Wexner Heritage House

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the staff providing care for Resident #85 during the day on 09/04/25 were not interviewed about Resident #85's reporting any concerns or if Resident #85's demeanor was different on 09/04/25. An interview on 10/16/25 at 10:08 A.M. with Resident #85's husband verified a rape kit was completed at the hospital for Resident #85, but the hospital stated it could take months to get the results back. Resident #85 had discharged back to an assisted living facility with the husband after the hospital stay. Resident #85's husband stated he was not sure if a sexual assault occurred but wanted to make sure it was thoroughly investigated. An interview on 10/16/25 at 12:17 P.M. with Registered Nurse (RN)/Wound Nurse #204 verified the skin assessment on 09/05/25 revealed Resident #85 had bruising behind both knees that had not been previously identified. An interview on 10/20/25 at 1:56 P.M. the Administrator verified the investigation was completed on 09/08/25 but CNA #201 was permitted to return to work on 09/08/25 at 6:00 P.M. The Administrator verified there was not an investigation about the bruising to the back of Resident #85's knees. A follow- up interview on 10/21/25 at 10:04 A.M. with the Administrator verified that a statement was not obtained from CNA #201 until 09/09/25 when CNA #201 returned to work the evening of 09/08/25.An interview on 10/23/25 at 8:19 A.M. with LPN #202 stated Resident #85 had loose stools and coughing when taking anything orally, but this was not uncommon for Resident #85. LPN #202 did not feel there was a change in condition that required a doctor to be notified. An interview on 10/23/25 at 9:20 A.M.

RN #204 verified she wrote out Resident #85's statement. RN #204 verified Resident #85 reported the male staff member had short hair, not short in stature. RN #204 verified Resident #85 had given the name (provided) and RN #204 had written the name on the statement. RN #204 again verified Resident #85 had bruising to the back of the legs, but the bruising did not seem to be suspicious and there was no further documentation of the bruising such as pictures, measurements, or description. The Abuse, Mistreatment, Neglect, Exploitation, and Misappropriate of Resident Property policy dated 01/25/25 revealed the investigation protocol included interviewing the resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident, came in close contact with the resident the day of the incident, and employees who worked closely with the accused employee and/or alleged victim

the day of the incident. If there are no direct witnesses, then the interviews may be expanded. (For example, consider interviews with all employees on the shift or unit). Review all relevant medical report/records as applicable. Evidence of the investigation should be documented in accordance with Quality Assurance protocols. This is an incidental finding discovered during the complaint investigation.

Event ID:

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wexner Heritage House

1151 College Avenue Columbus, OH 43209

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

medications.Further review revealed a BMP was completed on 09/03/25 and the resident's Potassium level returned to 4.5 mEq/L. An interview on 10/20/25 at 3:06 P.M. LPN #209 revealed she could not recall information about Resident #86's potassium being administered. An interview on 10/20/25 at 3:16 P.M. RN #208 revealed critical labs were called to the nursing supervisors. RN #208 verified she was notified of the critical labs and relayed the new orders for medications to LPN #209. RN #208 verified LPN #209 should have entered the orders and administered the Zofran and potassium as ordered. An interview on 10/23/25 at 10:51 A.M. DON verified the nurse note by LPN #209 dated 09/02/25 at 10:43 P.M. was confusing. DON verified there was no evidence in the medical record of the orders for Zofran or potassium being written or administered to Resident #86 as ordered on 09/02/25 or 09/03/25. Physician Orders policy dated 01/03/22 revealed a provider many give a medical order over the telephone. The nurse will transcribe the order into

the electronic medical record. The nurse that the physician order will be responsible for executing the order or provide for the safe hand-off to the next nurse. The medication administration record should automatically be updated with the new orders if a schedule has been assigned. This deficiency represents non-compliance investigated under Complaint Number 2609622

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wexner Heritage House

1151 College Avenue Columbus, OH 43209

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

interview on 10/21/25 at 10:51 A.M. the Director of Nursing (DON) revealed there was confusion over the type of area Resident #86 had to her buttock/sacrum/coccyx. The DON verified staff labeled the alteration as MASD, an open area, and an unstageable pressure. The DON verified neither MDS assessment or care plan reflected the resident had an unstageable pressure ulcer to the coccyx/sacrum upon admission. The DON also revealed the facility wound nurse was not notified of the resident's skin alteration on admission and expectation is for the wound nurse to be notified. The DON stated the discrepancies in the resident's wound assessment affected the facility's ability to determine if the resident needed additional intervention, care and assessment from the facility wound nurse or assessment from the facility consulting wound doctor. The DON verified RN #200 worked with the resident and felt the RN did assess the resident but failed to document the resident's wound assessment or take photographs per the facility policy/procedures.

