CAPITAL CITY GARDENS REHABILITATION AND NURSING CE
For profit - Limited Liability company
104 Beds
GARDEN HEALTHCARE GROUP
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
6/100
#629 of 913 in OH
Photo by Brooke Mentzer
Photo by Brooke Mentzer
Photo by Gina Cappitti
1 / 5 photos
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Capital City Gardens Rehabilitation and Nursing Center has received an F grade for trust, indicating significant concerns about the quality of care provided. Ranking #629 out of 913 in Ohio places it in the bottom half of facilities, while its county rank of #25 out of 56 suggests that there are better local options available. Although the facility is improving, reducing its number of issues from 13 to 10 over the past year, it still faces serious challenges, including $205,182 in fines, which is higher than 96% of other Ohio facilities. Staffing is a concern with a 1/5 star rating and a turnover rate of 54%, which is close to the state average but still indicates instability among staff. Specific incidents include a failure to follow fire protocols during a mattress fire, resulting in severe burns to a resident, and inadequate wound care that led to a resident developing serious pressure ulcers. While the facility boasts excellent quality measures, the overall environment raises significant red flags for prospective residents and their families.
- Trust Score
- F
- In Ohio
- #629/913
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $205,182 in fines. Lower than most Ohio facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 16 minutes of Registered Nurse (RN) attention daily — below average for Ohio. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 49 deficiencies on record. Higher than average. Multiple issues found across inspections.
6/100
Bottom 32%
Review needed
13 → 10 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 13 issues
2025: 10 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Ohio average (3.2)
Below average - review inspection findings carefully
Staff Turnover: 54%
Near Ohio avg (46%)
Higher turnover may affect care consistency
Federal Fines: $205,182
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: GARDEN HEALTHCARE GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 49 deficiencies on record
2 life-threatening 1 actual harm
Mar 2025
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on medical record review, resident interview, staff interview, and facility document review, the facility failed to allow residents to refuse treatment without the threat of being discharged fro...
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Based on medical record review, resident interview, staff interview, and facility document review, the facility failed to allow residents to refuse treatment without the threat of being discharged from the facility. This affected one (Resident #201) of two residents reviewed for dignity/rights. The census was 89.
Findings include:
Review of Resident #201's medical record revealed an admission date of 02/18/25. Resident #201's diagnoses included osteomyelitis, fusion of spine, asthma, discitis, intraspinal abscess and granuloma, arthritis due to other bacteria, methicillin susceptible staphylococcus aureus, bacteremia, viral hepatitis C, other psychoactive substance abuse, subluxation of L4/L5 (lumbar) vertebra, anemia, depression, anxiety disorder, muscle weakness, difficulty walking, and need for assistance with personal care. Review of the minimum data set (MDS) assessment, dated 02/25/25, revealed she was cognitively intact.
Review of Resident #201's Substance Use Disorder Program agreement revealed she signed the form to agree to substance use treatment in the facility on 02/13/25. She signed this document while she was in the hospital, prior to being admitted to the facility.
Interview with Resident #201 on 03/03/25 at 2:39 P.M. and 03/06/25 at 12:11 P.M., confirmed she felt forced to go through the stepping stones program (substance abuse program) while in the facility; she confirmed she does not want to be a part of it. She stated she does not remember talking or hearing about the stepping stones program at this facility. She remembers talking to someone in the hospital about multiple facilities she could go to, but she chose to go to the one she was in right now. She stated the facility Administrator and Stepping Stones Counselor #303 both went to her room after she was admitted and told her she needed to sign a variety of consent form or she would be discharged from the facility. She stated she could not remember what the consent forms were, but she was confident she was told that she needed to sign the documents and participate in the stepping stones program, or she would be discharged from the facility. She stated she would not have admitted to this facility had she known she would have had to go through with the stepping stones program. She confirmed she did not want to go to counseling, did not want to drug test, and did not want to have visitors in a public place.
Interview with Corporate Director #301 and [NAME] President of Business Development (VPBD) #305 on 03/06/25 at 10:05 A.M., revealed each resident who has a history of substance abuse, the facility will be notified about a possible referral due to this facility having the stepping stone program. The residents will sign a contract prior to entering the facility for medical care. They are told about the stepping stones program prior to admitted to this facility, while they are at the hospital. The facility hospital liaison goes to the hospital, discusses the program and what is expected of them if they are admitted , and get them to sign the contract that they will participate in the stepping stone program. They continued to say the resident signed the contract to participate in the stepping stones program, so they have to participate when they are in the facility. When asked if a resident would be discharged if they did not participate, their answer was, each resident is different, but it would be discussed.
Interview with Administrator on 03/06/25 at 12:00 P.M., revealed the resident will sign a contract at the hospital prior to being admitted to the facility, to participate in the stepping stones program. The hospital liaison will review the contract with the resident prior admitted to the facility, and then the resident will sign it. He confirmed if the resident comes into the facility, and they determine they don't want to do the stepping stones program, they will try to find another facility for the resident and perform a safe discharge.
Interview with Stepping Stones Counselor #303 on 03/06/25 at 12:27 P.M., revealed the hospital will give referrals to the facility about those who have a positive drug test or a history of substance abuse. She confirmed if they don't sign the consent forms (transportation, medical care, etc) in the facility for treatment, they can not go forward with stepping stones, and they will be removed from that program. She stated she has no decision power as to whether the resident stays in the facility if they don't continue with the stepping stones program.
Review of the undated facility agreement titled, Substance Use Disorder Program, revealed a Stepping Stone's counselor will conduct in-house counseling sessions on a frequency to be determined where attendance for those in the substance use disorder program is mandatory. Refusal to attend such sessions will result in immediate discharge planning due to refusals to participate as previously agreed prior to admission. The candidate for admission to the facility and Substance Use Disorder program will also agree, prior to admit, to the following protocol based on the team collaboration with the physicians and certified nurse practitioners (CNP) involved in the Substance Abuse program: leave of absences (LOA) based on physician order, supervised visits with outside visitors in a common area, visitors alone in the resident's rooms based on discretion of the physician and interdisciplinary team (IDT), ancillary physician appointments outside the facility may require a responsible escort, random labs and urine drug screens on an as needed basis. The resident will be immediately discharged based on the IDT investigation for any violation of the Substance Use program in collaboration with the involved physicians and CNPs.
