GOOD SHEPHERD THE
For profit - Corporation
125 Beds
Independent
Data: November 2025
Trust Grade
65/100
#266 of 913 in OH
Photo by The Good Shepherd Skilled Nursing and Rehabilitation
Photo by The Good Shepherd Skilled Nursing and Rehabilitation
Photo by The Good Shepherd Skilled Nursing and Rehabilitation
1 / 10 photos
Last Inspection: July 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Good Shepherd Nursing Home in Ashland, Ohio has a Trust Grade of C+, indicating it is decent and slightly above average among facilities. It ranks #266 out of 913 in Ohio, placing it in the top half of the state, and #2 of 4 in Ashland County, meaning only one local option is better. However, the facility is trending worse, with issues increasing from 1 in 2023 to 7 in 2024. Staffing is a strength, with a rating of 4 out of 5 stars and a turnover rate of 32%, which is significantly lower than the Ohio average of 49%. On the downside, the facility has had serious incidents, including a resident who fell and suffered significant injuries due to insufficient staff assistance during a transfer. Additionally, expired medications were found in multiple locations, posing a potential risk to residents. Lastly, there are concerns regarding antibiotic stewardship practices, as improper prescriptions affected numerous residents. Overall, while there are strengths in staffing and no fines, families should weigh these serious issues when considering this facility.
- Trust Score
- C+
- In Ohio
- #266/913
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 32% turnover. Near Ohio's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Ohio facilities.
- Skilled Nurses ✓ Good
- Each resident gets 58 minutes of Registered Nurse (RN) attention daily — more than average for Ohio. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 27 deficiencies on record. Higher than average. Multiple issues found across inspections.
65/100
Top 29%
Needs review
1 → 7 violations
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 1 issues
2024: 7 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (32%)
16 points below Ohio average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
Staff Turnover: 32%
14pts below Ohio avg (46%)
Typical for the industry
The Ugly 27 deficiencies on record
1 actual harm
Jul 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on staff interview and record review, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) for...
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Based on staff interview and record review, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) forms contained all the necessary information. This affected one (#65) of three residents reviewed for beneficiary notices. The facility census was 119.
Findings include:
Review of Resident #65's medical record revealed an admission date of 02/06/24. Medical diagnoses included cerebrovascular accident (stroke), dementia, type II diabetes mellitus with diabetic neuropathy and a history of falls.
Review of the Notice of Medicare Non-Coverage (NOMNC) provided to Resident #65's representative, dated 02/19/24, revealed the resident's skilled services would be ending on 02/21/24. The NOMNC did not list what specific type of skilled service would be ending.
Review of the SNF ABN provided to Resident #65's representative, dated 02/19/24, revealed the resident's skilled services were being discontinued as the resident no longer required skilled services. The noticed contained no specific information as to what skilled service was being discontinued, and what specific cost the resident would incur if they desired for skilled services to continue. The cost section of the notice was labeled for the semi-private room and board rate of $304 per day.
Interview on 07/18/24 at 9:25 A.M. with Director of Social Services and Admissions #605 confirmed the NOMNC and SNF ABN forms were completed incorrectly for Resident #65. The NOMNC did not contained the specific skilled service that was ending. The SNF ABN form contained only the facility's semi-private room and board rate and contained no details on what skilled services was ending, and what the cost would be for the resident to continue receiving skilled services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to implement a splinting program to preven...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to implement a splinting program to prevent further decrease in range of motion (ROM). This affected one (#23) of one resident reviewed for ROM. The facility census was 119.
Findings include:
Review of the medical record for Resident #23 revealed and admission date of 03/05/20. Diagnoses include aphasia, metabolic encephalopathy, contracture of the muscle of multiple sites, unspecified epilepticus, and contracture the right hand.
Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 had severe cognitive impairment and was fully dependent on staff for toileting, eating, and transferring.
Review of a therapy note dated 11/30/23 revealed Resident #23 was to have a rolled splint applied to the right hand and a resting splint should be used for the left hand to promote digit extension. The therapy note revealed pictures were printed and instructions were provided for staff.
Review of nurse aide documentation revealed Resident #23 was to wear bilateral hand splints one at a time for two hours each alternating for eight hours upon waking. Further review of July 2024 splint nurse aide task documentation for Resident #23 revealed splints were applied on the resident's hands on 07/02/24, 07/04/24, 07/05/24, 07/08/24, 07/09/24. 07/11/24, and 07/12/24. Resident #23 did not have splints applied on 07/01/24, 07/03/24, 07/06/24, 07/07/24, 07/10/24, 07/13/24, 07/14/24, 07/15/24, and 07/16/24.
Observation on 07/15/24 at 9:12 A.M., 07/16/24 at 1:34 P.M., 07/17/24 at 9:57 A.M., 07/17/24 at 2:30 P.M., 07/17/24 at 4:26 P.M., and 07/18/24 at 8:46 A.M. of Resident #23 revealed splints were not in place on the left or the right hand.
Interview on 07/17/24 at 2:42 P.M. with State Tested Nurse Aide (STNA) #400 confirmed splints were not on either of Resident #23's hands. STNA #400 stated Resident #23 had an order to use blocks with the resident's hands at one time but thought they did away with using blocks two months ago and was not aware of any interventions currently being used.
Interview on 07/18/24 at 8:48 A.M. with Licensed Practical Nurse (LPN) #517 confirmed Resident #23 should be wearing splints to her hands but splints were not in place.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, policy review, and review of facility incident reports, the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, policy review, and review of facility incident reports, the facility failed to ensure fall interventions were appropriate and resident-centered, and failed to ensure residents with Wander-guards had current physician orders for the security devices. This affected two (#65 and #45) of six residents reviewed for accidents. The facility census was 119.
Findings include:
1. Review of Resident #65's medical record revealed an admission date of [DATE]. Medical diagnoses included cerebrovascular accident (stroke), dementia, type II diabetes mellitus with diabetic neuropathy, and a history of falls
Review of Resident #65's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with severely impaired cognition. The resident had no recorded behaviors or rejection of care. The resident was identified to have two or more falls without injury and one fall with a minor injury since the prior assessment. Resident #65 was required supervision with eating, substantial/maximum assistance with activities of daily living, and required partial/moderate assistance with mobility and transfers.
Review of Resident #65's plan of care dated [DATE] revealed the resident had potential for falls related to a new environment and a decline in condition. Interventions implemented included to encourage and assist with wearing non-skid footwear at all times, monitor and notify the nurse of confusion and anxiety, place frequently used items within reach, and to utilize a personal sensor alarm to bed and chair per family request to assist with safety and fall prevention.
Review of Resident #65's medical record revealed she sustained falls on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].
Review of Resident #65's fall risk assessment, dated [DATE], revealed the resident was identified to be at moderate risk for falls.
Review of the facility-initiated incident reports for Resident #65 revealed on [DATE] Resident #65 sustained a fall from the wheelchair while seated in a common area near the nurse's station. The report indicated the resident was alert only to person and place and had impaired memory. The report described Resident #65 as forgetful and unable to remember that she cannot walk. A summary note of the fall, dated [DATE], revealed the intervention for Resident #65's fall dated [DATE] was to re-educate the resident on asking for assistance with transfers.
Review of an incident report dated [DATE] revealed Resident #65 sustained a fall after she was observed on the bathroom floor. The report indicated the resident was oriented to person and place. The report recorded Resident #65 as being confused and with impaired memory. A summary note of the fall, dated [DATE], revealed the intervention for Resident #65's fall dated [DATE] was to re-educate the resident against self-transfers.
Review of the incident report dated [DATE] revealed Resident #65 sustained a fall and was observed on the floor with the alarm sounding. The report indicated the resident was alert and non-compliant. A summary note of the fall, dated [DATE], revealed the resident was alert to person and place. The note indicated the resident had poor safety awareness and the listed intervention for the fall on [DATE] was to re-educate the resident on call light usage for assistance.
Review of the incident report dated [DATE] revealed Resident #65 sustained a fall in her room. The report indicated Resident #65 was oriented only to person, was confused, and had impaired memory. A summary note of the fall, dated [DATE], revealed the resident was alert and oriented to person and place with poor safety awareness. The listed intervention for the fall dated [DATE] was listed as re-educating the resident and a therapy screening was requested.
Review of the incident report dated [DATE] revealed Resident #65 sustained a fall in her room. Resident #65 was listed as oriented only to person, with confusion, and had impaired memory. A summary note of the fall, dated [DATE], revealed the listed intervention for the [DATE] fall was listed to continue to re-educate the resident.
Review of the incident report dated [DATE] revealed Resident #65 sustained a fall in her room. The resident was listed as only oriented to person, with confusion, and had impaired memory. A summary note of the fall, dated [DATE], revealed a room change was completed to move Resident #65 closer to the nurse's station.
Review of the incident report dated [DATE] revealed Resident #65 sustained a fall in her room. The resident was attempting to re-arrange furniture in her room and fell. The resident was listed as only oriented to person, with confusion, and had impaired memory. There was no included summary note and no listed intervention to prevent further occurrences.
