Warren Nursing & Rehab

a BIMS of 15, indicating intact cognition.

The MDS further revealed Resident #51 was a set up for oral

shower but their teeth had not been brushed since admission despite having oral care items available

Practical Nurse #380 verified the dirt under Resident #51's fingernails at the time of the observation.On 12/16/25 at 3:00 P.M. observation and interview with Resident #51 revealed their teeth had still not been brushed.

There was no toothbrush observed on Resident #51's bedside table. Resident #51 stated to look in the bathroom, and you will see my toothbrush that needs charged.

One toothbrush that had dry bristles without signs of use was noted in the battery-operated toothbrush holder and two new toothbrushes were noted to be in a clear plastic, unopened covering.

There was an unopened tube of toothpaste also observed.

Social Worker Designee #351 verified the findings at the time of the observation.A review of the policy titled Activities of Daily Living (ADL), Supporting dated 03/24 revealed residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Appropriate care and services will be provided to residents who are unable to carry out activities of daily living independently with the consent of the resident and in accordance with the plan of care.This deficiency represents noncompliance investigated under Complaint Numbers 2687759, 2684242, 2641584, and 2655919.

365539 12/31/2025

Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483

Review of the quarterly MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15, indicating Resident #28 was cognitively intact.

The MDS further revealed Resident #28 had no pressure areas and six arterial ulcers.

Review of the care plan dated 10/14/25 revealed Resident #28 had impairment of skin integrity related to vascular areas on admission.

Interventions included consulting the wound care practitioner as needed and ordering and providing treatments as ordered.

On 12/17/25 at 12:01 P.M. an interview with CNP #820 revealed there were problems with the facility not doing dressings as ordered.

On 12/18/25 at 10:30 A.M. an observation of the bilateral lower extremity dressings for Resident #28 revealed them to be dated for 12/16/25.

Licensed Practical Nurse (LPN) #843 verified the dates of 12/16/25 at the time of the observation. LPN #843 stated the dressings would have been dated for 12/17/25 if they had been done daily.

This deficiency represents noncompliance investigated under Complaint Number 2621765, 2647699, and 2621447.

365539 12/31/2025

Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483

Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, brain stem stroke syndrome, osteomyelitis of vertebra, cervical region, neuromuscular dysfunction of bladder, other seizures, pseudomonas, resistance to vancomycin, local infection of the skin and subcutaneous tissue, klebsiella pneumoniae, extended spectrum beta lactamase, methicillin resistant staphylococcus aureus infection, supraventricular tachycardia, dependence on respirator [ventilator] status, muscle weakness, dysphagia, major depressive disorder, acute embolism and thrombosis of left internal jugular vein, gastrostomy status, generalized anxiety disorder, tracheostomy status, quadriplegia, chronic viral hepatitis c and nonrheumatic mitral (valve) prolapse.

Review of Resident #58's care plan dated 10/25/25 revealed the resident had impairment of skin integrity due bowel and bladder incontinence, impaired mobility, quadriplegia, activities of daily living (ADL) dependence, altered nutritional status and had pressure injuries to the coccyx and bilateral heels.

Interventions included wound treatment as ordered, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations.

Review of Resident #58's MDS 3.0 assessment dated [DATE] revealed a BIMS score of 15, indicatin

365539 12/31/2025

Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483

Review of facility policy titled Urinary Continence and Incontinence-Assessment and Management last revised September 2024 revealed identification of urinary tract infections will follow relevant clinical guidelines.

The policy did not identify the relevant clinical guidelines in the policy.This deficiency represents noncompliance investigated under Complaint Number 2687759.

365539 12/31/2025

Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483

maintain a peripherally inserted central catheter (PICC) line for Resident #31.

This affected one

three additional residents (#1, #2, and #25) identified by the facility with IV access.

The facility census was 72.Findings include:A review of the medical record revealed Resident #31 was admitted to the facility on [DATE] and discharged on 12/12/25.

Significant diagnoses included diabetes type two with a foot ulcer, local infection of the skin and subcutaneous tissue, and methicillin resistant staphylococcus aureus (MRSA) of unspecified site.

Significant orders included de-clotting by thrombolytic agent of vascular access device or catheter dated 09/11/25, flush PICC line with 10 milliliters (ml) of 0.9 percent sodium chloride every day shift (09/06/25), replace PICC line (09/25/25), cathflo activase (a medication given through the PICC line to de-clot or clear an obstruction) use two milligram (mg) IV as needed for PICC line (09/10/25), and cefazolin (an antibiotic for infection) use two grams IV every eight hours for infection.

