resident #1 and later that day they were in the dining room and Resident #2 was very upset and he was giving Resident #1 dirty looks and taking his hands and waving them around in her face trying to intimidate her. She stated Resident #1 was upset and crying. She stated Resident #2 was constantly following Resident #1 around the building and back to her room. She stated Resident #1 was upset about it and has asked numerous times for something to be done about it and they were only told to keep an eye on him. She stated Resident #2 would get done eating and then he would stand right beside Resident #1 at her table, she stated Resident #1 tried to be nice and non-confrontational, but told her she was tired of it. She stated Resident #1 was having her friends walk with her back and forth to her room because she was scared of him, but they were told they did not need to do that anymore because Resident #2 was not a threat. Nursing Assistant #110 also stated Resident #1 was locking her door now, which she never did prior to this incident.

On 04/30/26 at 2:00 P.M. an interview with Resident #2 revealed he did not remember kissing Resident #1 and did not know who she was or remember anything about an incident with her.

On 05/04/26 at 6:00 P.M. an interview with Registered Nurse #113 revealed the DON had told her about the incident between Resident #1 and Resident #2 and was instructed to keep an eye on them. She stated on the day it happened, an unknown staff member came to her and stated Resident #1 was in the activity room and was upset about what had happened. She stated she notified the DON immediately.

On 05/05/26 at 9:20 A.M. an interview with Admissions #102 revealed at the time of the incident on 04/16/26, she was working in the activities department helping with nails. She stated she had went into the activity room and Resident #37 came up to her and stated she needed to listen to Resident #1's story. Admissions #102 stated Resident #1 was upset and crying because Resident #2 had kissed her and she did not want everyone to think she wanted his attention because she just wanted to be friends with him. Admissions #102 stated she reassured Resident #1 they would not think that of her and then she went and got the Director of Nursing.

Review of the undated facility policy titled, Abuse and Neglect

Based on review of the medical record, review of hospital records, review of home health records, review of the facility investigation, and interview, the facility failed to provide adequate care and services related to behavior management for Resident #82, which led to a skin tear to the right arm during care. This affected one resident (#82) out of three residents reviewed for abuse.

Findings included:

Review of the medical record revealed Resident #82 was admitted to the facility on 02/09/26. Diagnoses included vitamin D deficiency, cerebral infarction, dementia, adult failure to thrive, hypertension, atrial fibrillation, delirium, and rheumatoid arthritis. She resided on the facility's memory care unit (MCU). Resident #82 was discharged to the hospital on 03/31/26 and expired on 04/14/26 under hospice care.

Review of the Senior Living Level of Care and Service Plan dated 02/09/26 revealed Resident #82 had severely impaired cognition, required assistance with dressing, was independent with mobility, and had no skin issues.

Review of the physician's orders revealed Resident #82 had an order for Eliquis 2.5 milligrams (mg) dated 02/09/26.

Review of the incident note dated 03/10/26 at 6:40 P.M. revealed the staff called for the nurse because Resident #82 was bleeding. Resident #82 was observed sitting on the commode in her bathroom, trying to take off her pajama pants and dry brief. Resident #82 was wearing a long-sleeved pajama shirt. She had blood observed on her shirt and pants and she was in her bare feet. Resident #82 stated that it was her arm and then started to talk about other things that did not make sense. She refused vital signs and was cognitively at her baseline, however she appeared to be anxious/upset and did not want the nurse to assess arm, one-on-one was effective and the resident let the nurse assess her right arm. There was a skin tear present, moderately bloody, area was gently cleansed with normal saline, five Steri-strips were applied to approximate the skin tear edges and it was covered with a dry dressing, Resident #82 was assisted by the nurse to put on a clean pair of pajamas. The resident tolerated well with tender loving care and cues. The resident's husband, Nurse Practitioner (NP), and Director of Nursing (DON) were notified.

Review of the Resident Accident/Incident report revealed on 03/10/26 at 6:40 P.M. staff called the nurse to the room of Resident #82 due to bleeding. The resident was observed on the commode trying to take her pants and brief off, she had a long sleeves pajama shirt on and was in her bare feet. She also had blood on her pants and shirt. The type of injury noted was skin tear, hematoma, swelling and she had pain three out of 10 (on a pain scale of zero to 10, zero being no pain and 10 being the worst pain). The resident refused vital signs, she was alert and oriented per her baseline, was anxious and upset, one-on-one was effective. She had a skin tear to the right outer forearm with moderate amount of blood. The area was gently cleansed with normal saline, five Steri-strips were applied.

Review of the handwritten, signed witness statement by Nursing Assistant #126 dated 03/10/26 revealed she was grabbing Resident #82's clothes out of room 617 while Nursing Assistant #130 took Resident #82 back to her room to get changed, because she was walking up the hallway half naked. Then Nursing Assistant #130 asked for her [Nursing Assistant #126] to get Certified Medication Assistant #112 because Resident #82 was bleeding.