Review of Facility Services Agreement between this facility and Stepping Stones Outpatient Services, LLC, dated 03/10/21, revealed the agreement identified Stepping Stones as provider throughout the language of the agreement. Under the section of Resident Choice, the agreement stated, the parties agree that nothing contained in this agreement shall prevent any resident from electing services from any health care provider of resident's or their legal representative's choosing and at no time shall any resident of the facility be obligated to use the services offered by provider.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on medical record review, staff interview and policy review, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASARR) documents were accurate to resident c...
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Based on medical record review, staff interview and policy review, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASARR) documents were accurate to resident current conditions and diagnoses. This affected three (#3, #15, and #59) of four residents reviewed for PASARR documents. The census was 89.
Findings include:
1. Review of Resident #3's medical record revealed an admission date of 03/05/19. Her diagnoses included acute bronchitis, epileptic seizures, pulmonary embolism, post traumatic stress disorder, conversion disorder, phantom limb syndrome, bipolar disorder, unspecified protein calorie malnutrition, hypothyroidism, hypertension, other cervical disc degeneration, vitamin D deficiency, insomnia, atrial fibrillation, nonrheumatic mitral valve prolapse, muscle weakness, hypotension, repeated falls, pain, type II diabetes, depression, macular degeneration, hypermetropia, hyperlipidemia, anxiety disorder, acquired absence of right leg below knee, and epilepsy. Review of her Minimum Data Set (MDS) assessment, dated 12/09/24, revealed she was cognitively intact.
Review of Resident #3 PASARR document, dated 11/03/22, revealed under Section E, the diagnoses listed were panic or other severe anxiety disorder. But review of her diagnoses list, she also had the following diagnoses that should have been indicated/updated on her PASARR document: bipolar disorder, major depressive disorder, and post traumatic stress disorder.
2. Review of Resident #15's medical record revealed an admission date of 04/15/22. Her diagnoses were acute pulmonary edema, type II diabetes, ulcerative colitis, respiratory failure, major depressive disorder, chronic obstructive pulmonary disease, lymphedema, atrial fibrillation, chronic kidney disease (stage III), anxiety disorder, repeated falls, muscle weakness, dorsalgia, bipolar disorder, anemia, insomnia, heart failure, hypertension, adult failure to thrive, mood disorder, and nicotine dependence. Review of her MDS assessment, dated 02/13/25, revealed she was cognitively intact.
Review of Resident #15 PASARR document, dated 02/15/24, revealed under Section E, the diagnoses listed were mood disorder and depression. But review of her diagnoses list, she also had the following diagnoses that should have been indicated/updated on her PASARR document: bipolar disorder, anxiety disorder, and adult failure to thrive.
Interview with Social Services #207 on 03/06/25 at 8:35 A.M. confirmed the PASARR documents for Residents #3 and #15 need to be updated to accurately reflect her diagnoses.
3. Review of the medical record for Resident #59 revealed an admission date of 05/19/23, with diagnoses of major depressive disorder, post-traumatic stress disorder, panic disorder, schizophrenia and psychoactive substance abuse. Updated diagnoses included anxiety, insomnia and unspecified mood disorder.
Review of preadmission screening and resident review (PASARR) identification screen dated 04/10/23 revealed diagnoses present were schizophrenia, mood disorder, panic or other severe anxiety disorder and post-traumatic stress disorder.
Review of physician orders dated 08/19/24 revealed Melatonin capsule three milligrams (mg) at bedtime for insomnia.
Review of minimum data set (MDS) assessment completed 01/17/25 revealed Resident #59 has a brief interview for mental status (BIMS) score of 15, indicating the resident is cognitively intact. Review of additional active diagnoses included insomnia.
Review of physician note dated 02/16/25 revealed diagnoses of depressive disorder with anxiety and insomnia, treated with escitalopram, buspirone and Melatonin with a follow up with psychiatry.
Review of psychiatric note dated 02/18/25 revealed Resident #59 reports stable anxiety, however has a history of excessive worrying which occurs more days than not, for greater than 6 months with the following symptoms: restlessness, daytime fatigue, irritability and sleep disturbance.
Interview on 03/06/25 at 8:35 A.M., with Admissions/Social Services #207 confirmed Resident #59 PASARR screening completed on 04/10/23 was inaccurate because it did not include the diagnosis of insomnia.
Review of the undated policy titled, Resident Assessment - Coordination with PASARR Program, revealed the facility coordinates assessments with the PASARR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The social services director shall be responsible for keeping track of each resident;s PASARR screening stats, and referring to the appropriate authority. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0646
(Tag F0646)
Could have caused harm · This affected 1 resident
Based on medical record review, staff interview and policy review, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affecte...
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Based on medical record review, staff interview and policy review, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected three (#3, #15, and #59) of four residents reviewed for Pre-admission Screening and Resident Review (PASARR) documents. The census was 89.
Findings include:
1. Review of Resident #3's medical record revealed an admission date of 03/05/19. Her diagnoses included acute bronchitis, epileptic seizures, pulmonary embolism, post traumatic stress disorder, conversion disorder, phantom limb syndrome, bipolar disorder, unspecified protein calorie malnutrition, hypothyroidism, hypertension, other cervical disc degeneration, vitamin D deficiency, insomnia, atrial fibrillation, nonrheumatic mitral valve prolapse, muscle weakness, hypotension, repeated falls, pain, type II diabetes, depression, macular degeneration, hypermetropia, hyperlipidemia, anxiety disorder, acquired absence of right leg below knee, and epilepsy. Review of her Minimum Data Set (MDS) assessment, dated 12/09/24, revealed she was cognitively intact.
Review of Resident #3 PASARR document, dated 11/03/22, revealed under Section E, the diagnoses listed were panic or other severe anxiety disorder. But review of her diagnoses list, she also had the following diagnoses that should have been indicated/updated on her PASARR document: bipolar disorder, major depressive disorder, and post traumatic stress disorder.
Review of her progress notes revealed no evidence to support the state mental health agency was notified of the significant mental health changes as required.
2. Review of Resident #15's medical record revealed an admission date of 04/15/22. Her diagnoses were acute pulmonary edema, type II diabetes, ulcerative colitis, respiratory failure, major depressive disorder, chronic obstructive pulmonary disease, lymphedema, atrial fibrillation, chronic kidney disease (stage III), anxiety disorder, repeated falls, muscle weakness, dorsalgia, bipolar disorder, anemia, insomnia, heart failure, hypertension, adult failure to thrive, mood disorder, and nicotine dependence. Review of her MDS assessment, dated 02/13/25, revealed she was cognitively intact.