An observation on [DATE] at 12:50 P.M. revealed Resident #65 was seated in her wheelchair in the common area. The resident had a personal alarm to her wheelchair in place and in the on position. An interview was attempted with Resident #65 and was unsuccessful due to the resident's cognition.
Interview on [DATE] at 1:16 P.M. with Assistant Director of Nursing (ADON) #427 stated she does not attend the weekly fall meeting, but other members of nursing leadership attend and review falls to ensure appropriate interventions were in place. ADON #427 confirmed it was the facility's practice to implement interventions after instances of falls.
Interview on [DATE] at 9:05 A.M. with Staff Development Nurse #478 revealed she oversaw and tracked falls at the facility. Staff Development Nurse #478 stated falls are reviewed weekly with the fall committee, and interventions are placed following instances of fall.
Interview on [DATE] at 9:05 A.M. with the Director of Nursing (DON) verified Resident #65 was severely cognitively impaired. The DON verified the fall interventions placed following instances the resident's falls of education and re-education were inappropriate and ineffective due to the resident's cognition.
Review of the fall policy dated [DATE] revealed the use of specific interventions to try and reduce a resident's risks from hazards in the environment. The process includes documenting interventions and ensuring the interventions are put in place.
2. Review of Resident #45's medical record identified admission to the facility occurred on [DATE] with medical diagnosis including dementia, weakness, and pneumonia.
Review of an elopement risk assessment dated [DATE] revealed Resident #45 was identified by the facility to be a moderate risk for elopement. The record identified no physician orders for a Wander-guard. Resident #45's most recent admission MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired.
Observation of Resident #45 on [DATE] at 7:16 A.M. and [DATE] at 12:29 P. M. revealed the resident was observed with the Wander-guard device on her right ankle.
Interview with Registered Nurse (RN) #500 on [DATE] at 8:34 A.M. confirmed Resident #45 had a Wander-guard on her right ankle and had physician's order for the device.
Review of the Wander Management policy, updated [DATE], identified the purpose was to establish a means of prevention for elopement. The policy revealed a wander system equipped with door alarms is in place to alert staff to a resident leaving the facility unassisted. In the event the alarm system fails and or a resident is able to circumvent the system and their location cannot be determined, the facility shall take immediate action to locate the resident. The wander system bracelets will be checked each shift to ensure they are still in working order and not expired. The policy identified an assessment of residents will occur upon admission, after changes in condition, and at regular intervals thereafter. The nursing and social services departments will identify residents at risk for wandering and seek physician orders for security alarm ankle bracelets. The policy identified the process if a resident is determined to be at risk for elopement and an order will be obtained for a wander management bracelet to to applied.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, medical record review, and policy review, the facility failed to ensure resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, medical record review, and policy review, the facility failed to ensure residents who required non-invasive mechanical ventilation through the use of a continuous positive airway pressure (CPAP) machine had a physician order in place with specified settings for the machine. This affected two (#09 and #59) of two residents reviewed for respiratory care. The facility census was 119.
Findings include:
1. Review of Resident #09's medical record revealed an admission date of 02/24/21. Medical diagnoses included asthma, chronic obstructive pulmonary disease (COPD), and morbid obesity.
Review of Resident #09's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had severely impaired cognition and had no recorded behaviors or rejection of care.
Review of Resident #09's physician order dated 01/04/23 revealed the resident was to have a CPAP machine that was to be applied per home settings nightly at bedtime and as needed. The order did not include detailed settings.
Review of Resident #09's treatment administration record for April, May, and July 2024 through 07/17/24 revealed the resident was recorded to have used the CPAP on a nightly basis.
Observation on 07/16/24 at 6:42 A.M. revealed Resident #09 was lying in bed. The resident had a facial mask in place and was connected to her CPAP machine. There were no clearly visible settings on the machine.
Interview on 07/16/24 at 6:46 A.M. with Licensed Practical Nurse (LPN) #474 revealed the facility had on-site respiratory therapists who would clarify any orders and program equipment to the ordered settings. LPN #474 confirmed the staff nurses do not set or program respiratory equipment. LPN #474 verified she was unsure what the resident's ordered CPAP settings were, but stated she could check the orders. LPN #474 checked the residents orders and confirmed the order only specified CPAP per home settings. LPN #474 confirmed she had no way to verify if the CPAP was on the correct setting.
Interview on 07/17/24 at 6:41 A.M. with Registered Nurse (RN) Supervisor #496 revealed residents with CPAP machines were supposed to have orders and settings in their respective physician's orders. RN Supervisor #496 explained the respiratory therapy department assisted with clarifying respiratory-related orders.
Interview on 07/17/24 at 6:51 A.M. with Respiratory Therapist (RT) #575 revealed the respiratory therapy department assisted in clarifying respiratory-related orders if needed. RT #575 confirmed settings should be in the provider's orders for all respiratory devices, including CPAP machines.
Interview on 07/18/24 at 6:41 A.M. with the Director of Nursing (DON) confirmed Resident #09's CPAP order did not contain settings.
2. Review of Resident #59's medical record identified admission to the facility occurred on 08/31/20 with medical diagnosis including sleep apnea, heart failure, anxiety, and bipolar disorder.
Review of Resident #59's physician orders for July 2024 identified no evidence of any CPAP orders.
Observation of Resident #59 occurred on 07/16/24 at 8:57 A.M. Resident #59 was in bed and was observed to have his CPAP machine on and running.
Interview with Resident #59 on 07/16/24 at 12:49 P.M. confirmed he has been using the CPAP machine for a long time and someone came in weekly to service the machine.
Interview with the Director of Nursing (DON) on 07/17/24 at 1:55 P.M. confirmed Resident #59 did not have any physician orders or evidence of tubing changes in his medical record, even though the tubing is dated as being changed. The DON confirmed the facility policy did contain the need for physician orders and documented servicing of the CPAP machine.
Review of the facility noninvasive ventilation (CPAP) policy dated 06/12/23 revealed it was the policy of the facility to provide noninvasive ventilation as per physician's orders and current standards of practice. The facility will obtain an order for the use of the CPAP and settings from the practitioner. Staff are to document the use of the machine, resident tolerance, and any skin respiratory or other changes and responses.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to provide dental care in a timely ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to provide dental care in a timely manner. This affected one (#28) of one residents reviewed for dental care. The facility census was 119.
Findings include:
Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses that included type II diabetes, anxiety, and dementia.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact.
Review of a dental note dated 03/15/24 revealed Resident #28 had the potential need for a consultation with an oral maxillofacial surgeon. Resident #28 potentially had extractions that were surgical in nature. Resident #28 had ankylosed (fusion between tooth/teeth and underlying bony support tissues) teeth that would need to be surgically removed by an oral surgeon. Resident #28 was ordered Peridex (used to treat gum inflammation) twice a day for seven days and amoxicillin (antibiotic) 500 milligrams every six hours. A health status note dated 03/15/24 at 2:30 P.M. revealed Resident #28 was seen by the facility dentist for a tooth extraction. The dentist was unable to pull Resident #28's tooth and was to be referred to an oral surgeon.
Review of a dental note dated 06/17/24 revealed the dentist was not present and Resident #28 was seen by the dental hygienist for dental prophylaxes and topical fluoride. Resident #28 had issues with two teeth which were mobile and had a treatment for one of them to be removed.
Interview on 07/16/24 at 9:00 A.M. with Resident #28 stated the resident needed to see the dentist because of a loose tooth.
Interview on 07/18/24 at 9:32 A.M. with the Director of Nursing (DON) revealed there had been communication with an oral surgeon, but the oral surgeon could not pull Resident #28's tooth until 2025. The DON verified there was no documentation of the oral surgeon being contacted.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to use the proper cleaning ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to use the proper cleaning chemicals were utilized in a resident room with isolation precautions. This affected one (#365) of one residents in contact isolation. The facility census was 119.
Findings include:
Review of the medical record revealed Resident #365 was admitted on [DATE] with diagnoses that included cellulitis of the left lower leg, Clostridium difficile (C. diff), and dementia.
Review of the plan of care dated 07/15/24 revealed Resident #365 had an infection and had the potential for complications related to infection and the treatment of infection. Resident #365 was on the antibiotic vancomycin for C. diff until 07/21/24. Interventions included to administer medications as ordered and use the appropriate precautions.
Observation on 07/16/24 at 12:47 P.M. revealed Resident #365 was sitting on the side of the bed and Housekeeper #556 was mopping the floor in Resident #365's room.
Interview on 07/16/24 at 12:49 P.M. with Housekeeper #557 revealed the mop water had chemicals in it filled the mop bucket with the chemicals located on the wall in the housekeeping room. Housekeeper #557 stated she thought the chemicals would kill C. diff bacteria because the chemical killed everything.
