Wyngate at Rivers Edge The

Based on record review, observations, and resident and staff interviews, the facility failed to ensure a resident at high risk for falls and a history of unwitnessed falls with minor injuries received timely fall interventions as ordered by the physician. This affected one (Resident #24) of three residents reviewed for falls. The facility census was 55.

Findings include:

Record review for Resident #24 revealed the resident was admitted to the facility on 10/30/23. Diagnoses included insomnia, Alzheimer's dementia, atrial fibrillation, and cerebral ischemia.

Review of the nursing assessment revealed Resident #24 was assessed to have impaired cognition and was at risk for falls as a result of multiple unwitnessed falls.

Review of the facility investigation and nursing notes dated 05/21/25 revealed Resident #24 was identified by family and staff with unexplained bruising, scratches, and skin tears. Upon interviewing Resident #24 at the time of discovery, the resident stated she had a few falls in the past and was able to explain how she received these injuries. A request for a bed and chair alarm was made by the family and notified Hospice of the order.

Review of Resident #24's physician orders dated 05/31/25 revealed an order for a bed and chair alarm, with hospice to order the devices due to recent falls and decreased cognition.

Observation and interview with Resident #24 on 06/12/25 at 10:10 A.M. revealed upon entering the resident's room, Resident #24 was ambulating throughout her room per self with no indication of a bed or chair alarm in place. Upon inspection of the room, there were no indications of either alarm being in place for the physician order obtained on 05/31/25. Resident #24 currently resided at the end of the 300 hallway, which was at the opposite end nearest the nursing station. Resident #24 stated she had a history of falls and stated her injuries had occurred as a result of these falls in May 2025.

Interview with Wellness Manager #170 and the Regional Clinical Manager #630 on 06/12/25 at 11:58 A.M. verified Resident #24 was given a written order for a bed and chair alarm to maintain safety as an interventions for falls and injuries of unknown origin on 05/31/25. Wellness Manager #170 and the Regional Clinical Manager #630 verified they were waiting on hospice to provide these devices and verified Resident #24 does not currently have either device in her room.

This violation represents non-compliance investigated under Complaint Number OH00166020.

Based on observation and staff interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all 51 facility-identified residents who received food from the kitchen. The facility census was 52 residents.

Findings include:

Observation of the kitchen on 10/16/24 at 1:25 P.M. with Dietary Manager (DM) #61 revealed the walk-in refrigerator and freezer doors had brown streaks from top to bottom and black area on doors and door frame. The floors of the kitchen had grime and a sticky brown substance, and food crumbs on them. The baseboards were covered with black sticky grime. The walls had brown drip marks on them. The walls behind and adjacent to the stove and adjacent to the grill were greasy and dusty. The front of the stove and the grill areas were dirty with dust and grease. The air conditioner in the window had black dust and grime on the outside vent. The shelves that held food and clean pans and dishes had dust, grime, food crumbs noted throughout. The red fire pull tab and fire extinguishers in the kitchen were covered in dust, grime and black fuzzy material.

Interview on 10/16/24 at 1:34 P.M. with DM #61 confirmed the kitchen floors and multiple surfaces were dirty and the kitchen needed a good cleaning. DM #61 confirmed the facility had a cleaning schedule but the facility was unable to provide the schedule.

Based on review of fire drill records and staff interview, the facility failed to ensure fire drills were conducted at varied times, failed to verify receipt of fire alarm signals, failed to evacuate residents to safe areas in at least two fire drills each year on each shift, and failed to transmit a fire alarm signal and verify receipt of that signal no more than twelve hours after a coded announcement for night shift. This had the potential to affect all 52 residents residing in the facility. The facility census was 52 residents.

Findings include:

Review of fire drill records revealed the following concerns:

a. Review of night shift fire drills held on 11/15/23 at 5:10 A.M. and 05/30/24 at 5:15 A.M. revealed the fire alarm signal was not transmitted. There was no documentation that the facility transmitted the fire alarm signal and verified receipt no more than twelve hours after the coded announcement for the night shift drills.

b. Review of fire drills held on 12/29/23, 01/30/24, 02/09/24, 03/20/24, 04/30/24, 06/20/24, 07/31/24, 08/30/24, 09/11/24, and 10/02/24 revealed no documentation that the facility verified that the fire alarm signal was received by the monitoring station.

c. Review of fire drills held on 11/15/23, 12/29/23, 01/30/24, 02/09/24, 03/20/24, 04/30/24, 05/30/24, 06/20/24, 07/31/24 ,08/30/24, and 09/11/24 revealed no documentation that residents were evacuated to safe areas in at least two fire drills each year on each shift.