Review of Resident #15 PASARR document, dated 02/15/24, revealed under Section E, the diagnoses listed were mood disorder and depression. But review of her diagnoses list, she also had the following diagnoses that should have been indicated/updated on her PASARR document: bipolar disorder, anxiety disorder, and adult failure to thrive.
Review of her progress notes revealed no evidence to support the state mental health agency was notified of the significant mental health changes as required.
Interview with Social Services #207 on 03/06/25 at 8:35 A.M., confirmed she had not notified the state mental health agency of the significant changes for either resident.
3. Review of the medical record for Resident #59 revealed an admission date of 05/19/23 with diagnoses of major depressive disorder, post-traumatic stress disorder, panic disorder, schizophrenia and psychoactive substance abuse. Updated diagnoses included anxiety, insomnia and unspecified mood disorder.
Review of preadmission screening and resident review (PASRR) identification screen dated 04/10/23 revealed diagnoses present were schizophrenia, mood disorder, panic or other severe anxiety disorder and post-traumatic stress disorder.
Review of physician orders dated 08/19/24 revealed Melatonin capsule three milligrams (mg) at bedtime for insomnia.
Review of MDS assessment completed 01/17/25 revealed Resident #59 has a brief interview for mental status (BIMS) score of 15, indicating the resident is cognitively intact. Review of additional active diagnoses included insomnia.
Review of physician note dated 02/16/25 revealed diagnoses of depressive disorder with anxiety and insomnia, treated with escitalopram, buspirone and Melatonin with a follow up with psychiatry.
Review of psychiatric note dated 02/18/25 revealed Resident #59 reports stable anxiety, however has a history of excessive worrying which occurs more days than not, for greater than 6 months with the following symptoms: restlessness, daytime fatigue, irritability and sleep disturbance.
Interview on 03/06/25 at 8:35 A.M. with Admissions/Social Services #207 confirmed Resident #59 PASARR screening completed on 04/10/23 was inaccurate because it did not include the diagnosis of insomnia. Additionally, this incorrect review had been sent to the Department of Aging and would need to be corrected.
Review of the undated policy tiled, Resident Assessment - Coordination with PASARR Program, revealed the facility coordinates assessments with the preadmission screening and resident review (PASARR) program under medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Additionally any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
2. Review of Resident #77's medical record revealed an admission date of 01/28/25. His diagnoses included fracture of tibia or fibula, end stage renal disease, type II diabetes, edema, hyperlipidemia,...
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2. Review of Resident #77's medical record revealed an admission date of 01/28/25. His diagnoses included fracture of tibia or fibula, end stage renal disease, type II diabetes, edema, hyperlipidemia, congestive heart failure, dependence on renal dialysis, hypertension, insomnia, muscle weakness, and acquired absence of spleen. Review of his minimum data set (MDS) assessment, dated 02/04/25, revealed he was cognitively intact.
Review of Resident #77's weights, dated 01/29/25 to 02/10/25, revealed the following weights and dates they were taken: 01/29/25 (200 pounds), 02/05/25 (186.7 pounds), 02/07/25 (180.2 pounds), 02/10/25 (180.2 pounds), and 02/10/25 (182.3 pounds). From 01/29/25 to 02/05/25, there was a decrease of 6.7 percent, and from 01/29/25 to 02/07/25, there was a decrease of 9.9 percent.
Review of Resident #77's nutritional progress note, dated 02/06/25 and 02/14/25, revealed a trigger for 5 percent and 7.5 percent weight decrease respectively. It was documented that there may be some expected weight fluctuation, but the dietitian recommended that the weekly weights continue so they could establish a weight baseline. Also, there was a note that the initial weight could be erroneous, so they wanted to continue the weekly weights.
Review of Resident #77's physician orders, dated 02/03/25, revealed the facility was to take Resident #77 weights on a weekly basis for a month.
Review of Resident #77's nutritional care plan revealed an intervention added on 02/14/25 for the facility to continue weekly weights.
Review of Resident #77's weights, dated 02/10/25 to 03/06/25, revealed no further weights were taken, which did not comply with the dietary recommendation and the physician/nutritional order as written to establish his baseline weight.
Interview with Dietitian #302 on 03/06/25 at 11:43 A.M. confirmed weights weekly for first four weeks is standard and what she would have liked to have happened for Resident #77. She reviewed the weights for the first two weeks, and then put an order/recommendation that she wanted the weekly weights to continue to get two more weights. She confirmed she didn't count the 02/07/25 and 02/10/25 weights as weekly weights; only verifications. She confirmed there was no additional weight in the record. She confirmed she is not certain the initial weight of 200 was accurate or they got it from hospital records/from him personally, which is why she wanted to weekly weights to continue to establish an accurate baseline weight.
Review of the policy titled, Weight Assessment and Intervention, dated September 2012, revealed the team will strive to prevent, monitor, and intervene for undesirable weight loss for residents. Weight assessment includes nursing staff will measure residents weights on admission, the next day, and weekly for two weeks thereafter. If no weights concerns are noted at this point, weights will be measured monthly thereafter.
Based on record review, staff interview, and policy review, the facility failed to ensure weekly weights were obtained per physician orders. This affected two (#77 and #92) of five reviewed for nutritional monitoring. The facility census was 96.
Findings include:
1. Review of the medical record for Resident #92 revealed an admission date of 11/12/24, with diagnoses of acute and subacute infective endocarditis, bacteremia, viral hepatitis, presence of heart valve replacement, rheumatic tricuspid insufficiency, shortness of breath, psychoactive substance use, hypertension, pulmonary embolism without acute cor pulmonale and edema.
Review of nutritional assessment review dated 11/15/24 revealed Resident #92's most recent weight measurement for Resident #92, taken on 11/12/24, showed a weight of 178 pounds. To help maintain a stable weight, interventions included fluid restriction, protein supplements three times daily, double protein with meals, a no-added-salt diet, and weekly weight monitoring.
Review of the medical record for Resident #92 revealed the only weight taken by facility staff was on 11/12/24 with a result of 178 lbs.
Review of the care plan dated 11/15/24 revealed Resident #92 has nutritional problem related to recent surgery, infective endocarditis, bacteremia, hepatitis, shortness of breath, psychoactive substance abuse, hypertension, and anxiety. As of 11/27/24, it is noted to continue monitoring weekly weights to establish a baseline. Interventions include following the prescribed fluid restriction, serving the ordered diet, recording meal intake at each meal, and having the dietitian assess and make any necessary diet adjustments. Additionally, the resident will be monitored for any significant weight loss.