Interview with Housekeeping and Laundry Manager (HLM) #447 on 07/17/24 at 12:26 P.M. revealed housekeepers were aware of why residents were on contact isolation precautions so the proper chemicals could be used to clean the room. Observation on 07/17/24 at 12:29 P.M. of chemicals located on the wall in the housekeeping room revealed the chemical was called BNC-15 and was a multi-purpose cleaner. Review of the label for BNC-15 revealed it was a one-step disinfectant, cleaner, sanitizer, fungicide, mildewstat, and virucide. HLM #447 verified BNC-15 did not list it was effective in killing C. diff bacteria, and verified another chemical was to be used if contact isolation was due to C. diff.
Review of the policy and procedure for C. diff revised on 03/14/17 revealed the disinfectant must be a environmental protection agency (EPA) registered, hypochlorite-based (bleach based), and directions will be followed as per label for drying and kill time.
Review of the policy and procedure for daily cleaning of isolation rooms revised on 02/20/19 revealed housekeeping will use approved environmental cleaners and follow directions provided by the manufacturer. All C. diff rooms will be cleaned with bleach-based products.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
Based on infection control tracking, staff interview, and policy review, the facility failed to follow antibiotic stewardship practices in prescribing antimicrobials. This affected 17 (Resident #6, #7...
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Based on infection control tracking, staff interview, and policy review, the facility failed to follow antibiotic stewardship practices in prescribing antimicrobials. This affected 17 (Resident #6, #7, #9, #21, #27, #40, #51, #55, #69, #57, #70, #73, #76, #78, #83, #101, and #107) of 57 resident entries for antimicrobial treatments initiated in May and June 2024. The facility census was 119.
Findings include:
Review of infection control tracking for May 2024 revealed there were 32 antimicrobial (antibiotic and antifungal) treatments tracked for the month. The treatments were prescribed from a variety of sources that include from the hospital upon admission, emergency room prescribers, hospice prescribers, and the facility's prescribers. Of the antimicrobial treatments tracked in May 2024, 21 were prescribed by the facility's prescribers. Of the antimicrobial treatments prescribed by the facility's prescribers in May 2024, nine did not meet criteria for use and the antimicrobial was not discontinued.
Review of infection control tracking for June 2024 revealed there were 25 total antimicrobial treatments tracked for the month. The treatments were prescribed from a variety of sources that include from the hospital upon admission, emergency room prescribers, hospice prescribers, and the facility's prescribers. Of the antimicrobial treatments tracked in June 2024, 13 were prescribed by the facility's prescribers. Of the antimicrobial treatments prescribed by the facility's prescribers in June 2024, 11 did not meet criteria for use and antimicrobial was not discontinued.
Interview on 07/018/24 at 01:00 PM with Assistant Director of Nursing (ADON) #427 confirmed facility used McGeer's criteria to determine the existence of an infection and need for antimicrobial treatment. ADON #427 confirmed 11 residents did not meet the criteria for treatment in June 2024 and nine did not meet the criteria for antimicrobial treatment in May 2024, but antimicrobial treatments were not discontinued. ADON #427 confirmed the facility did not do an antibiotic timeout within 48 to 72 hours of initiation of the antibiotics to review for appropriateness.
Review of the antibiotic stewardship policy dated 04/03/17, and revised 12/05/23, revealed the Medical Director oversees adherence to antibiotic prescribing practices, and reviews antibiotic use data and ensures best practices are followed. The policy revealed the facility uses the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) surveillance definitions, updated McGeer criteria, or other surveillance definitions to define infections and the Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics. The policy further revealed that nursing will conduct an antibiotic timeout within 48 to 72 hours of antibiotic therapy to review laboratory results and consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on findings.
Nov 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Bas...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Based on observation, medical record review, hospital documentation review, resident and staff interview, review of a personnel file, review of a disciplinary action document, review of an investigation, policy review, and review of facility initiated corrective action, the facility failed to ensure appropriate care and assistance was provided to prevent a resident fall. This resulted in actual harm when Resident #104 was transferred by a mechanical (Hoyer) lift using only one staff member to assist, and subsequently fell, causing a facial laceration requiring sutures and a fractured right leg which required hospitalization and surgical intervention. This affected one (#104) of three residents reviewed for falls. The facility census was 113.
Findings include:
Review of Resident #104's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to diabetes mellitus, acute kidney failure, and multiple sclerosis.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/28/23, revealed Resident #104 was assessed as cognitively intact, and was dependent on two staff members for transfers.
Review of the plan of care, dated 11/07/21, revealed Resident #104 had a potential for falls related to chronic disease process with an intervention to include the use of a mechanical (Hoyer) lift with two staff members for all transfers.
Review of a nursing progress note dated 11/19/23 at 3:00 P.M. revealed Resident #104 fell during a transfer and sustained an injury to his head and had complaints of right hip pain. Resident #104 was transferred to the hospital via emergency medical services (EMS), and Resident #104's family and doctor were notified.
Review of an incident investigation dated 11/19/23 revealed State Tested Nurse Aide (STNA) # 207 transferred Resident #104 via Hoyer lift by herself and the resident fell from the lift. Resident #104 was transferred to the hospital via EMS for evaluation due to a head injury and complaints of right hip pain.
Review of a written statement from STNA #207 revealed on 11/19/23 she took Resident #104 back to his room to sit in his recliner. STNA #207 admitted to using the Hoyer lift without another staff member present to assist in the transfer. STNA #207 indicated she made sure the mechanical lift transfer pad was strapped properly, and during the transfer the lift pad strap fell off the Hoyer lift and Resident #104 fell to the floor. STNA #207 immediately called for Licensed Practical Nurse (LPN) #210, and LPN #210 along with STNA #211 and STNA #212 came to Resident #104's room. STNA #207 indicated she did not mean for Resident #104 to fall and was trying to keep Resident #104 from disturbing other residents.
Review of a hospital document revealed Resident #104 was admitted to the hospital on [DATE] following a fall in the nursing home. Resident #104 was found to have a closed fracture of the right femoral neck, right periorbital ecchymosis (bruising around the right eye), and a right eyebrow laceration with sutures placed on 11/19/23. On 11/20/23, Resident #104 was taken to the operating room for a closed reduction with intramedullary rod fixation of the right subtrochanteric femur fracture. Resident #104 was stabilized and returned to the nursing home on [DATE].
Observation and interview on 11/27/23 at 10:34 A.M. with Resident #104 revealed Resident #104 had several stitches over his right eye and his face was bruised but did not appear to be in pain. Resident #104 stated an STNA was not doing her job correctly when he fell. Resident #104 stated he was lifted with the Hoyer lift and then fell to the floor. Resident #104 stated his fall from the Hoyer lift on 11/19/23 was the only time there was only one staff member to operate the lift, and verified there was usually always two staff members to assist with his transfers. Resident #104 stated he liked the facility.
A telephone interview on 11/27/23 at 12:00 P.M. with LPN #206 stated on 11/19/23 around 2:00 P.M., STNA #207 was very upset and adamant about LPN #206 coming to Resident #104's room. LPN #206 stated STNA #207 was crying and was hard to understand. LPN #206 stated upon arrival to Resident #104's room, the resident was laying on the floor with blood noted and the resident was in pain.
A telephone interview on 11/27/23 at 12:16 P.M. with Registered Nurse (RN) #208 stated he was on another unit, when he was asked to go to Resident #104's room. When RN #208 got to the room, there were two nurses and two STNAs already in the room. RN #208 stated Resident #104 was alert and oriented but in pain, and STNA #207 was crying and really upset. RN #208 stated he pulled STNA #207 from the floor and asked her to calm down to write a statement. RN #208 stated STNA #207 indicated she did not want Resident #104 to disturb the other residents.
A telephone interview on 11/27/23 at 2:04 P.M. with LPN #210 stated she was sitting at the desk when STNA #207 ran up the hall and stated Resident #104 was on the floor. LPN #210 stated STNA #207 was really upset and crying. LPN #210 stated she told STNA #207 to go get the other nurse (LPN #206), and told STNA #211 and STNA #212, who were at the nurses' desk, to go to Resident #104's room. LPN #210 stated she found Resident #104 lying on the floor in his room with some blood noted and he was in pain. LPN #210 stated she did not know why STNA #207 would have transferred Resident #104 using the Hoyer lift by herself, and stated there were enough staff members working to safely transfer the resident and there were no other problems that day.
Review of STNA #207's personnel file revealed on 09/14/22, STNA #207 was provided an in-service on mechanical lift safety guidelines which included there must be two people assisting with mechanical lift transfers.
Review of a disciplinary action document dated 11/20/23 revealed on 11/19/23 at approximately 1:30 P.M., STNA #207 took a resident (#104) to his room to lay him down in a recliner after lunch. STNA #207 reported she utilized the Hoyer lift alone and the lift pad sling came loose from the Hoyer lift causing the resident to fall to the floor resulting in major injuries. STNA #207 was terminated from employment on 11/20/23.
Review of the facility policy titled, The Good [NAME] Transfer Policy, with an implementation date of 12/15/22, revealed two staff members must be utilized when transferring residents with a mechanical lift.