There were no orders to monitor the PICC line for infection, change the PICC line dressing or to flush PICC line before and after medication administration.A review of Resident #31's medication administration record (MAR) dated 09/01/25 through 09/30/25 revealed no administration of cathflo activase.A care plan dated 09/05/25 revealed Resident #31 was on IV medications related to a wound infection.

Interventions included monitoring for infection at the site and monitoring for signs of leaking.

There were no interventions noted for routine care of the PICC line site.A progress note dated 09/09/25 at 11:46 P.M. revealed Resident #31 did not receive her antibiotics due to the PICC line being occluded.A progress note dated 09/10/25 at 5:02 A.M. revealed Resident #31 did not receive her antibiotic as the facility was waiting for PICC line replacement.Upon further review of the progress notes from 09/10/25 through discharge, 12/12/25, revealed no documentation as to when the PICC line was replaced or discontinued.A five-day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating Resident #31 was cognitively intact.On 12/30/25 at 11:30 A.M. an interview with the Director of Nursing (DON) verified there were no orders for PICC maintenance or flushing after medication administration for Resident #31. A review of the facility policy titled Central Venous and Midline Catheter Flushing, dated 04/16, revealed catheters are to be flushed at regular intervals to maintain patency and before and after administration of intermittent solutions, administration of medications, obtaining blood samples and or converting from continuous to intermittent therapies.A review of the facility policy titled Central Venous Catheter Dressing Changes, dated 04/16, revealed dressings to central venous catheters are to be changed if it becomes damp, loosened or visibly soiled and at least every seven days.This deficiency represents noncompliance investigated under Master Complaint Number 2702276 and Complaint Number 2621447.

365539 12/31/2025

Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483

Review of the quarterly MDS assessment dated [DATE] revealed Resident #67 had severe cognitive

Review of Resident #67's plan of care dated 12/29/25 revealed Resident #67 had oxygen use continuously via a tracheostomy as ordered.

Observation on 12/11/25 at 12:20 P.M. of Resident #67 revealed the resident in bed with oxygen being administered via mechanical breathing support.

The oxygen tubing was dated as 11/26/25, which was greater than two weeks prior.

Interview at the time of the observation with the Director of Nursing (DON) verified the date on the oxygen tubing as 11/26/25.

The DON stated that oxygen tubing was to be changed weekly by respiratory therapy when a resident was on mechanical ventilation.

Interview on 12/30/25 at 4:08 P.M. with Respiratory Therapist #328 confirmed oxygen tubing was to be changed weekly.

Residents who were on mechanical ventilation had tubing changed by respiratory therapy and residents who had nasal cannulas had tubing changed by floor nurses.

Review of facility policy entitled, Oxygen Administration, dated October 2022 revealed to change oxygen cannulas and tubing every seven days or as needed.

This deficiency represents noncompliance investigated under Complaint Number 2679591 and Complaint Number 2655919.

365539 12/31/2025

Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483

- 12/02/25: No post dialysis assessment.

The section of the form was blank. - 12/03/25: No pre or post dialysis assessments completed.

The sections of the form were blank. - 12/04/25: No pre or post dialysis assessments completed.

The sections of the form were blank. - 12/05/25: No pre or post dialysis assessments completed.

The sections of the form were blank.

On 12/10/25 at 4:00 P.M. an interview with Dialysis Registered Nurse (DRN) #841 revealed the facility was to complete pre and post dialysis assessments on the communication document. DRN #844 further stated most often the pre and post dialysis assessments are blank for those residents' receiving dialysis.

On 12/15/25 at 2:40 P.M. an interview with DON verified the lack of pre and post dialysis pre and assessments for Residents #02, #21, #29, #44, #63 and #67.

The DON also verified no physician orders for pre and post dialysis assessments or care plan interventions for Residents #02, #21, #29, #44, #63 and #67.

A review of the policy titled End Stage Renal Disease, Care of a Resident with, dated 09/24, revealed residents with end-stage renal disease will be cared for according to currently recognized standards of care.

The policy further stated staff caring for residents with end-stage renal disease, including residents receiving dialysis care shall assess data that is to be gathered about the residents' condition on a daily or per shift basis, review signs and symptoms of worsening condition or complications of end stage renal disease, and monitor care of grafts and fistulas.