Review of physician orders dated 11/15/24 revealed an order for fluid restriction was placed, limiting intake to 1500 milliliters every 24 hours. Additionally, on 11/16/24, an order for a house shake was made for three times a day. On 11/17/24, an order for weekly weight checks for four weeks, followed by monthly weigh-ins.
Review of care conference dated 11/18/24 revealed Resident #92 current diet includes no added salt, regular texture, and a fluid restriction of 1500 milliliters per day. They are also receiving a house shake three times a day. The resident has reported weight loss during their hospital stay, with a goal of maintaining their weight.
Review of admission minimum data set (MDS) assessment completed 11/19/24 revealed Resident #92 had a brief interview for mental status of 15, indicating the resident was cognitively intact. Additionally the record revealed the resident has not experienced a 5% weight gain or loss in the past month, nor a 10% or greater weight change over the last six months. Review of section K Swallowing/Nutritional status revealed a weight of 178 pounds (lbs).
Interview on 03/05/25 at 5:17 P.M., with Corporate Nurse #304 confirmed the facility has recognized an issue with staff not consistently obtaining weekly weights upon admission and as ordered. The facility has been actively working on finding a solution to this issue and tracking progress
Interview on 03/06/25 at 11:46 A.M., with Dietician #302 confirmed Resident #92 has physician orders to have weekly weights since admission. The dietitian confirmed the resident has several risk factors for weight loss or gain, including diagnosis of hepatitis with a history of ascites, cardiac disorder with prescribed antibiotics, a prolonged hospital stay, and a fluid restriction. She also confirmed that facility staff did not complete the weekly weights as ordered.
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 medical record review, review of hospital records and staff interviews, the facility failed to ensure a resident's resp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records and staff interviews, the facility failed to ensure a resident's respiratory needs were being met. This affected the one resident (#196) of one resident reviewed for oxygen use. The facility census was 89 residents.
Findings include:
Review of Resident #196's medical record revealed an admission on [DATE], with diagnoses that included chronic obstructive pulmonary disease, unspecified asthma, pulmonary embolism and heart failure. Review of Resident #196's census revealed she was hospitalized from [DATE] until 02/28/25.
Review of Resident #196's physician orders revealed she was ordered to have a Bilevel Positive Airway Pressure (BiPap) face mask, humidified, oxygen at 3 liters per minute at bedtime starting on 01/30/25 and ending on 02/27/25. On 03/04/25, Certified Nurse Practitioner #350 entered orders for Resident #196 to have BiPap to be worn at bedtime. Resident #196's record was silent for BiPap orders from 02/28/25 until 03/04/25.
Review of Resident #196's hospital records dated 02/26/25 revealed she had physcian orders for a BiPap and she needed to wear it for a minimum of six hours at night on a daily basis, or she would risk death.
Interview on 03/05/25 at 2:30 P.M., with the Director of Nursing, confirmed Resident #196's BiPap orders were omitted from her facility readmission orders on 02/28/25 and were not entered into her orders until 03/04/25.
Interview on 03/06/25 at 8:54 A.M., with Certified Nurse Practitioner #350 confirmed when Resident #196 was readmitted to the facility on [DATE], she should have had BiPap orders entered into her physician orders, as she should never be without her BiPap daily.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews and review of policy, the facility failed to ensure communication...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews and review of policy, the facility failed to ensure communication between the facility and dialysis vendor regarding dialysis treatments was on going for continuity of care. This affected one (#24) of one resident reviewed for dialysis. Seven residents currently receive dialysis treatments. The facility census was 89 residents.
Findings include:
Review of Resident #24's medical record revealed an admission on [DATE], with diagnoses that included chronic kidney disease, end stage renal disease, chronic viral hepatitis C, hypertension and dependence on renal dialysis. Review of Resident #24's physician orders revealed a standing appointment for dialysis at an outside dialysis clinic three times weekly. Orders for nursing to complete a pre- and post-dialysis communication form on Mondays, Wednesdays and Fridays.
Observation of Resident #24's hard chart on 03/04/25 at 3:24 P.M., revealed some post dialysis forms in the hard chart, but not in completion.
Interview on 03/04/25 at 3:24 P.M., with Licensed Practical Nurse (LPN) #154, revealed when Resident #24 returns from dialysis, she does not always bring a communication sheet from the dialysis center with her. LPN #154 revealed when Resident #24 does not return with a communication form, she does not follow up with the dialysis center or inquire about the services performed at the dialysis center.
Observation on 03/04/25 at 3:38 P.M., of a binder in the Director of Nursing's office revealed the remainder of the dialysis communication forms for Resident #24 were located in this binder.
Interview on 03/04/25 at 3:38 P.M., with the Director of Nursing (DON) confirmed the communication with the dialysis center needed to be more defined.
Interview on 03/06/25 at 12:40 P.M., with the DON revealed she expects the nurses to read the communications from the dialysis center.
Review of an undated policy titled Hemodialysis revealed there should be ongoing communication between the dialysis center staff and the facility, including but not limited to weight changes, medication administration, and treatment complications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
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 parameters for as needed pain medication. Thi...
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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 parameters for as needed pain medication. This affected one (#3) of five residents reviewed for unnecessary medications. The census was 89.
Findings Include:
Review of Resident #3's medical record revealed an admission on [DATE]. Her diagnoses included acute bronchitis, epileptic seizures, pulmonary embolism, post traumatic stress disorder, conversion disorder, phantom limb syndrome, bipolar disorder, unspecified protein calorie malnutrition, hypothyroidism, hypertension, other cervical disc degeneration, vitamin D deficiency, insomnia, atrial fibrillation, nonrheumatic mitral valve prolapse, muscle weakness, hypotension, repeated falls, pain, type II diabetes, depression, macular degeneration, hypermetropia, hyperlipidemia, anxiety disorder, acquired absence of right leg below knee, and epilepsy. Review of her Minimum Data Set (MDS) assessment, dated 12/09/24, revealed she was cognitively intact.
Review of Resident #3 physician orders, dated December 2024 to March 2025, revealed an order for acetaminophen 325 milligrams (mg), three tablets every six hours as needed for pain. Also, there was an order for Naproxen 500 mg every 12 hours as needed for pain. Finally, an order for oxycodone 5 mg every six hours for pain. None of the medications had parameters as to which pain medication should be given and what pain level each medication should be given at.