The deficient practice was corrected on 11/24/23 when the facility implemented the following corrective actions:
•
On 11/19/23 at 1:30 P.M., STNA #207 was caring for Resident #104, who tends to yell out, so STNA #207 decided to bring him back to his room after eating lunch and transfer him to his recliner. STNA #207 elected to transfer Resident #104 by herself in a Hoyer lift even though the facility had adequate staffing available to assist. STNA #207 ran to get LPN #210, STNA #211, and STNA #212 to Resident #104's room. STNA #207 indicated the Hoyer lift pad strap by the right side of Resident #104's head popped off the bar and the resident then slid out onto his right side to the floor. LPN #210 called EMS as soon as she saw Resident #104 on the floor with a head laceration.
•
On 11/19/23 at 1:33 P.M., EMS arrived at the facility and LPN #206 performed a visual inspection of the lift pad that was under Resident #104, and found the straps were completely intact with no tears or fraying.
•
On 11/19/23 at 1:55 P.M., RN #208 performed a visual inspection of the Hoyer lift in use, and discovered the lift was in good working condition with no defects.
•
On 11/19/23 at 1:59 P.M., RN #208 informed LPN Staff Development #209 of the incident with Resident #104 and indicated once STNA #207 completed a written statement regarding the incident and STNA #207 would be sent home.
•
On 11/19/23 at 2:11 P.M., LPN Staff Development #209 notified the DON of the incident with injury to Resident 104 and was informed STNA #207 would be going home once her written statement was completed.
•
On 11/19/23 at 2:30 P.M., the DON called RN #208 to review the incident and to verify that STNA #207 was going home once her statement was completed.
•
On 11/19/23 at 2:35 P.M., RN #208 called Resident #104's representative and informed him of the fall with injury.
•
On 11/19/23 at 2:37 P.M., STNA #207 finished her written statement while being supervised by RN #208 then clocked out and went home.
•
On 11/19/23 at 3:17 P.M., the DON emailed an education and followed up with a phone call to RN #208 to immediately in-service staff on proper transfer via Hoyer lift. All staff were educated by 11/24/23.
•
On 11/19/23 at 6:17 P.M., RN #208 informed the DON that Resident #104 was admitted to the hospital.
•
On 11/19/23, STNA #200 and STNA #201 checked Hoyer lift pads to ensure there were no frays, rips, or tears with no concerns noted. A second check of the Hoyer lift pads was completed by STNA #204 and STNA #205 on 11/20/23 with no concerns. Additional audits of all Hoyer lift pads on 11/21/23, 11/22/23, 11/25/23, and 11/26/23 revealed no concerns.
•
On the morning of 11/20/23, Maintenance Director #216 did a visual inspection of all facility Hoyer lifts and hanger bars and found them to be intact, without defect, and functioning properly. Audits will continue weekly for four weeks and then monthly for three more months to ensure compliance.
•
On 11/20/23 at 2:45 P.M., the DON and Assistant Director of Nursing (ADON) #213 met with STNA #207, and STNA #207 admitted to knowing the facility's policy and practice was to perform all mechanical lifts with two staff members. STNA #207 indicated although staffing was good, she attempted to perform Resident #104's transfer by herself to be efficient. STNA #207 was terminated from her position on 11/20/23.
•
On 11/20/23, resident care plans were reviewed to ensure residents who required a mechanical lift for transfers had appropriate interventions in place. All care plans were reviewed and updated by 11/22/23.
•
On 11/20/23, Hoyer lift pads were labeled and tracked by Laundry Aide #217 with each time they were laundered and were inspected and logged. Any Hoyer pad with fraying or tears were immediately taken out of circulation and were destroyed.
•
On 11/20/23 at 9:00 A.M., a Quality Assurance and Performance Improvement (QAPI) meeting was held with the DON, ADON #213, the Administrator, and LPN Staff Development #209 to discuss Resident #104's fall. The Medical Director was in the facility at 4:00 P.M. and was updated on the facility's action plan.
•
On 11/20/23, Hoyer lift transfers were observed by LPN #214 with no concerns. LPN #214 made additional observations of Hoyer lift transfers on 11/21/23 and 11/24/23 with no concerns observed. LPN #214 and ADON #213 will continue to observe a minimum of two mechanical lift transfers each week for four weeks then twice monthly for two months to ensure compliance.
•
Interviews on 11/27/23 from 6:40 A.M. through 3:30 P.M. with STNA #200, STNA #201, STNA #202, STNA #204, and STNA #205 all verified they were educated on the need for two staff members for all Hoyer lift transfer and confirmed appropriate knowledge of the facility's mechanical lift policy and procedure. All STNAs verified they check Hoyer lift pads for defects before use and indicated nurses will assist with Hoyer lift transfers when necessary.
This deficiency represents non-compliance investigated under Complaint Number OH00148536.
Mar 2022
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on record review, staff interviews, resident interviews, and review of the facility's policy, the facility failed to ensure the residents were assisted with showers routinely and timely as sched...
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Based on record review, staff interviews, resident interviews, and review of the facility's policy, the facility failed to ensure the residents were assisted with showers routinely and timely as scheduled. This affected two (Residents #27 and #65) of three residents reviewed for bathing. The facility identified all 92 residents required assistance or were dependent on staff for assistance with bathing. The facility census was 92.
Findings include:
1. Review of Resident #27's medical record revealed an admission date of 10/16/18. Diagnoses included tremors, congestive heart failure, asthma, and chronic kidney disease.
Review of Resident #27's quarterly Minimum Data Set (MDS) assessment, dated 12/21/21, revealed the resident had a high cognitive function. Resident #27 required a one person physical assist with hygiene and was a total dependence on staff for bathing.
Review of Resident #27's shower schedule revealed the resident was to have a bath every Monday and Friday.
Review of Resident #27's shower documentation electronic records revealed she received a shower/bath on Wednesday 02/02/22, Friday 02/04/22, Friday 02/11/22, Saturday 02/12/22, Friday 02/18/22, Saturday 02/19/22, Monday 02/21/22, and Saturday 02/26/22.
Interview with Resident #27 on 02/28/22 at 10:03 A.M. revealed the resident was not receiving timely showers. She stated she was given a shower once weekly, but had gone two weeks without a shower or bath.
Interview with the Assistant Director of Nursing (ADON) #500 on 03/03/22 at 10:14 A.M. verified the facility failed to administer Resident #27's showers timely. The ADON verified Resident #27 went seven days without a shower or bath between 02/04/22 and 02/11/22 and six days between 02/12/22 and 02/18/22.
2. Review of Resident #65's medical record revealed an admission date of 11/09/20. Diagnoses included left lower extremity amputee, peripheral vascular disease, cerebral vascular accident, and dementia.
Review of Resident #65's quarterly MDS assessment, dated 01/24/22, revealed the resident had a moderate impairment in cognitive function. Resident #65 required an extensive assistance two person assist for personal hygiene and bathing.
Review of Resident #65's most recent care plan revealed she resident required one staff participation with bathing.
Review of Resident #65's shower schedule revealed the resident was to have a bath every Wednesday and Friday.
Review of Resident #65's shower documentation electronic records revealed she received a shower/bath on Tuesday 02/08/22, Monday 02/14/22, Wednesday 02/16/22, and Saturday 02/19/22. The resident was documented as refusing a bath/shower on Tuesday 02/15/22 and Friday 02/25/22.
Interview with Resident #65 on 02/28/22 at 10:47 A.M. revealed her showers/bathes were not given timely and she may go a couple of weeks without a shower.
Interview with the Assistant Director of Nursing (ADON) #500 on 03/03/22 at 10:14 A.M. verified the facility failed to administer Resident #65's timely. The ADON verified Resident #65 went without a shower for six days between 02/08/22 and 02/14/22 and had no shower from 02/19/22 through 03/01/22. The ADON also stated the nursing staff failed to document any refusals or why the showers had not been completed.
Review of the facility's policy titled Resident Shower/Bathing revealed residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Resident bath schedules will be posted at each nurses station. The staff must document the resident bath acceptance in Point Click Care or alternative record if needed. Report any declined baths to the charge nurse.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
Based on review of the facility's policy, observation, record review and resident and staff interview, the facility failed to provide adequate activities for Resident #9. This affected one (Resident #...
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Based on review of the facility's policy, observation, record review and resident and staff interview, the facility failed to provide adequate activities for Resident #9. This affected one (Resident #9) of two residents reviewed for activities. The facility census was 92.
Findings include:
Review of Resident #9's medical record revealed an initial admission date of 01/09/21. Diagnoses included anxiety, depression, and obstructive sleep apnea.
Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 11/24/21, revealed Resident #9 had intact cognition. Resident #9 was totally dependent on staff for bed mobility, transfers, toileting, and personal hygiene. Resident #9 considered doing things with groups of people to be somewhat important and participating in her favorite activities to be very important.