This deficient practice represents noncompliance investigated under Complaint Number 2687759.

365539 12/31/2025

Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483

Review of facility's automated medication machine inventory list revealed there were five tablets of Amoxicillin-Pot Clavulanate 875-125 mg available for administration at time of the physician order for Resident #41 on 11/18/25.

Review of the facility policy entitled, Administering Medications, last revised April 2019, revealed all medications were to be administered in a safe and timely manner and as prescribed.

This deficiency represents noncompliance investigated under Complaint Number 2621765, Complaint Number 2621447, and Complaint Number 2688137.

365539 12/31/2025

Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483

Residents may self-administer their own medications only if the attending physician, in conjunction

365539 12/31/2025

Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483

Review of Resident #27's medical record revealed an admission date of 12/07/07, a significant diagnosis of diabetes mellitus type two, and current physician orders to obtain lab work for a Hemoglobin A1C quarterly (every three months).

Review of Resident #27's care plan dated 12/04/25 revealed the resident had potential for hypo/hyperglycemic episodes related to diabetes.

Interventions included obtaining blood work as ordered and reporting any abnormal lab values to the physician.

Additional review of Resident #27's medical record revealed a Hemoglobin A1C test was completed on 03/10/25, 06/09/25 and 12/02/05.

There was no test completed in September 2025.

Interview on 12/23/25 at 11:44 A.M. with Assistant Director of Nursing (ADON) #350 verified Resident #27 had no lab test completed in September 2025 as ordered. ADON #350 stated the floor nurses and she were responsible for tracking the labs, and there was no system in place for the tracking of labs due and being completed.

Interview on 12/30/25 at 4:26 P.M. with [NAME] President of Clinical Services #806 and Regional Director of Clinical Services #803 revealed there was no facility lab policy.

The facility would just follow physician orders.

This deficiency represents noncompliance investigated under Complaint Numbers, 2695949, 2687759, and 2688137.

365539 12/31/2025

Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483

serve food in accordance with professional standards.

professional standards for food service safety.

This had the potential to affect 35 residents (#3, #8,

#49, #51, #50, #55, #56, #57, #63, #64, #65, #66, #83, and #84) receiving meals from the second floor kitchenette out of 57 residents who received meals from the facility.

The facility identified 15 residents (Resident #90, #18, #21, #22, #25, #27, #02, #10, #41, #42, #11, #58, #01, #62, #67) who did not eat by mouth (NPO).

The facility census was 72.Findings include:An observation was conducted on 12/18/25 at 5:00 P.M. of the evening meal service on the second floor and revealed an open to air food transport cart was being pushed off the elevator towards the kitchenette near the common areas dining room. On the cart were three full trays of mini pizza that were not covered during transport. An interview on 12/18/25 at 5:05 P.M. with Dietary Manager (DM) #317 verified the uncovered trays of pizza were transported uncovered from the kitchen on the first floor, up the elevator and to the second floor dining room for the resident meal service. DM #317 verified the pizza should have been covered during transport.

This deficiency represents non-compliance investigated under Complaint Number 2687759.

365539 12/31/2025

Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483

in accordance with accepted professional standards.

record review, interview, and review of facility policy, the facility failed to ensure a complete and

for the annual survey.

The facility census was 72.Findings include:

Review of the medical record revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including cervical disc disorder with myelopathy, high cervical region, spinal stenosis, cervical region, anemia, hyperkalemia, obesity, benign neoplasm of right ovary, type 2 diabetes mellitus with diabetic polyneuropathy, essential (primary) hypertension, acute respiratory failure with hypoxia, altered mental status, acute kidney failure, obstructive sleep apnea, metabolic encephalopathy, quadriplegia, iron deficiency anemia, pain in right knee, vitamin D deficiency, muscle weakness, history of methicillin resistant staphylococcus aureus infection.

Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #80 dated 06/25/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition.

The MDS further revealed Resident #80 required set-up with eating, moderate assistance with oral hygiene, and maximum assistance to dependence with all other activities of daily living (ADLs). No significant moods or behaviors were indicated in the MDS.Review of Resident #80's medical record revealed an ultrasound of the pelvis on 03/14/24 that stated Impressions: large 11-centimeter suspicious right adnexal mass with recommendation for follow-up Magnetic Resonance Imaging (MRI) study.