Review of Resident #3 medication administration record (MAR), dated December 2024 to February 2025, revealed the following as needed pain medications were administered: in December 2024, acetaminophen was administered five times for pain levels between 3 and 8, Naproxen was administered five times all for pain level of 6, and oxycodone was administered a total of 55 times for pain levels between 0 to 8. For January 2025, acetaminophen was administered 18 times for pain levels between 5 and 8, Naproxen was administered twice for pain level 6 and oxycodone was administered a total of 57 times for pain levels between 0 and 9. Lastly, in February 2025, acetaminophen was administered eight times for pain levels between 3 and 10, Naproxen was administered once for pain level 5, and oxycodone was administered 48 times for pain levels between 4 and 10.
Interview on 03/06/25 at 10:00 A.M., with Licensed Practical Nurse (LPN) #154, confirmed she has not typically seen parameters for resident as needed pain medications. She will ask the residents pain level and provide pain medications related to the pain level. She will administer the higher strength medication (examples include oxycodone, tramadol, etc) for pain levels 6 to 10, and the lower strength medication (acetaminophen, ibuprofen, etc) for pain levels 1 to 5. She will document the pain level and which medication she administered.
Interview on 03/06/25 at 10:17 A.M., with Director of Nursing (DON) confirmed the doctor does not order parameters for as needed pain medications. The doctor allows the residents to make the decision on which pain medication they want to take. Nurses will ask if resident is in pain, and if the resident has multiple pain medications, they will ask the resident which medication they want. DON confirmed Resident #3 does not have any parameters for her as needed pain medications.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interviews, and policy review, the facility failed to secure and store medica...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interviews, and policy review, the facility failed to secure and store medications appropriately. This affected one (#72) of 24 residents observed during the annual survey. The facility census was 89.
Findings include:
Review of Resident #72's medical record revealed an admission date of 10/06/23, with diagnoses that included cerebral infarction, dysphagia, major depressive disorder, psychoactive substance abuse, disorientation, anxiety disorder and pain.
Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #72 was cognitively intact, mild depression, with no signs of psychosis noted.
Review of records for Resident #72 revealed no assessment or screening for self - medication documented and there was no physician's order to administer self-medications.
Observations on 03/04/25 at 9:12 A.M. noted a medicine cup with several tablets and capsules on the over bed table for Resident #72.
Interview on 03/04/25 at 9:12 A.M. with Resident #72 revealed Resident #72 had been sleeping. Resident #72 then stated those pills might be his morning medications he would need to ask his nurse.
Interview on 03/04/25 at 9:15 A.M. with Licensed Practical Nurse (LPN) #154 confirmed the medication cup with morning medications for Resident #72 were left on the overbed table. Resident #72 was still eating breakfast when the medications were brought in and Resident #72 prefers to take medications after breakfast. LPN #154 stated she didn't realize he hadn't taken the medication yet.
Interview on 03/06/25 at 8:40 A.M., with the Director of Nursing (DON) confirmed the expectations are the nurse will follow the professional standards of medication administration including watching the patient take the medication at the time the medication is brought into the room.
Review of the policy titled, Administering Medications, dated December 2012 confirmed the expectations and process to prepare, administer, and document the administration of medications according to standard professional practice guidelines.
This deficiency represents non-compliance investigated under Complaint Numbers OH00162277.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record for Resident #59 revealed an admission date of 05/19/23, with diagnoses of major depressive diso...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record for Resident #59 revealed an admission date of 05/19/23, with diagnoses of major depressive disorder, post-traumatic stress disorder, panic disorder, schizophrenia, psychoactive substance abuse, anxiety, insomnia and unspecified mood disorder.
Review of the care plan dated 10/27/23 revealed Resident #59 has diagnoses of anxiety with an intervention of maintaining a calm environment.
Review of MDS assessment completed 01/17/25 revealed Resident #59 has a brief interview for mental status (BIMS) score of 15, indicating the resident is cognitively intact. Review of functional abilities section revealed the resident requires supervision or touching assistance with oral hygiene, toileting, and personal hygiene.
Observation on 03/05/25 at 3:46 P.M., of Resident #59 revealed a significant buildup of scaling between the porcelain and the left handle of the sink faucet. This buildup prevented the sink from shutting off completely, causing a continuous flow of water to spill into the sink basin
Interview on 03/05/24 at 3:44 P.M., with Resident #59 voiced concern regarding the constant leaking of the sink since admission to the facility, the resident voiced that staff members were notified of the issue and the noise was annoying.
Observation on 03/06/25 at 10:31 A.M., of Resident #59's room revealed the sink was still leaking with the large amount of scaling and build up.
Interview on 03/06/25 at 10:35 A.M., with Maintenance Director #178 confirmed presence of building up on the sink, he confirmed he was unaware of the issue and currently did not have a request out to fix the sink.
Review of policy titled, Quality of Life - Homelike Environment dated May 2017, revealed residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: comfortable and safe temperatures (71-81 degrees).
This deficiency represents non-compliance investigated under Complaint Numbers OH00162277, OH00162188, and OH00161970.
3. Review of Resident #247's medical record revealed admission date of 02/20/25, with diagnoses that included iron deficiency anemia, peripheral vascular disease, end stage renal disease with dependence on renal dialysis, type 2 diabetes mellitus with neuropathy and retinopathy, psychoactive substance abuse, atrial fibrillation, seizures, and an acquired absence of left leg below the knee.
Review of the admission MDS assessment dated [DATE] revealed Resident #247 was cognitively intact with brief interview for mental status (BIMS) score of 13/15.
Interview on 03/03/25 at 09:48 A.M., with Resident #247 in his room, revealed Resident #247 feels the room is always cold. Resident #247 has been in the facility for a week and there has been no heat in the room the whole time. Resident #247 states he has asked several times for the heat to be fixed and the temperature in the room never gets warmer.
Observation on 03/03/25 at 10:30 A.M., of Resident #247's room with RDM #300 revealed the air thermometer registered a temperature fluctuating between 69- and 70-degrees Fahrenheit.
Interview on 03/03/25 10:33 A.M., with RDM #300 confirmed room temperature reading topped out at 70.7 degrees Fahrenheit. Regional director of maintenance #300 confirmed room temperature readings should be warmer at 71 - 81 degrees Fahrenheit.
Based on observations, medical record review, resident interview, staff interview, and facility policy review, the facility failed to ensure air temperatures remained in the appropriate range. This affected three (#81, #79, and #247) of seven resident rooms observed for air temperatures. Also, the facility failed to repair a sink to prevent continuous dripping noises. This affected one (#59) of seven residents rooms observed. The census was 89.