Review of the plan of care, dated 10/16/21, revealed Resident #9 had the potential for alteration in scheduled/self-initiated events. Interventions included encouraging the resident to participate in activities, offering invites and encouragement, and providing assistance to and from activities as needed. Resident #9 was dependent on staff for activities, cognitive stimulation, and social interaction related to disease process, Multiple Sclerosis, immobility, and physical limitations. Interventions included assuring activities the resident was attending were compatible with the resident's physical and mental capabilities, compatible with known interests and preferences, and the resident would be provided with a program of activities that were of interest and empowered the resident.
Review of the activities progress notes dated 08/02/21 at 10:07 A.M. revealed Resident #9 continued to enjoy manicures, group activities, one-on-one visits, listening to music on her phone, and going outside on walks. No activities progress notes were documented from 09/21/21 through 03/03/22 regarding the resident attending activities, declining activities, or an activities progress note update.
Review of the activity logs for December 2021, January 2022, and February 2022 revealed one-on-one visits were documented as provided to the resident on 02/01/22, 02/07/22, 02/08/22, 02/09/22, 02/11/22, 02/14/22, and 02/16/22. Activities cart was documented for resident participation on 02/03/22. No other activities were documented for the resident within this time period.
Interview on 03/03/22 at 10:42 A.M. with the Assistant Director of Nursing (ADON) verified there were no additional activities progress notes for Resident #9 from 09/21/21 through 03/03/22.
Observations on 02/28/22 at 10:41 A.M., on 03/01/22 at 11:16 A.M., on 03/02/22 at 1:51 P.M., and on 03/03/22 at 8:47 A.M. revealed Resident #9 was sitting upright in her motorized wheelchair, with the television turned on.
Interview on 02/28/22 at 10:41 A.M. with Resident #9 revealed the resident enjoyed participating in activities but the facility had not been having any activities for several months.
Review of the faciliy's activities calendars for the Rehabilitation Unit dated January 2022, February 2022, and March 2022 revealed there were no scheduled group activities for January 2022 or February 2022. Activities on each calendar included self-directed activities and the March 2022 calendar included unscheduled staff visits to resident rooms.
Interview on 03/02/22 at 2:36 P.M. with Activities Director #204 verified there were no scheduled activities or group activities for January 2022, February 2022, and March 2022. Activities Director #204 stated this was due to activities personnel being trained as State Tested Nursing Assistants (STNA) and often getting pulled to work as STNAs. Activities Director #204 reported there was a full-time activities staff member who worked the rehabilitation unit but they had not worked at the facility since August or September of 2021.
Review of the facility's policy titled Resident Activities, revised January 2002, revealed the activities department would provide activities designed to meet the specific needs and/or interests of all residents on each unit.
Review of the facility's policy titled Activities Department Documentation revealed each resident's medical record would contain a quarterly activities update progress note.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and review of a nursing manual, the facility failed to ensure a midline ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and review of a nursing manual, the facility failed to ensure a midline catheter's placement per nursing standards. This affected one (Resident #65) observed for intravenous medication administration. The facility identified one resident on intravenous therapy. The facility census was 93.
Findings include:
Review of Resident #65's medical records revealed an admission date of 11/09/20. Diagnoses included a bacterial infections to the right ankle and foot.
Review of Resident #65's physician's order, dated 02/22/22, revealed an order to flush the midline with 10 milliliters (ml) of normal saline before and after each use every 12 hours.
Observation with Licensed Practical Nurse (LPN) #134 on 03/03/22 at 9:22 A.M. revealed LPN #134 completed the physician ordered flush on Resident #65's midline intravenous access. LPN #134 was observed cleaning the access and placing a 10 ml syringe of normal saline to the access site. LPN #134 pushed the solution directly into the midline catheter without checking for any blood return prior to administering the normal saline.
Interview with LPN #134 on 03/03/22 at 9:35 A.M. verified she failed to check for catheter placement prior to administering normal saline to Resident #65.
Interview with the Director of Nursing on 03/03/22 at 11:22 A.M. verified the facility did not have a policy regarding this issue.
Review of the nursing manual found at https://www.bd.com/assets/documents/PDH/CVC/BDPI_Hickman-[NAME]-Broviac_BD-30813_Nursing-Procedure-Manual_EN.pdf revealed prior to administering normal saline the catheter placement must be confirmed by aspirating slowly until a blood return is visualized.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and policy review, the facility failed to remove expired medications from the medicatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and policy review, the facility failed to remove expired medications from the medications carts and medication storage rooms. This affected three of six medication carts and two of three medication storage rooms. This had the potential to affect all 92 residents residing in the facility.
Findings include:
Observation of Windsor medication cart on 03/01/22 at 7:55 A.M. revealed a bottle of CoQ 10 was found with an expiration date of 01/2022 and a bottle of aspirin 325 milligrams (mg) was located in the cart with an expiration date of 11/2021.
Observation of the Windsor [NAME] Hall medication room on 03/01/22 at 8:22 A.M. revealed the following medications expired: Melatonin (sleep aid) 3.0 mg expired 10/2021, Loperamide (anti-diarrhea) 2.0 mg expired 11/2021, B6 vitamins 100 mg expired 11/2021, Geri Dry diphenhydramine (antihistamine) expired 11/2021, and cetirizine hydrochloride (antihistamine) 10 mg which had expired on 07/2021.
Observation of the [NAME] hall cart on 03/01/22 at 8:35 A.M. revealed two bottles of Vitamin B12 500 mg had expired in 03/2021 and two bottles of simethocone (gas relief) 125 mg had expired on 06/2021.
Observation of the medication room on the [NAME] hall on 03/01/22 at 8:43 A.M. revealed a bottle of Vitamin B12 500 mg was found to be expired in 03/2021 and a bottle of Geri Dry Allergy Relief had expired in 11/2021.
Interview with Licensed Practical Nurses #134 and #192 and Registered Nurse #110 on 03/01/22 between 7:58 A.M. and 8:46 A.M. verified the medications had expired and should have been removed from the medication carts and medication storage rooms. These medications were stock and used by all residents who were prescribed them.
Review of the facility's policy titled Medication Storage, dated May 2017, revealed it was the policy of the facility to ensure all medications house on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendation and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.
MINOR
(B)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the representative of the Office of the State Long-Ter...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the representative of the Office of the State Long-Term Care Ombudsman was notified of the resident's transfers to the hospital. This affected two (Resident #60 and #334) of two residents reviewed for hospitalization. The facility census was 92.
Findings include:
1. Review of Resident #60's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included aphasia following cerebral vascular disease, syncope and collapse, and hemiplegia and hemiparesis.
Review of the nursing progress notes revealed Resident #60 was sent out and subsequently admitted to a local hospital on [DATE].
Review of both the electronic and hard charts for Resident #60 revealed there was no evidence the representative of the Office of the State Long-Term Care Ombudsman was notified of Resident #60's transfers to the hospital on [DATE].
Interview on 03/01/22 at 3:00 P.M. with the Administrator verified that the facility did not notify the representative of the Office of the State Long-Term Care Ombudsman of Resident #60's transfers to the hospital on [DATE].
2. Review of Resident #334's medical record revealed an admission to the facility occurred on 09/19/19. Diagnoses included fractured left femur, Alzheimer's disease, anxiety and dementia. The record identified Resident #334 required a hospitalization from 02/19/22 through 02/22/22. There was no evidence the representative of the Office of the State Long-Term Care Ombudsman was notified of Resident #334's transfers to the hospital on [DATE].
Interview with the Administrator on 03/01/22 at 3:30 P.M. verified the facility was not sending the notice of a resident's transfers to the representative of the Office of the State Long-Term Care Ombudsman, including for Resident #334.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation, policy review, and staff interview, the facility failed to ensure posted nursing staff information was updated timely and accurate. This had the potential to affect all 92 reside...
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Based on observation, policy review, and staff interview, the facility failed to ensure posted nursing staff information was updated timely and accurate. This had the potential to affect all 92 residents residing in the facility.
Findings include:
Observation of the posted nursing staff information on 02/28/22 at 8:12 A.M. and at 10:50 A.M. revealed the posted nursing staff information was from 02/25/22 and contained the staff numbers for the 7:00 A.M. to 3:00 P.M. shift.
Observation of the posted nursing staff information on 03/02/22 at 7:41 A.M. and at 9:13 A.M. revealed the posted nursing staff information was from 03/01/22 and contained the staffing numbers for the 7:00 A.M. to 3:00 P.M. shift.
Interview on 03/02/22 at 10:20 A.M. with the Licensed Practical Nurse (LPN) #265 revealed the nurse supervisors were to update and post nursing staff information each shift.
Interview on 03/02/22 at 11:16 A.M. with the Assisted Director of Nursing (ADON) #156 verified nurse supervisors were to update and post nurse staff information each shift. The ADON #156 further verified the posted nursing staff information was not up to date and information was missing.
Review of the facility's policy titled BIPA (Benefits Improvement and Protection Act of 2000) Report, dated 02/28/06 with a revision date of 06/23/15, stated the Nursing Supervisor is responsible for initiating, updating, and posting the daily nurse staff information.
Apr 2019
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observations, medical record review, policy review and staff interviews, the facility failed to ensure a urinary catheter drainage bag was appropriately covered. This affected one of one (#45...