Review of the handwritten, signed witness statement by Certified Medication Assistant (CMA) #112 dated 03/10/26 revealed she was told by a nursing assistant she was needed in Resident #82's room because she had a skin tear on her arm and was bleeding all over her pajamas. The resident was not letting her near her, and the resident was upset. CMA #112 stated they needed to get the nurse, so she called Registered Nurse (RN) #113. Resident #82 was in the bathroom with a skin tear on the right forearm bleeding, she was very upset sitting on the toilet, telling the her to stay away from her. CMA #112 noted she tried to talk calmly to her to relax her. CMA #112 stayed in the doorway, so she did not crowd her or upset her until RN #113 came.

Review of the handwritten, signed witness statement by Nursing Assistant #130 dated 03/10/26 revealed she had taken Resident #82 into her room because she was naked in the hallway. She had her pants and brief off in room 617. She got the resident into her bathroom and got her underwear. She indicated Resident #82 started to get upset because she did not want any clothes on. She stated she got her pants on her and her right arm into her shirt, and then she started swinging her arms because she did not want it over her head. When she swung her arms her right arm had hit off the bone from her [Nursing Assistant #130's] arm. They got her left arm in, and she could then see blood on the right sleeve, so she got CMA #112 and she called for RN #113.

Review of the Health Status note dated 03/11/26 at 10:57 A.M. revealed the husband of Resident #82 was at the facility and was updated on her skin tear. It was reported by an afternoon caretaker that Resident #82 was ambulating into another resident's room, and the resident grabbed her by the arms attempting to guide her. Resident #82 was noted with discolored area to bilateral arms and a raised hematoma to the right arm . She was having tenderness with the dressing change. It noted the resident was on Eliquis. The NP was notified and would address it while rounding next week and a new order was received for daily dressing change. A call was placed to the daughter to update her.

Review of the facility investigation completed by the DON on 03/11/16 at 3:15 P.M. revealed a review of the video surveillance camera on 03/10/16 at 3:55 P.M. revealed a female resident [Resident #31] and Resident #82 were in the hallway and that resident attempted to guide Resident #82 by the arms toward the dining room and staff intervened. At 6:00 P.M. she went into room 617, at 6:09 she came out of room 617 with no pants or brief on and a staff member directed Resident #82 to her room, at 6:13 P.M. the nursing assistant left the room, at 6:14 P.M., the nursing assistant and the CMA return to the room, at 6:20 P.M. the nurse entered the room and at 6:37 P.M. the nurse left the room. The investigation noted the nurse on duty reported the daughter of Resident #82 was upset due to the bloody gauze pad in the resident's storage container in the bathroom. The DON and Assistant DON went to the residents room and found the gauze pad and disposed of it and emptied the trash can. They found dried blood on the floor near the toilet and on the bathroom grab bar.

Review of the Health Status note dated 03/11/26 at 9:20 P.M. revealed the son and husband of Resident #82 were at the facility and stated they had taken her to the hospital to have both arms looked at. They both verbalized their concerns with the recent incident and stated the resident would be staying at home after being released from the hospital. They requested her medication for the next day. The medication was given to them, and they were reminded the NP would be at the facility the next day to see Resident #82. They then went into her room to collect a few belongings sand exited the MCU with a large tote bag. The DON was updated.

Review of the Health Status note dated 03/11/26 at 10:02 P.M. revealed the nurse called the emergency department for an update on Resident #82. The nursing supervisor indicated the resident had been discharged with her family and her arm had been wrapped and they were given orders to follow up with wound care. The nursing supervisor also stated they gave a new order for Keflex in case she had signs of infection. The DON was updated and a note for the NP was placed.

Review of the facility investigation completed by the Executive Director dated 03/12/26 revealed the Executive Director (ED) met with the husband of Resident #82 and they spoke about the incident with Resident #82 and another female resident. The husband was very upset the staff was not willing to give any information as to what had happened. The husband indicated they were unable to give the hospital any information as to what happened. After the investigation was concluded the ED believed the staff were embarrassed to tell the family that Resident #82 was having behaviors and was hard to redirect, and was half naked in the hallway wandering in and out of other resident's rooms. He was upset about the bloody bandages in the bathroom where they kept her depends, the blood on and/or near the toilet paper holder, and the soiled pajamas in the bottom of her closet.

Review of the Home Health Care note dated 03/12/26 revealed the nurse at the facility asked the Home Health Nurse to see Resident #82 when he was at the facility visiting another resident. The facility wanted to know if the wound would be appropriate for in-house wound care. The wound of Resident #82 was assessed for appropriateness and determined the wound could be managed appropriately in house. At that time, the family meeting was occurring and the Home Health Nurse asked to speak to the residents family to educate them on the home health and the wound care process and what would occur in the assisted living facility setting. There was no description of the wound or measurements documented.

Review of the NP progress note dated 03/12/26 revealed Resident #82 was being seen today for a skin tear, hematoma and right arm pain. Nursing reported Resident #82 was grabbed by another resident causing a skin tear, hematoma and pain to the right upper extremity. The area was cleansed with normal saline, five Steri-strips were applied, and it was covered with a dry dressing. The resident was currently on Eliquis for atrial fibrillation. There were no reports of continued bleeding. Per the staff, the family was upset with the incident, came in yesterday and took her to the hospital emergency department, however there were no hospital records to be seen at this time. The resident's daughter had concerns with infection, but per the facility there were no signs or symptoms of infection, and she had been given an order for Keflex from the hospital if she did have an infection.