Findings include:
1. Review of Resident #81's medical record revealed an admission dare on 12/15/24. Her diagnoses included cachexia, unspecified protein calorie malnutrition, hypotension, fatty liver, post traumatic stress disorder, borderline personality disorder, bipolar disorder, polyneuropathy, vitamin A deficiency, asthma, type II diabetes, malingerer, anxiety disorder, muscle weakness, cellulitis, pulmonary embolism, anemia, thrombocytopenia, and intellectual disability. Review of her minimum data set (MDS) assessment, dated 12/20/24, revealed she was cognitively intact.
Observation on 03/03/25 at 4:03 P.M., revealed Resident #81 underneath three different blankets, lying in her bed. She expressed that it was very cold in her room. Observation of with Regional Maintenance Director #300 during this time, found that his air temperature tool deemed the room to be 77 degrees, but the air vent to her room was blowing cold air and there was cold air blowing in from her window, which is where her bed was located. Regional Maintenance Director #300 confirmed they would have the Heating Ventilation Air Conditoning (HVAC) vendor to the facility as soon as possible to assess the heating units for each room that had issues.
Observation on 03/04/25 at 7:38 A.M., revealed Resident #81 was again under three blankets in bed, but she was covering her head with the blankets as well. The room was frigid to feel, and Resident #81 confirmed she was cold. Regional Maintenance Director (RMD) #300 entered Resident #81 room and confirmed with his air temperature tool that it was 66 degrees in her room. He confirmed the HVAC vendor would be in the facility that day to work on the units. Administrator offered for Resident #81 to move to a semi-private room for the time being, but she declined due to wanting to remain in her private room.
Interview with Resident #81 on 03/03/35 at 4:03 P.M. and 03/04/25 at 7:40 A.M., confirmed her room is constantly that cold. She confirmed the maintenance staff told her that a valve needed to be replaced in her room unit, but she is unsure if that has been completed. She confirmed she was covering her head on 03/04/25 because she did not want icicles to form from her nose because it was so cold.
Interview with RMD #300 on 03/04/25 at 7:45 A.M. and 03/05/25 at 9:00 A.M., confirmed that Resident #81 room temperature on 03/04/25 was 66 degrees. He confirmed that was too cold and they would be addressing the issue. On 03/05/25, he confirmed the HVAC vendor came to the facility and found that the HVAC lines needed to be bled so they got air pockets out. The system is working appropriately now.
2. Review of Resident #79's medical record revealed an admission date of 05/31/24. Her diagnoses included end stage renal disease, type I diabetes, hypertension, chronic pain syndrome, asthma, hypothyroidism, insomnia, polyneuropathy, other psychoactive substance abuse, anxiety disorder, major depressive disorder, scoliosis, history of falling, and anemia. Review of her MDS assessment, dated 01/24/25, revealed she was cognitively intact.
Observations on 03/04/25 at 7:53 A.M., found that Resident #79 room was 68 degrees, after she had complained her room was cold. The temperature was confirmed by Regional Maintenance Director #300.
Interview with Resident #79 on 03/04/25 at 7:53 A.M., confirmed her room was cold and had been that way for about a week. She stated she doesn't want to move, but would prefer to have her heat fixed soon.
Interview with RMD #300 on 03/04/25 at 7:55 A.M. and 03/0/25 at 9:00 A.M., confirmed Resident #79 room temperature was 68, which was outside the acceptable range. He gave same reason as Resident #81 room for being cold; they had to bleed the HVAC lines to get the air pockets out. They would be monitoring the affected rooms three times daily until they have deemed the temperature issue has been resolved.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on resident record review, observations, staff interviews, and review of policy, the facility did not have proper personal protective equipment in the laundry room to manage infectious material....
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Based on resident record review, observations, staff interviews, and review of policy, the facility did not have proper personal protective equipment in the laundry room to manage infectious material. Also, the facility did not follow proper isolation procedures for Resident #89. This had the potential to affect 87 residents of 89 residents in the facility. The facility identified two residents (#13 and #43) who did not have the facility launder their items. The facility census was 89.
Findings include:
1. Observation of the facility laundry room, on 03/04/25 at 8:32 A.M., revealed there was no personal protective equipment in the laundry room.
Interview on 03/04/25 at 8:36 A.M., with Housekeeping Supervisor #340 confirmed there was no personal protective equipment in the laundry room for handling infectious materials.
Interview with Laundry Aide #330 on 03/04/25 at 9:44 A.M., confirmed there was no personal protective equipment in the laundry room for handling infectious materials.
Interview with Corporate Nurse #304 on 03/06/24 at 10:00 A.M., revealed on 03/04/25, there were two residents (#12 and #32) who were on transmission-based precautions due to infections.
Review of the policy titled Infection Control, dated August 2014 revealed that gloves will be worn for contact with any potentially hazardous materials.
2. Review of Resident #89's medical record revealed an admission date of 01/27/25, with diagnoses that included end stage renal disease and dependence on renal dialysis. Review of Resident #89's physician orders revealed that he had a hemodialysis catheter in his right upper chest wall. Resident #89 was on Enhanced Barrier Precautions related to this indwelling medical device, effective on 02/26/25.
Observations on 03/05/25 at 4:46 P.M. and on 03/06/25 at 9:00 A.M., revealed Resident #89 did not have a sign on his door or outside of his room indicating that he was on Enhanced Barrier Precautions.
Interview on 03/06/25 at 9:14 A.M., with the Director of Nursing confirmed Resident #89 was on Enhanced Barrier Precautions and did not have a sign on his door or outside of his room notifying staff of the precautions.
Review of the policy titled Enhanced Barrier Precautions dated 04/01/24, revealed when implementing Enhanced Barrier Precautions, it is critical to ensure that staff has an awareness of the facility's expectations about hand hygiene and gown/glove use. To accomplish this, the facility posts signage on the door or outside of the resident room indicating that Enhanced Barrier Precautions are to be used.
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility investigations, staff interviews, and facility policy and procedure, the facility fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility investigations, staff interviews, and facility policy and procedure, the facility failed to ensure allegations of abuse and misappropriation had thorough investigations and documentation of the investigation. This affected three residents (#86, #94, and #95) out of four residents reviewed for allegations of abuse and misappropriation. The facility census was 89.
Findings include
1. Review of the medical record for Resident #94 revealed an admission date of 11/12/24 and a discharge date of 12/09/24. Diagnoses included surgical aftercare, endocarditis, bacteremia, shortness of breath, anxiety, and edema.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was cognitively intact with a BIMS of 15 and was independent with mobility.