On 10/21/25 at 12:13 P.M. Administrator indicated the resident's MDS assessment was updated to reflect Resident #86 was admitted with an unstageable pressure ulcer (despite there being no documented evidence the resident had an unstageable pressure ulcer on admission according to the assessments provided).An interview on 10/23/25 at 9:25 A.M. RN/Wound Nurse #204 revealed the floor nurses take pictures of the wounds and should do measurements and a description of the wound. RN/Wound Nurse #204 verified LPN #200 only documented the measurements and did not document slough or any other description of the wound. RN/Wound #204 stated any skin concerns should have a wound consult order put in. This order would identify the resident needed to be seen by the facility wound nurse and the outside wound doctor. The nurse verified the resident's pressure ulcer declined from admission on [DATE REDACTED] to 09/02/25 when she evaluated the wound and implemented the air mattress. The wound nurse did not have any documentation of the wound on 09/02/25 to provide. The wound nurse stated the Wound Doctor should have seen the resident's wound when he visited on 08/27/25 and she should have been notified of the resident's skin alteration on admission.An interview on 10/23/25 at 11:19 A.M. LPN #200 stated pictures were taken of any skin open areas, but LPN #200 does not think she would have staged a wound. LPN #200 could not recall any specific details about Resident #86 but verified she would have taken a picture if there was an open area but could not recall any other details about the resident's wound and verified she did not document an assessment of the resident's skin to provide her additional details. Wound Care Treatment Guidelines dated 03/31/22 revealed a weekly assessment should be done on all wounds requiring treatment. This should include measurements and a description. Documentation of the treatment should be done immediately after the treatment. This deficiency represents non-compliance investigated under Complaint Number 2609622.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wexner Heritage House

1151 College Avenue Columbus, OH 43209

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770

Provide timely, quality laboratory services/tests to meet the needs of residents.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, interview, and policy review, the facility failed to ensure laboratory testing was completed per physician order. This affected one (#86) of three residents reviewed for condition change.

The facility census was 84. Findings include: Review of the closed medical record revealed Resident #86 was admitted on [DATE REDACTED] with diagnoses that included but not limited to acute osteomyelitis to the left ankle and foot, anorexia, sepsis due to Methicillin-resistant Staphylococcus aureus (MRSA), aftercare following surgical amputation, type 2 diabetes mellitus, peripheral vascular disease, congestive heart failure, atrial fibrillation, dementia, and an open wound on the left foot. The resident was discharged on 09/03/25.A comprehensive metabolic panel (CMP) laboratory test dated 08/27/25 revealed Resident #86's potassium level was 4.0 milliequivalents per liter (mEq/L) of blood. The normal reference range for Potassium was 3.5 mEq/L to 5.3 mEq/L.Review of Minimum Data Set (MDS) 3.0 assessment dated [DATE REDACTED] revealed Resident #86 had severe cognitive impairment. CMP laboratory results dated [DATE REDACTED] revealed Resident #86's Potassium was 2.6 mEq/L which was critically low. An order dated 09/02/25 was received for a STAT (immediate) basic metabolic panel (BMP) laboratory test. The BMP dated 09/02/25 revealed Resident #86's potassium was 2.7 mEq/L which was critically low. A general nurse's note dated 09/02/25 at 10:43 P.M. authored by Licensed Practical Nurse (LPN) #209 revealed Resident #86 potassium was 2.7 mEq/L. The physician called the supervisor and ordered potassium.A general nurse's note dated 09/03/25 at 12:10 A.M. authored by Registered Nurse (RN) #208 revealed orders were received to administer potassium chloride 40 mEq orally thirty minutes after Zofran (anti-nausea) and then again at 3:00 A.M. and 7:00 A.M.

If Resident #86 was unable to tolerate the medication, the physician needed to be notified, and Resident #86 may need sent to the hospital. The physician also ordered a CMP and Magnesium level to be drawn on 09/03/25. RN #208 relayed the orders to LPN #209 to place the orders and order the labs. LPN #209 verbalized understanding. Review of the closed medical record revealed a BMP was completed on 09/03/25 and the resident's Potassium level returned to 4.5 mEq/L. However, a CMP and Magnesium were not completed.An interview on 10/20/25 at 10:51 A.M. Director of Nursing (DON) verified orders for CMP and Magnesium blood work for Resident #86 were not completed as ordered (the RN and LPN did not enter the order in the medical record).An interview on 10/20/25 at 3:06 P.M. LPN #209 revealed she could not recall information about Resident #86's potassium or ordered blood work.An interview on 10/20/25 at 3:16 P.M.

RN #208 revealed critical labs were called to the nursing supervisors. RN #208 verified she was notified of

the critical labs and relayed the new orders for medications and blood work to LPN #209 for the LPN to address.Physician Orders policy dated 01/03/22 revealed a provider many give a medical order over the telephone. The nurse will transcribe the order into the electronic medical record. The nurse that the physician gave the order to will be responsible for executing the order or provide for the safe hand-off to the next nurse. Contact laboratory services as required to execute the medical order. Laboratory Services and Reporting policy dated 04/2022 revealed the community provides or obtains laboratory services to meet the needs of its residents. The community is responsible for the timeliness of the services. This deficiency represents non-compliance investigated under Complaint Number 2609622.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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