Review of the Wound Center note dated 03/17/26 revealed Resident #82 was being seen due to a right arm wound sustained at the nursing facility; She had a hematoma which had Steri-strips over the area. Resident #82 was on Eliquis and had mild dementia. The wound type was a traumatic wound to the right arm which measured 5.1 centimeters in length by 1.6 centimeters in width by 0.1 centimeters in depth with a large amount of sanguineous drainage. The wound bed was 95 percent eschar. The wound was debrided and had good potential to heal.

On 05/04/26 at 10:15 A.M. an interview with the Executive Director revealed she could not find the statement from the nursing assistant who saw the resident [Resident #31] grab Resident #82.

On 05/04/26 at 2:10 P.M. an interview with Registered Nurse #113 revealed she was told that Resident #82 had a skin tear on her right forearm. She went into the room to check on her and Resident #82 was sitting on the commode, she was very preoccupied with pulling her up her pants and would not let her do anything to her arm or even get close to her, but she finally got her calmed down and was able to look at her arm. She stated it was a pretty large skin tear, and it was bleeding a lot because she was on Eliquis. She stated she finally got it cleaned up and put five Steri-strips on it and a dressing. She stated she was not aware that another resident had grabbed her earlier until after everything happened, so she had not assessed her then. She stated Nursing Assistant #130 had told her that another resident had a pretty good hold on her arms and they had to forcefully remover her arm from her grip but they were not sure it if [the skin tear] had happen then or if she had hit it in the bathroom when they were trying to get her dressed, but they just noticed it after the started getting her dressed. She verified she had not performed a complete skin assessment of the wound, but indicated the resident was upset.

On 05/04/26 at 2:40 P.M. an interview with CMA #112 revealed the aide came to get her because Resident #82 was bleeding. She stated when she went into the room, Resident #82 had blood on her arm and her pajama bottoms had blood all over them. She stated the resident would not let her touch her arm. She stated she was concerned because she was on Eliquis twice a day, so she immediately went and got RN #113, who came over to assess the wound. She stated she did not see anything that happened with the aides or the other residents.

On 05/04/26 at 3:10 P.M. an interview with Nursing Assistant #130 revealed she had seen Resident #82 coming out of room 617 without any pants or brief on. She stated she did not see any blood on her at that time. She stated that her and Nursing Assistant #126 took her into her bathroom and sat her on the toilet. She stated Resident #82 took her own shirt off and she was completely naked on the toilet, she stated she went to put her pajama top on her and the resident started swinging her arms and would not put her shirt on. She stated Resident #82's arm (she pointed to the area on her left arm right past the wrist on the ulna side of the wrist) hit her [Nursing Assistant #130's] arm hard, but she did not think it was hard enough to cause a skin tear. She stated she finally got her shirt on her, then Nursing Assistant #126 went to get the nurse when they saw the blood. She stated the resident could have done it to herself when she took her own shirt off but verified she did not see any blood at that time when she was naked and she did not see the blood until after she had helped her get dressed. When asked why she did not just walk away from the resident when she was fighting to get dressed, she stated she did not walk away from her because she was concerned she would fall off the toilet. She verified they were trained to walk away and come back later, but she did not do that because she was concerned about her falling off the toilet.

On 05/04/26 at 2:48 P.M. an interview with Nursing Assistant #126 revealed Resident #82 had come out of room 617 with no pants on so Nursing Assistant #130 took her into her room and told her to go get the residents clothes out of room 617, before the resident in that room had a fit about it. She stated when she went into Resident #82 room, she was on the toilet and Nursing Assistant #130 told her to go get CMA #112 because the resident was bleeding everywhere. She stated the resident had her pajama top on already and she did not see any blood, but she did not go all the way into the bathroom. She stated she saw all the blood when she went back into the room with CMA #112. She stated she did not hear a struggle, but Resident #82 had fought them before to get changed. She stated earlier in the day around lunch time Resident #31 had grabbed Resident #82's wrist but it was not very hard. She stated she walked up to Resident #31 and asked her to let go of Resident #82's arm and to go to the dining room and she did.

This violation represents non-compliance investigated under Complaint Number OH00170531.

Based on observation, interview and policy review, the facility failed to ensure food was not kept past the expiration date. This had the potential to affect 83 of 83 residents who receive meals at the facility. The facility census was 83.

Findings include:

Observation and interview with Dietary Supervisor (DS) #101 on 07/21/25 at 10:25 A.M. revealed a one-quart sized container of cottage cheese in the refrigerator which expired on 07/05/25. DS #101 confirmed the finding and stated it should have been removed upon the date of expiration.

Review of the policy titled Dietary Services dated 01/2023 revealed perishable and/or prepared foods shall be stored and used according to the usage guidelines set forth. Ready to eat foods and unused portions of opened commercially prepared ready-to-eat foods including open beverages must be date marked and used within 24 hours. If held at 41 degrees, these ready to eat foods must be used in seven days or less. The ready-to-eat foods must be marked with use by dates.