Further review of the Resident's medical record revealed an MRI was scheduled on three different occasions (05/15/25, 05/29/25 and 06/30/25) but no results or documentation about the MRI results were available in the medical record for review during the time of the survey.

Review of the nursing progress notes in Resident #80's medical record revealed a note on 04/29/25 at 4:49 P.M. authored by Licensed Practical Nurse (LPN) #372 that revealed the resident stated she was not feeling right, blood pressure was checked and was 174/101, the pulse was 88.

The nurse notified the physician and received a new order for a one-time dose of 0.25 (milligrams (mg)) of Catapress and to resume blood pressure (BP) medications: Amlodipine 10 mg in the morning and Lisinopril 20 mg at bedtime. No additional follow-up or communication with the physician was documented regarding this incident with the resident's blood pressure until the resident's vital signs were documented again on 05/16/25.Interview with the Director of Nursing (DON) on 12/15/2025 at 2:50 P.M. confirmed the lapse in charting or the lack of follow up documentation.

The DON was also unable to confirm if the resident ever received the MRI as ordered or why it was rescheduled three times.

The DON also stated she was unfamiliar with the facility's documentation policy.Interview on 12/30/25 at 3:00 P.M. with LPN #372 revealed she was able to recall Resident #80 and stated she provided care to her in the past while she lived in the facility, but did not recall her change in condition, ultrasound, or her need for the MRI.

She stated nurses were responsible for arranging appointments and transportation but did not recall whether the resident received the MRI as ordered or why the appointment was rescheduled three times.

Review of the facility's policy titled Charting and Documentation revised July 2023 revealed the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.This deficiency represents noncompliance investigated under Complaint Number 2695949, Complaint Number 2614520, Complaint Number 2621447 and Complaint Number 2679591, and Complaint Number

• 365539 12/31/2025

Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483

Observation revealed duct work was not replaced, a plastic drain pipe was disconnected, wet insulation removed from the duct work was left in the area, and signs of what appeared to be water stains and mold on drywall.

Observation also revealed a decomposed rodent resembling an opossum outside of Resident #76's room in the ceiling.

Photographs were taken at the time of the observation by the life safety surveyor and verified by MS #368. MS #368 stated the air flow from the attic ran into Resident #76's room. An interview and observation were conducted on [DATE] at 2:06 P.M. with MS #368 of the Somerset unit. MS #368 stated the Somerset unit had been flooded by creek water back in [DATE] and had not been in use for some time.

When asked about stagnant water lines/deadlines on the unit, MS #368 stated the water is shut off.

Observation of water faucets in the mop closet and the shower room at 2:10 P.M. on the Somerset Unit, revealed the water was still turned on to that part of the building. MS #368 verified the taps and pipes were not being flushed on that unit. MS #368 verified there were no other log books of documentation to review regarding testing and monitoring for the water management plan. A request for water flushing logs was made at this time and MS #368 stated there were no logs to prove flushing was being done on the Somerset unit.

Despite his prior statement that the water to the [TRUNCATED]

365539 12/31/2025

Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483

Review of the facility policy titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, last revised July 2025, revealed as part of the facility Antibiotic stewardship program all clinical infections treated with antibiotics will undergo review by the Infection Preventionist or designee and be documented on facility approved surveillance tracking forms.

This deficient practice represents noncompliance investigated under Complaint Number 2655919.

365539 12/31/2025

Warren Nursing & Rehab 2473 North Rd NE Warren, OH 44483

Observation on 12/18/2025 at 11:41 A.M. of room [ROOM NUMBER] revealed the plastic door protector was now attached to the door with duct tape and the privacy curtain was cleaned and replaced.Observation and interview on 12/29/2025 at 2:47 P.M. with Unit Manager (UM) #846 of room [ROOM NUMBER] door protector revealed the duct tape had come unstuck and the door protector was not attached to the door.

UM#846 stated she would put in another work order.Observation on 12/31/2025 at 11:08 A.M. of room [ROOM NUMBER] door protector revealed the door protector was now secured to the door with screws.Review of facility policy titled Quality of Life Homelike Environment, date revised May 2017, revealed facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.

These characteristics include a clean, sanitary and orderly environment.This deficiency represents non-compliance investigated under Complaint Numbers 2683142, 2687759, 2674189, 2684242, and 2688137.