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Based on observations, medical record review, policy review and staff interviews, the facility failed to ensure a urinary catheter drainage bag was appropriately covered. This affected one of one (#45) of one residents reviewed for dignity. The facility identified nine residents with urinary catheters. The facility census was 118.
Findings include
Review of Resident #45's medical record revealed an admission date of 09/11/18 and diagnoses included: sepsis, a pressure ulcer of the sacral region, osteomyelitis, chronic kidney disease stage three, anemia, respiratory failure, hypotension and quadriplegia.
Observation on 04/02/19 at 11:06 A.M. and on 04/03/19 at 11:34 A.M., revealed Resident #45's urinary catheter drainage bag was not covered.
Interview on 04/03/19 at 11:36 A.M., with Licensed Practical Nurse (LPN) #256 verified Resident #45's urinary catheter drainage bag was uncovered. LPN #256 told Resident #45 she would get a cover.
Interview on 04/03/19 at 1:42 P.M., with the Assistant Director of Nursing (ADON) #243 revealed urinary catheter drainage bags should be covered.
Review of the policy, Catheter-Foley Insertion, Maintenance and Removal last revised 06/04/14, revealed no guidelines for covering a urinary drainage bag when the resident was in their room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, resident and staff interviews, the facility failed to ensure residents and reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, resident and staff interviews, the facility failed to ensure residents and resident representatives were given an opportunity to participate in the care planning process. This affected two (#12 and #88) of 26 residents reviewed for care plans. The facility census was 118.
Findings include:
1. Review of Resident #12's medical record revealed an admission date of 03/30/18, with diagnoses including: Diabetes Mellitus, acute kidney failure, and cerebralvascular disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact.
Review of the resident's Interdisciplinary Team Care Conference Summary forms dated 04/10/18, 07/10/18, 10/02/18, and 01/01/19 revealed a documented Care Conference was held for the resident. Multiple staff members signed the form indicating they were in attendance. None of the forms contained the resident or the resident's wife's signatures.
Review of the resident's progress notes revealed documentation dated 10/02/18 at 1:30 P.M., of a care conference held this date with the resident and his wife. No other documentation of a care conference for Resident #12 could be found in the progress notes.
Interview on 04/02/19 at 10:53 A.M., with Resident #12 revealed he had no recollection of being invited to or attending any care conferences since his admission to the facility.
Interview on 04/03/19 at 2:00 P.M., with Licensed Practical Nurse (LPN) #215 verified the resident and his wife attended a care conference on 10/02/18, but could not provide evidence the resident and his wife were invited to or attended care conferences on 04/10/18, 07/10/18, or 01/01/19.
Interview on 04/04/19 at 11:27 A.M., with State Tested Nursing Assistant (STNA) #260 verified she signed the resident's Interdisciplinary Team Care Conference Summary forms dated 04/10/18, 07/10/18, and 01/01/19. STNA #260 stated she was unable to verify if the resident and/or his wife attended a care conference on these dates because she did not actually attend the meetings. STNA #260 revealed LPN #215 periodically prided her with a stack of Interdisciplinary Team Care Conference Summary forms for multiple residents, and have her sign them indicating she attend the meetings.
2. Review of Resident #88's medical record revealed an admission date of 01/28/19, with diagnoses including: throat mass, difficulty swallowing, throat cancer, and dementia. Resident #88's admission MDS assessment dated [DATE], identified no behaviors or mood issues. The assessment identified Resident #88 had a BIMS (brief interview for mental status) score of 11, which identifies mildly impaired cognition.
Review of the resident's Interdisciplinary Team Care Conference Summary forms dated 02/06/19, 02/13/19 and 02/27/19 revealed a documented care conference was held for the resident. Staff member RN #216 and STNA #260 signed the form indicating they were in attendance. None of the forms contained the resident or the resident's families signature.
Interview with the facility DON on 04/04/19 at 2:46 P.M., verified she could not locate any information that identified Resident #88 and or his family was invited and or attended any care plan meetings regarding his care.
Review of a facility policy titled, Care Plan Meeting, dated 02/02/15, revealed the policy did not address inviting the resident or the resident's representative to care conferences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to notify a resident's physician and fami...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to notify a resident's physician and family of a significant weight loss. This affected one (#6) of two residents reviewed for nutrition. The facility census was 118.
Finding include
Record review of Resident #6's medical record revealed an admission date of 08/16/16, with diagnoses including: Alzheimer's disease, dysphagia, difficulty walking, dementia, anxiety and osteoarthritis.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had severe cognitive impairment.
Review of the monthly weight report revealed Resident #6 weighed 94 pounds on 02/01/19. Resident #6 weighed 89 pounds on 03/01/19 indicating a 5.32% weight loss in thirty days.
Review of a health status progress note dated 03/01/19 at 4:12 P.M., revealed Resident #6 had a significant weight loss of 5.3 percent in the past 30 days.
Review of the nurse's progress notes from 03/01/19 through 04/02/19 revealed no documentation Resident #6's physician or family were notified of the significant weight loss noted on 03/01/19.
Interview on 04/04/19 at 12:50 P.M., with the Director of Nursing (DON) revealed Resident #6's family was notified of the significant weight loss on 04/03/19 and the physician was notified on 04/04/19.
Review of the policy Physician Notification, last revised 07/16/12, revealed physicians would be notified by fax for non-urgent updates.
Review of the policy Resident and Family notification last revised 07/10/11, revealed the facility would immediately, within a reasonable time frame, inform the resident and/or power of attorney of any changes in the resident's condition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide written notification to residents and residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide written notification to residents and resident representatives of emergency transfers to the hospital. This affected three (#98, #101 and #314) of five residents reviewed for discharge. The facility census was 118.
Findings include:
1. Review of Resident #314's medical record revealed an admission date of 07/28/16, with a most recent readmission date of 03/26/19. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively impaired.
Review of the facility's Resident Transfer Forms for Resident #314 revealed the resident was transferred to an acute care hospital on [DATE], 12/28/18, and 03/21/19. No documentation was available of the facility providing written notification to the resident, the resident's representative, or the State Ombudsman's office of the emergency transfers.
2. Review of Resident #98's medical record revealed an admission date of 09/26/18. The medical record identified Resident #98 required hospitalization on 01/05/19 and 01/30/19. The record further identified Resident #98 was alert, oriented and able to make his needs known. The medical record contained no documentation of any notification to the resident and or family regarding the reason for the emergency discharge to the hospital.
3. Review of Resident #101's medical record revealed an admission date of 01/25/19. The record confirmed Resident #101 was alert, oriented and able to make all her needs known. The record further identified Resident #101 required hospitalization on 01/28/19. The medical record contained no documentation of any notification to the resident and or family of the hospitalization.
Interview on 04/03/19 at 1:44 P.M., with the Administrator verified the facility did to provide written notification to the resident or the resident's representative of the three resident's emergency transfers. The Administrator further revealed the current policy, at the time of the survey, did not address providing written notification to residents or residents representatives of emergency transfers.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, bed hold notification policy and staff interview, the facility failed to provide a medicaid resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, bed hold notification policy and staff interview, the facility failed to provide a medicaid resident with bed hold notice upon transfer to the hospital. This affected one (#101) of five residents reviewed for hospitalization. The facility census was 118.
Findings include:
Review of Resident #101's medical record revealed an admission date of 01/25/18. The record revealed Resident #101's payer source was medicaid. The record further identified Resident #101 required hospitalization on 01/28/19. The record was silent to any notification of bed hold upon discharge to identify the number of bed hold days Resident #101 had left. Resident #101 was readmitted to the facility on [DATE].
Review of the facility's current admission packet identified bed reserve policy dated 05/26/18, identified the facility follows the state Medicaid plan which reimburses up to 30 days for hospitalization per calendar year. The policy did not contain any need to notify residents upon hospitalization of the days left.
Interview with the facility Director of Nursing on 04/04/19 at 10:19 A.M., confirmed the facility does not provide residents with bed hold notification to any residents upon discharge. The DON confirmed the facility goes over the bed hold policy upon admission but were unaware they needed to do this upon transfer to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review and staff interview, the facility failed to complete a recapitulation/discharge summary fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review and staff interview, the facility failed to complete a recapitulation/discharge summary for a resident discharged from the facility. This affected one (#113) of one reviewed for discharge. The facility census was 118.
Findings include:
Review of Resident #113's closed medical record revealed an admission date of 01/04/19 and discharged to home on [DATE]. Diagnoses included: congestive heart failure, admitted with right femur and right radius fractures and patella fracture, Parkinson's disease and macular degeneration.
Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #113 was cognitively intact with no noted behaviors. Review of Section Q - Participation in Assessment and Goal Setting revealed the resident participated in the assessment and goal setting and expected to be discharged to the community.
Review of the progress notes dated 01/09/19 revealed the resident was discharged home with Palliative care. Further review of the complete medical record revealed there was no evidence of a discharge summary or recapitulation of care.