. Review of fire drills revealed the drills were not held at varied times. The night shift drills were held on the following dates/times: 11/15/23 at 5:10 A.M., 02/09/24 at 5:13 A.M., 05/30/24 at 5:15 A.M., 09/11/24 at 5:00 A.M. The evening shift drills were held on the following dates/times: 01/30/24 at 3:25 P.M., 04/30/24 at 3:50 P.M., 07/31/24 at 3:37 P.M.

Interview on 10/10/24 at 2:00 P.M. with Maintenance Director (MD) #94 confirmed the facility did not have documentation of transmittal of the fire alarm signal for the night shift drills held on 11/15/23 and 05/30/24 and did not have documentation of verification the fire alarm signal was received by the monitoring station for the drills dated 12/29/23, 01/30/24, 02/09/24, 03/20/24, 04/30/24, 06/20/24, 07/31/24, 08/30/24, 09/11/24, and 10/02/24. Further interview with MD #94 confirmed the facility had no documentation of evacuation drills and drills were not held at varied times as required.

Based on staff interviews, record reviews, and review of facility policy, the facility failed to ensure care and services were provided timely and appropriately to prevent skin alterations. This affected one resident (#99) out of the three residents reviewed for skin alterations during the complaint survey. The facility census was 59.

Findings include:

Review of the medical record review for Resident #99 revealed an admission date of 02/28/24 with diagnoses including hypertension, hypothyroidism, and dementia and a discharge date of 03/14/24.

Review of the admission assessment for Resident #99 dated 02/28/24 revealed the resident was dependent on staff for activities of daily living (ADLs) and had no skin alterations to her coccyx.

Review of the nurses' progress note for Resident #99 dated 03/07/24 revealed the resident had an area on her tail bone which was purple in color. The nurse applied a sacral Mepilex dressing and turned the resident onto her side.

Review of the nurses' progress note for Resident #99 dated 03/11/24 revealed an open area was observed to the resident's coccyx.

Review of the facility request for physician form for Resident #99 dated 03/11/24 revealed the resident had a small open area on the coccyx. There was no depth, but the area was cracked open and unable to be measured. The staff requested the physician to provide a treatment for the coccyx.

Review of the nurses' progress note for Resident #99 dated 03/13/24 the resident had two wounds to the coccyx. The first wound measured 3.5 centimeters (cm) long by 3.0 cm wide by 0.2 cm deep. The second wound measured 4.5 cm long by 3.0 cm wide by 0 cm deep. The physician provided wound care orders and they were added to the Treatment Administration Record (TAR.) Review of the physician's order for Resident #99 dated 03/13/24 revealed an order to cleanse the coccyx wound with normal saline, pat dry with gauze, and cover with Mepilex dressing. Change dressing daily and as needed.

Review of the Treatment Administration Record (TAR) date March 2024 for Resident #99 revealed the treatment orders for wound care to the areas of the coccyx were not implemented until 03/13/24.

Telephone interview on 04/01/24 at 12:44 P.M. with Licensed Practical Nurse (LPN) #200 confirmed on 03/14/24 Resident #99 had a wound to her coccyx which contained black tissue and a foul odor. LPN #200 stated she was concerned the resident might have become septic due to the condition of the wound.

Telephone interview on 04/01/24 at 1:17 P.M. with LPN #300 confirmed Resident #99 had a purple discoloration on her coccyx on 03/07/24 which appeared to likely be an area of deep tissue injury. LPN #300 confirmed she applied a Mepilex dressing to the area for prevention and sent notification to the physician of the area, but never received treatment orders or further instructions for care back from the physician. LPN #300 confirmed on 03/11/24 the area to Resident #99's coccyx appeared to have opened up but was small and unable to be measured. LPN #300 confirmed she again sent notification of the skin alteration to the physician, but never received treatment orders or further instructions for care back from the physician. LPN #300 confirmed on 03/13/24 the resident was observed to have two open areas to her coccyx which were reported to the physician. LPN #300 stated the physician responded and provided orders for treatment of the wounds which were implemented the same day they were received.

Interview on 04/01/24 at 2:30 P.M. with the Executive Director (ED) confirmed there were no orders for wound care treatment implemented for Resident #99 until 03/13/24.

Review of the facility policy titled Wound Care not dated revealed residents with compromised skin integrity should receive appropriate care.

This violation represents noncompliance identified during the investigation of Complaint OH00152164.