Review of the online Self-Reported Incident (SRI) #254189 dated 11/18/24 revealed Resident #94 reported, during a care conference with social services staff, that he had to wake up Certified Nursing Aide (CNA) #55 for assistance. The resident also reported when he woke the CNA up, the CNA pushed Resident #94 away. The social service staff reported the allegation to the Administrator and an investigation was initiated. The summary stated the facility conducted a further interview with Resident #94, interviews with like residents, and interviews with staff. The facility also revealed they completed a head-to-toe assessment on the resident, reviewed Resident 94's care plan, removed the CNA from the schedule and reviewed CNA #55's employee file.
Review of the SRI investigation file revealed only a face sheet and care plan for Resident #94 were included. Upon request of further documentation the facility provided staff education, standardized questionnaire interviews with like residents and identical typed statements from staff. Review of the six identical staff statements revealed the statements were dated 11/19/24 and stated, I am unaware of any incident or allegation of abuse by a staff member toward Resident #94 or of any Resident at Capital City Gardens. None of the statements recalled events of the shift in question or interactions with Resident #94 or CNA #55 during the shift in question. Review of CNA #55's statement revealed he/she denied the allegation. The SRI investigation further revealed the facility had no interviews or statements from Resident #94, who reported the abuse allegation. The investigation revealed social service staff spoke with the resident during the care conference, and then the facility completed an initial interview/statement with the resident, and they also completed a follow-up interview/statement with the resident that was the same as the initial statement. Further review of the facility investigation revealed the facility had no actual statement written or signed as true by Resident #94.
Interview on 12/11/24 at 1:07 P.M. with the Administrator revealed Resident #94's statement was incorporated in the allegation with details in the SRI summary. A follow up interview at 1:30 P.M. confirmed facility had no written statements or signed statements of Resident #94's direct account of the allegation. The Administrator also did not agree that the investigation was incomplete, but acknowledged the investigation summary was a summary of the evidence, but not actual evidence itself.
2. Review of the medical record for Resident #86 revealed an admission date of 12/01/22. Diagnoses included hemiparesis, cerebral infarction, diabetes, dysphagia, anemia, heart failure and schizoaffective disorder.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 was cognitively intact with a BIMS of 14 and was dependent with transfers and activities of daily living.
Review of Resident #86's progress notes dated 11/26/24 revealed the resident reported another resident entered her room and groped her breast. The police were notified and a report was made.
Review of the Self-Reported Incident (SRI) #254518 dated 11/26/24 revealed Resident #86 reported a male resident (Resident #46) entered her room and touched her inappropriately and the resident was also asked to reveal her breasts. An unnamed staff reported the allegation to the Administrator and an investigation was initiated. The summary revealed police were notified and interviews with like residents and staff were also completed. Resident #86 was interviewed by social service staff and revealed she had no recollection of the allegation and she denied interactions with Resident #46.
Review of the SRI investigation file revealed along with the summary of the investigation, only a face sheet and care plan for Resident #86 was included. Upon request of further documentation, the facility provided facility education, standardized questionnaire interviews with like residents and identical typed statements from staff. Review of the six staff statements revealed the facility had identical statements dated 11/27/24 that stated, I am unaware of any incident or allegation involving inappropriate behavior or touching between Resident #46 and #86 or of any allegation involving appropriate behavior or touching between any resident. None of the staff statements recalled events of the shift in questions or interactions with Resident #46 or Resident #86 during the shift in question. Review of the signed statement from Resident #46 revealed he denied any knowledge of the issue or wrongdoing.
Review of the additional information provided for the SRI investigation revealed the facility had no interviews or statements from Resident #86 with specific details of her allegation. The facility had only provided a three-question questionnaire with yes or no answers from Resident #86. The questions were Do you feel safe? and the resident answered yes; Has another resident ever entered your room without being invited, if yes did you report it and what happened? the resident answered no; and If someone enters your room or touches you without consent, do you know how to report it? and the resident answered that they would call the police.
Interview on 12/11/24 at 1:07 P.M. with the Administrator revealed Resident #86's statement was incorporated in the allegation with details in the SRI summary. A follow up interview at 1:30 P.M. confirmed the facility had no written statements or signed statements of Resident #86's direct account of the allegation. He also stated they facility came to the conclusion that Resident #46 was involved due to the initial report from Resident #86, but when the resident was re-interviewed, she denied anything happened. The Administrator also did not agree that the investigation was incomplete, but acknowledged the investigation summary was a summary of the evidence, but not actual evidence itself.
3. Review of the medical record for Resident #95 revealed an admission date of 11/05/24 and discharge date of 11/22/24. Diagnoses included cervical displacement, cutaneous abscess, endocarditis, opioid use, bacteremia, chronic hepatitis, and bipolar disorder.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #95 was cognitively intact with a BIMS of 15 and was independent with transfers and mobility.
Review of the Self-Reported Incident (SRI) #253938 dated 11/11/24 revealed Resident #95 reported she was missing a half-carat diamond earring, but there was no specific allegation that it was stolen or as misappropriated. The resident had endorsed she wrapped the earring in a napkin and may have thrown it away, but an investigation was initiated. The summary revealed interviews were conducted with like residents and staff.
Review of the SRI investigation file revealed standardized questionnaire interviews with like residents. The facility provided no evidence of interviews or statements from Resident #95, who reported the allegation, and also failed to provide any evidence of staff statements.
Interview on 12/11/24 at 1:07 P.M. with Administrator revealed Resident #95's statement was incorporated in the allegation with details in the SRI summary. A follow up interview at 1:30 P.M. confirmed the facility had no written or signed statements of Resident #95's direct account of the allegation, nor any staff statements related to the investigation of missing items. The Administrator also did not agree that the investigation was incomplete, but acknowledged the investigation summary was a summary of the evidence, but not actual evidence itself.
Interview on 12/12/24 at 8:18 A.M. with Regional Clinical Nurse #100 revealed the facility corporate office used universal statements. She acknowledged facility investigations should be complete and thorough and verified the investigation files were not complete and documents had to be located from various sources at the facility, and several items remained unaccounted for including staff statements and resident statements.
Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/27/17, revealed it was the facility's policy to investigate all alleged violations involving Abuse, Neglect, and Misappropriation. It stated the facility staff shall immediately report all such allegations to administration/designee. The policy revealed the allegation shall be investigated and the investigation shall include interviews with the accused and all witnesses. A statement shall be obtained from the resident(s) involved, the accused, and each witness. The policy further stated the evidence of the investigation should be documented.