Interview on 04/04/19 at 4:10 P.M., with the Director of Nursing verified there was no discharge summary or evidence of recapitulation of the resident's stay.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, the facility failed to initiate restorative programs for one (#88) of 26 sampled residents. The facility census was 118.
Findings include:
Review of...
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Based on medical record review and staff interview, the facility failed to initiate restorative programs for one (#88) of 26 sampled residents. The facility census was 118.
Findings include:
Review of Resident #88's medical record revealed an admission date of 01/28/19, following a hospitalization. The record identified prior to admission Resident #88 resided at home with his daughter. Review of the discharge plan of care, dated 03/20/19 identified Resident #88 plans on returning home following rehabilitation at the facility.
Review of the Therapy Restorative Recommendation dated 03/23/19, revealed orders for a restorative walking and dressing/grooming programs. Further review of the medical record revealed as of 04/04/19, there was no documentation of the restorative programs being initiated.
Interview with Registered Nurse (RN) #130, on 04/04/19 at 1:44 P.M., revealed she was in charge of the restorative programs at the facility. The interview identified when residents are discharged from therapy, they recommend restorative programs. RN #130 identified therapy completes a Therapy Restorative Recommendation form and places it into her mailbox. RN #130 confirmed Resident #88 restorative form was located in the resident's paper chart and she had no seen and or started him on any of the recommended restorative programs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, staff and resident interviews, the facility failed to provide restorative range o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, staff and resident interviews, the facility failed to provide restorative range of motion services. This affected two (#9 and #88) of two residents reviewed for restorative. The facility census was 118.
Findings include
1. Review Resident #9's medical record revealed an admission date on 10/08/14. Diagnoses included atherosclerosis of native arteries of the right leg with ulceration of the heel and midfoot, peripheral vascular disease, hypertension and chronic kidney disease.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had intact cognition.
Review of a physician order dated 01/10/19 revealed Resident #9 was ordered seated active range of motion (AROM) to the bilateral upper extremities for 15 minutes a day, six to seven days per week.
Review of restorative task documentation from 03/05/19 through 04/03/19, revealed Resident #9 was not offered AROM on 18 days. Resident #9 received AROM on 03/25/19, 03/26/19, 03/28/19, 04/01/19 and 04/03/19. Resident #9 refused AROM on seven days.
Interview on 04/02/19 at 10:45 A.M., with Resident #9, revealed the restorative aide use to complete exercises with him but then she left.
Interview on 04/04/19 at 10:29 A.M., with the Restorative Aide (RA) #100, verified the last restorative aide had left the position. RA #100 revealed a new restorative aide was being trained. RA #100 revealed Resident #9 had not received restorative services as ordered as there was not a staff member trained to provide the restorative exercises.
Review of the policy Restorative Nursing, last revised 07/08/12 revealed restorative programs would be initiated as needed upon referral from other health care team members. Individualized nursing intervention would be implemented to assist or promote each resident's ability to attain his/her maximum functional potential.
2. Review of Resident #88's medical record revealed an admission date of 01/28/19, following a hospitalization. The record identified prior to admission Resident #88 resided at home with his daughter. Review of the discharge plan of care, dated 03/20/19 identified Resident #88 plans on returning home following rehabilitation at the facility.
Review of the Therapy Restorative Recommendation dated 03/23/19, revealed orders for a range of motion programs. Further review of the medical record revealed as of 04/04/19, there was no documentation of the restorative programs being initiated.
Interview with Registered Nurse (RN) #130, on 04/04/19 at 1:44 P.M., revealed she was in charge of the restorative programs at the facility. The interview identified when residents are discharged from therapy, they recommend restorative programs. RN #130 identified therapy completes a Therapy Restorative Recommendation form and places it into her mailbox. RN #130 confirmed Resident #88 restorative form was located in the resident's paper chart and she had no seen and or started him on any of the recommended restorative programs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, medical record, facility policy and staff interview, the facility failed to administer physician ordered tube feeding in accordance with the orders. This affected one (#2) random...
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Based on observation, medical record, facility policy and staff interview, the facility failed to administer physician ordered tube feeding in accordance with the orders. This affected one (#2) random resident observed of 13 residents identified receiving enteral tube feeding. The facility census was 118.
Findings include:
Review of Resident #2's medical record revealed re-admission date of 01/06/19, with medical diagnosis including: dysphasia, respiratory failure and tracheotomy. Review of the physician orders for April 2019 identified Resident #2 should be receiving enteral tube feeding (Isosource 1.5) 40 milliliter/hour (ml/hour) via peg tube around the clock.
Observation of Resident #2 on 04/04/19 at 8:30 A.M., during her medication administration time, revealed Resident #2 was noted to be receiving enteral tube feeding at that time of Isosurce 1.5 at a rate of 60 ml/hour. The observation identified the bag of solution hanging did not include the rate at which the feeding should be infused. Registered Nurse (RN) #233 was observed to place the tube feeding on hold, administer Resident #2's medication and restart the enteral feeding at 60 ml/hour.
Interview with RN #233 on 04/04/19 at 8:42 A.M., confirmed the current medication administration record (MAR) identified Resident #2 should be receiving her enteral feeding at 40 ml/hour. RN #233 then entered Resident #2's room and changed the feeding rate to 40/ml hour and confirmed there was no rate identified on the bag currently hanging. RN #233 obtained Resident #2's current physician orders and confirmed Resident #2 should be receiving the tube feeding at 40 ml/hour and she is not sure when or whom had started Resident #2's tube feeding pump at 60 ml/hr.
Review of the facility policy titled Enteral Feeding dated 01/30/07, identified feeding container is to be labeled with formula name, strength, rate, date, time, patient name and nurses initials.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family and staff interviews, the facility failed to ensure a resident receiving an anti-psychoti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family and staff interviews, the facility failed to ensure a resident receiving an anti-psychotic medication had a justified medical diagnosis to support the use. This affected one (#88) of five residents reviewed for medications. The facility census was 118.
Findings include
1. Review of Resident #88's medical record revealed an admission date of 01/28/19, with diagnoses including: throat mass, diarrhea, difficulty swallowing, throat cancer, and dementia.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE], identified Resident #88 was receiving an anti-psychotic medication (Seroquel 200 mg) and identified no behaviors or mood issues. The assessment identified Resident #88 had a BIMS (brief interview for mental status) score of 11, which identifies mildly impaired cognition. Further review of the record identified no targeted behaviors Resident #88 was being evaluated for. The medical record identified no psychiatric history and or targeted behaviors Resident #88 may have.
Review of a facility Interdisciplinary Team Care Conference Summary dated 02/27/19 identified Resident #88 was receiving Seroquel. The form had a section for Psychotropic medication usage. The form also identified reasons for the medications continue to be valid. The form dated 02/27/19 was blank in the area that identified the validation for use of the medication for Resident #88. The form also lacked any resident and or family involvement in that meeting.
Interview with Registered Nurse (RN) #288 occurred on 04/04/19 at 1:13 P.M., revealed she was not sure why Resident #88 was on Seroquel, but that he was admitted with the medication. RN #288 suggested to call Resident #88's son, whom is a Pharmacist. The interview confirmed the facility does not have any targeted behaviors listed for Resident #88.
A telephone interview was completed with Resident #88's daughter, whom is also listed as Power of Attorney (POA), on 04/04/19 at 1:37 P.M. Resident #88's POA identified she believed the medication Seroquel was used for an anti-depressant. The daughter confirmed she provided care for Resident #88, at her home prior to admission and there is no history of mental illness and or behaviors.
Telephone interview was conducted with Resident #88's son on 04/04/19 at 2:09 P.M. The interview identified he had no idea why his father was taking a anti-psychotic medication and confirmed he has no history of mental illness or behaviors.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation and staff interview the facility failed to ensure necessary room repairs were completed. This affected three of 32 resident rooms observed. Residents #84, #87, #29, #6, #172, and ...
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Based on observation and staff interview the facility failed to ensure necessary room repairs were completed. This affected three of 32 resident rooms observed. Residents #84, #87, #29, #6, #172, and #49 resided in these rooms. The facility census was 118.
Findings include
1. Observation on 04/03/19 at 2:55 P.M. in the shared bathroom of Resident #84 and Resident #87 revealed there was no mopboard. The drywall was exposed and damaged at the base of the bathroom walls.
Interview on 04/03/19 at 2:55 P.M., with the Director of Environmental Services (DES) #300 revealed the damage was caused by a water leak in another room in January. DES #300 revealed it was an oversight the bathroom mopboard had not been replaced.
2. Observations on 04/03/19 at 2:55 P.M. and 3:02 P.M., revealed water stained ceiling tiles in two bathrooms shared by four residents (#6, #29, #172, #49).
Interviews on 04/03/19 at 2:55 P.M. and 3:02 P.M. with the Director of Environmental Services (DES) #300 confirmed the ceiling tiles in the two bathrooms were stained. DES #300 stated staff should report rooms in need of repair.
