Vista Care Center Of Milan

Review of the undated facility policy Abuse Prohibition, revealed residents would not be subjected to abuse, neglect, exploitation, mistreatment, or misappropriation of property by anyone. A thorough investigation of all alleged violations would be conducted.

Any alleged allegation was to be communicated immediately to the Administrator or designee.

Residents would be assessed by the Director of Nursing or designee.

The attending physician would be notified, along with family or responsible party.

Residents would be interviewed if cognitively able to communicate.

All alleged violation concerning abuse, neglect, misappropriation of property, and injuries of unknown origin are reported immediately to the Administrator/Designee.

Allegations involving abuse or result in serious bodily injury would be reported to the state agency within two hours after the alleged incident was discovered.

Reporting of allegations not involving abuse or serious bodily injuries must not exceed 24 hours.

The results of a thorough investigation of the allegation would be reported to the state agency within five working days of the incident.This deficiency represents non-compliance investigated under Complaint Number

• 366067 09/09/2025

Vista Care Center of Milan 185 S Main St Milan, OH 44846

Review of the staffing schedules from 02/03/25 through 02/17/25 revealed CNA #601 and CNA #602 were assigned to residents on unit one and unit two.

Interview on 09/09/25 at 11:10 A.M., Corporate MDS Registered Nurse (CMDSRN) #622 verified there was no reevaluation of the resident ' s ability to transfer when he could no longer wear his prosthesis.

Interview on 09/09/25 at approximately 11:00 A.M. with Assistant Director of Nursing (ADON) #196 revealed Resident #7 was not using his prosthetic leg prior to his fall. ADON #196 revealed she thought staff were using the mechanical lift to transfer the resident. ADON #196 was not sure why the resident was not using his walker. ADON #196 revealed if the resident was not using his prosthesis then we would have discussed that in morning meeting. ADON #196 revealed RD #150 was present at morning meetings and would have been aware the resident may have needed reevaluated for transfers.

Interview on 09/09/25 at 12:18 P.M., CNA #602 revealed CNA #601 assisted him to transfer Resident #7 from the bed to the wheelchair. CNA #602 stated they were on each side of the resident to lift him to the wheelchair. CNA #602 revealed Resident #7 started sliding out of the wheelchair and we asked the resident ' s roommate to push the wheelchair back under the resident. CNA #602 revealed they were not using a gait belt and should have used a gait belt during the transfer. CNA #602 also verified they were not using the resident ' s walker and he could not recall the resident ever using a walker. CNA #602 stated the resident was not using his prosthetic leg and it was not safe to transfer the resident with one person. CNA #602 revealed he had not reported the incident because he had not considered it a fall because the resident ' s bottom touched his foot and not the floor. CNA #602 revealed he should have reported the incident to the nurse. CNA #602 denied falling on the resident. CNA #602 denied the resident required a mechanical lift transfer.

Interview on 09/09/25 at 4:21 P.M., Quality Assurance Registered Nurse (QARN) #180 revealed staff should have used a gait belt when transferring Resident #7 and should have been using his walker per his physician orders and plan of care.

Review of the personnel records for CNA #601 and CNA #602 revealed both were terminated for not reporting Resident #7 ' s fall on 02/17/25.

Review of the undated facility policy Fall Management revealed the facility would identify each resident who was at risk for falls and would develop a plan of care and implement interventions to manage falls.

The licensed nurse would perform a fall risk assessment immediately if the resident was deemed to be at risk.

The care plan would be updated routinely and with significant change in the resident ' s condition.

Review of the facility procedural guidelines Safe Patient Handling and Mobility, revealed to consult with physical therapy for best transfer methods for resident and physical therapy would conduct a functional assessment.

Staff were to use a gait belt, sling, or lapboard (as needed), lateral transfer device, mechanical lift or stand assist lift device for transfers. If the resident was partially or not at all able to assist and was greater than 200 pounds then use a ceiling lift with supine sling, a lateral transfer device or air-assisted device with three caregivers.

This deficiency represents non-compliance investigated under Complaint Number 2570390, Complaint Number 1331531, and Complaint Number 1331530.

366067 09/09/2025

Vista Care Center of Milan 185 S Main St Milan, OH 44846

nothing was ever done about it.

Interview on 09/09/25 at 3:12 P.M., Resident #55 revealed a nurse

of LPN #174's personnel record revealed a hire date of 04/09/23 and a termination date of 06/04/25

Administration, dated 12/2012 revealed prior to administration, nurses would review and confirm medication orders for each individual resident on the Medication Administration Record.

Personnel authorized to administer medication do so only after they have familiarized themselves with the medication.

Medications are administered in accordance with written orders of the prescriber.

Medications were to be administered at the time they were prepared.

Note allergies or contraindication the resident may have prior to medication administration.

The individual who administers the medication dose records the administration on the residents MAR immediately following the medication being given.

Once removed from the package/container, unused medication doses shall be disposed of according to the nursing care center policy.

Observe resident for medication actions/reactions and record in the nurses notes as appropriate.This deficiency represents non-compliance investigated under Complaint Number 1331531.