The facility was unable to provide a policy related to resident room maintenance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Minimum Data Set (MDS) Resident Assessment Instrument manual review and staff interviews, the fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Minimum Data Set (MDS) Resident Assessment Instrument manual review and staff interviews, the facility failed to ensure MDS assessments were accurate. This affected four (#6, #86, #56, #98) of 26 resident MDS assessments reviewed. The facility census was 118.
Findings include:
1. Review of Resident #6's medical record review revealed an admission date of 08/16/16, with diagnoses including: Alzheimer's disease, dementia, dysphagia, difficulty walking, dementia, anxiety and osteoarthritis.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had severe cognitive impairment and a weight gain.
Review of the monthly weight report revealed Resident #6 weighed 94 pounds on 02/01/19. Resident #6 weighed 89 pounds on 03/01/19 indicating a 5.32% weight loss in thirty days.
Review of a health status progress note dated 03/01/19 at 4:12 P.M., revealed Resident #6 had a significant weight loss of 5.3 percent in the past 30 days.
Interview on 04/05/19 at 9:39 A.M., with the MDS Director #216, confirmed a coding error occurred and the quarterly assessment should have reflected the significant weight loss.
2. Review of Resident #86's medical record revealed and admission date of 05/15/17, with diagnoses including: depressive disorder, dysphagia, excoriation disorder, hypertension, muscle weakness, cerebral infarction, type two diabetes mellitus, and repeated falls.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #86 was cognitively impaired and had no falls since her annual assessment dated [DATE].
Review of a nurse's note date 01/23/19 revealed Resident #86 was on the floor face down with scratch and hematoma noted by the right eye. Resident #89 was sent to the emergency room.
Interview on 04/03/19 at 11:10 A.M., with MDS Director #216, revealed the fall on 01/23/19 was not documented on the quarterly MDS assessment dated [DATE].
3. Review of Resident #56's medical record review revealed admission date of 02/17/14, with diagnoses including: hypertension, Alzheimer's disease, and sciatica of the right side.
Review of the quarterly MDS assessment, dated 01/29/19, under section N-410H, did not identify Resident #56 received opioid pain medication.
Review of the resident's physician orders revealed on 01/23/19 the resident was ordered Tramadol (opioid pain medication) 50 milligrams (mg) to be administered every eight hours as needed for pain.
Review of Resident #56's Medication Administration Record (MAR) revealed the resident was administered Tramadol 50 mg on 01/24/19, 01/28/19, and 01/29/19.
Interview on 04/04/19 at 9:54 A.M., with Licensed Practical Nurse (LPN) #215 revealed she was the MDS coordinator and completed Resident #56's quarterly MDS assessment dated [DATE]. LPN #215 confirmed Resident #56's section N-410H should have identified she was receiving opioid medication.
Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, chapter three, page N-10, dated 10/2017, revealed opioid medication received by a resident should be coded on the MDS assessment at N-410H.
4. Review of Resident #98's medical record revealed an admission date of 09/26/18, with diagnosis including: stage 4 pressure ulcers to the coccyx, fractured 5th vertebra and paraplegia. Resident #98 had re-admissions from the hospital on [DATE].
Review of the quarterly MDS assessment dated [DATE] and 02/28/19 revealed the assessments both identified Resident #98 had one unstageable pressure ulcer.
Review of the facility wound physician notes dated 12/05/18 identified development of two additional pressure ulcers. The ulcers were identified on the left and right gluteal folds.
Interview with Registered Nurse (RN) #216, on 04/05/19 at 9:13 A.M., revealed Resident #98 had four total pressure areas since 12/05/19 and they were not properly identified on Resident #98's MDS.
Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, chapter three, page M-6, dated 10/2017, revealed pressure ulcers should be coded on the MDS assessment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, facility policy review, resident and staff interviews, the facility failed to imple...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, facility policy review, resident and staff interviews, the facility failed to implement interventions to prevent falls. This affected one (#88) of three sampled residents reviewed for accidents. The facility also failed to ensure staff did not leave medications, unattended in one resident's room (Resident #98). This could potentially affect three (#57, #67, and #77) residents identified by the facility as confused and independently mobile. The facility census was 118.
Findings include
1. Review of Resident #88's medical record revealed an admission date of 01/28/19, with diagnoses including: throat mass, diarrhea, difficulty swallowing, throat cancer, and dementia. Review of the admission assessment (MDS) dated [DATE] identified Resident #88 was high risk for falling and a written plan of care was required. The assessment further identified Resident #88 required extensive assistance of two persons for transfers.
Resident #88's medical record identified while in the facility falls occurred on 02/03/19, 02/07/19, 02/10/19, 03/06/19, 03/10/19, 03/12/19, 03/16/19 and 04/01/19. The facility was noted to conduct investigations with all falls and identified interventions needed to attempt to prevent Resident #88 from falling. The fall occurring 04/01/19 identified the nature of the fall included Resident #88 self transferred from his wheelchair and fell. The listed intervention at that time was re-direct resident from sitting in his room alone.
Observation of Resident #88 occurred on 04/04/19 at 4:18 P.M., revealed Resident #88 was in his wheelchair sitting alone in his room.
Interview with State Tested Nursing Assistant (STNA) #58 was conducted on 04/04/19 at 4:24 P.M., identified staff use a card ([NAME]) located in the closet door to identify current interventions for falling for each resident. The interview confirmed Resident #88 does not have the card located in the door and she was unable to identify any location of Resident #88's fall interventions. The interview further confirmed the STNA's get report for other staff during shift change, but she was unaware Resident #58 was not to be left alone, while in his wheelchair in his room.
Observation of Resident #88 occurred on 04/05/19 at 7:51 A.M., to be up in his wheelchair, alone in his room. Resident #88 was getting clothing out of the closet at that time.
Interview with STNA #115 occurred on 04/05/19 at 7:53 A.M. The interview identified she was not aware of where to find fall interventions that should be in place for Resident #88. STNA #115 confirmed she was not aware Resident #88 should not be left alone in his room or his high number of fall.
Interview with Registered Nurse (RN) #216 occurred on 04/04/19 at 4:45 P.M., confirmed a [NAME] is completed for all residents upon admission and is placed in their closet in the room. The interview identified STNA's utilize these to know what care they need to provide to residents. The interview confirmed RN #216 could not locate a [NAME] for Resident #88. The interview confirmed the current written plan of care does not include all interventions developed following falls occurring. The plan does not include: early sense (device located on bed to notify staff of movement), not to leave resident alone in room in wheelchair, and ensure laying resident down after radiation treatments.
2. Review of Resident #98's medical record review revealed an admission date of 03/21/19. Diagnoses included: Diabetes mellitus, hyperlipidemia, and anxiety. Review of the admission assessment dated [DATE] revealed the resident was alert and oriented to person, place, and time.
Observation of Resident #98's room on 04/02/19 at 8:43 A.M., revealed a medicine cup sitting on a bedside table near the resident. There were 12 pills noted in the medicine cup. Interview at this time with Resident #98 revealed the nurse brought him the medication and left them for him to take.
Interview on 04/02/19 at 8:50 A.M., with Licensed Practical Nurse (LPN) #256 revealed she gave Resident #98 his pills this morning. LPN #256 verified she left the resident's pills on his bedside table while she went to provide care for another resident. LPN #256 revealed she should have waited for the resident to take the medication before leaving the room.
Interview on 04/03/19 at 1:00 P.M., with the Director of Nursing (DON) revealed it was against the facility's standard of practice to leave medications in resident's rooms unattended. Nursing staff were to remain with the resident until the medications were consumed to verify the resident took them. The DON identified three residents (#57, #67 and #77) as being confused and independently mobile.
Review of a facility policy titled, Medication Administration Specific Procedures, dated 03/01/07, revealed it was the facility's policy to administer medications in an organized and safe manner.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Ohio facilities.
- • 32% turnover. Below Ohio's 48% average. Good staff retention means consistent care.
Concerns
- • 27 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.
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About This Facility
What is Good Shepherd The's CMS Rating?
CMS assigns GOOD SHEPHERD THE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Ohio, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Good Shepherd The Staffed?
CMS rates GOOD SHEPHERD THE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 32%, compared to the Ohio average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Good Shepherd The?
State health inspectors documented 27 deficiencies at GOOD SHEPHERD THE during 2019 to 2024. These included: 1 that caused actual resident harm, 24 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Good Shepherd The?
GOOD SHEPHERD THE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 125 certified beds and approximately 110 residents (about 88% occupancy), it is a mid-sized facility located in ASHLAND, Ohio.
How Does Good Shepherd The Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, GOOD SHEPHERD THE's overall rating (4 stars) is above the state average of 3.2, staff turnover (32%) is significantly lower than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Good Shepherd The?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Good Shepherd The Safe?
Based on CMS inspection data, GOOD SHEPHERD THE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Ohio. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Good Shepherd The Stick Around?
GOOD SHEPHERD THE has a staff turnover rate of 32%, which is about average for Ohio nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Good Shepherd The Ever Fined?
GOOD SHEPHERD THE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Good Shepherd The on Any Federal Watch List?
GOOD SHEPHERD THE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.