Nov 2024
2 deficiencies
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review and policy review, the facility failed to implement infection control procedures ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review and policy review, the facility failed to implement infection control procedures during a dressing change and while storing soiled laundry. This affected one (Resident #92) of three residents reviewed for wounds and had the potential to affect all residents residing in the facility. The facility census was 93.
Findings include:
1. Review of the medical record for Resident #92, revealed an admission date of 12/10/22. Diagnoses included but were not limited to type 2 diabetes mellitus with diabetic neuropathy, human immunodeficiency virus disease, pneumonia due to other gram-negative bacteria and methicillin susceptible staphylococcus aureus infection as the cause of diseases classified elsewhere.
Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of resident is rarely/never understood. The resident was assessed to require total dependence on all aspects of assisted with daily living care.
Review of the active plan of care dated 09/25/24 for Resident #92 revealed enhanced barrier precautions related to indwelling medical device with interventions to wear gown and gloves for high contact resident care.
Review of the active physician order dated 09/21/24 for Resident #92 revealed enhanced barrier precautions related to indwelling medical device and/or wound and /or infection during high contact resident care activities.
Further review revealed a physician order dated 11/11/24 for this resident revealed a wound order for the chest area: cleanse with normal saline, pat dry, apply collagen, cover with border dressing.
Observation on 11/14/24 at 1:02 P.M. of Licensed Practical Nurse (LPN) #399 revealed a wound dressing change was completed to the left chest area of Resident #92. LPN #399 did not don a gown prior to providing wound care to Resident #92 despite requiring the use of enhanced barrier precautions. Observation also revealed LPN #399 did not wash her hands after a glove change when removing the soiled dressing and donned a new pair of gloves to complete wound care.
Interview on 11/14/24 at 1:11 P.M. with LPN #399 verified no hand washing was completed between the removal of soiled gloves (worn when removing the soiled dressing) and the donning of new gloves. The LPN also verified a gown was not worn during the dressing change despite the resident having orders for enhanced barrier precautions.
Review the facility policy titled Wound Care revised October 2010 revealed put on exam gloves, loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle and to wash and dry hands thoroughly.
Review of the facility policy titled Enhanced Barrier Precautions dated 04/01/24 revealed examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include wound care.
2. Observation on 11/14/24 at 10:15 A.M. revealed a stairwell leading to the basement with a small landing. Further observation revealed the facility's laundry room was located in the basement.
Interview on 11/14/24 at 10:30 A.M. with Laundry Staff (LS) #357 revealed since the facility's elevator has been out of order, the laundry staff have had to take the laundry up and down the stairs. LS #357 stated the staff will throw the soiled laundry down the stairs to the landing and then the laundry staff will remove the laundry from the landing and place it in the cart at the bottom of the stairs which is then taken to the laundry room for processing.
Observation on 11/18/24 at 1:11 P.M. revealed a large pile of bagged and unbagged soiled laundry on the landing of the stairwell leading to the basement of the facility. There were several unbagged clothing articles, towels and a visibly soiled washcloth lying on the steps. There was an empty wheeled cart located at the bottom of the stairwell.
Interview on 11/18/24 at 1:16 P.M. with LS #252 confirmed the unbagged soiled laundry laying on the landing and the visibly soiled washcloth laying on the step. LS #252 donned gloves and removed the laundry from the landing and the stairs and placed it in the cart at the bottom of the stairwell.
Observation on 11/19/24 at 2:20 P.M. revealed a moderate sized pile of bagged, soiled laundry located on the landing of the stairwell, leading to the facility basement.
Interview on 11/19/24 at 2:25 P.M. with Regional Registered Nurse (RRN) #550 confirmed the bagged soiled laundry located on the stairwell landing. RRN #550 stated the expectations of the staff were to ensure soiled laundry was bagged and handled using infection control procedures which included not having the soiled laundry be thrown down the stairwell and stored on the landing of the stairwell until the laundry staff could remove and take it to the laundry room.
This deficiency represents non-compliance investigated under Complaint Number OH00159824.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, review of plumbing invoices, and review of facility policy, the facility fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, review of plumbing invoices, and review of facility policy, the facility failed to maintain a safe, functional, and sanity environment in the shower room for the B hallway. This deficient practice had the potential to affect all residents residing in the facility. The facility census was 93.
Findings Include:
Review of the plumbing company invoice #143340436 dated 11/12/24 revealed plumbing company arrived at the customers property for a shower drain back up. After attempting to cable the shower drain, the blockage was removed and restored flow to the drain.
Review of the plumbing company invoice #143544314 dated 11/13/24 revealed the facility was experiencing emergency flooding in the B hallway over the course of three days. The plumbing company attempted to clear the main line using high pressure jetter and a camera to evaluate the line.
Observation on 11/14/24 at 10:10 A.M. revealed the shower room located on the B hallway there were multiple ceramic tiles laying on the floor revealing the wet wall material. There was a hole approximately three inches in diameter into the wall behind the toilet at the base of the wall. In the shower stall/area, there was a brown substance with dried particles of building material and dirt in a circle pattern radiating from the drain in the center of the shower stall/area. The shower room for B hallway had been removed from service for resident use.
Interview on 11/14/24 at 10:55 A.M. with Resident #35 revealed there had been water in the hallway and in the room coming from the B hallway shower room on Monday 11/11/24 into Tuesday 11/12/24, the water was brown in color and had a horrible smell. Resident #35 stated the administration had offered to relocate Resident #35 and spouse Resident #34, neither Resident #34 or Resident #35 wanted to be separated so they remained in their room. Resident #35 stated the shower room has not been usable since the flooding occurred.
Observation on 11/18/24 at 7:50 A.M. revealed the shower room located on the B hallway had been placed back into service for resident use. The shower stall/area had been cleaned with the previous brown substance and dried building material and dirt having been removed and the shower area appeared to have been recently used for showering. There continued to be a three-inch diameter hole at the base of the wall behind the toilet and the wall tiles continued to be laying on the floor with the wall material exposed.
Review of the facility timeline email of the emergency flooding received on 11/18/24 at 9:11 A.M. authored by the Regional Director of Plant Operations (RDPO) #512 revealed on 11/12/24 at 9:20 A.M. there was reported severe flooding of the bathroom at the facility which included most of the hallway and leaking into several resident rooms (rooms and hallway was not identified). The plumbing company was contacted, arrived at the facility and had stated the blockage was removed and flow was restored at 10:30 A.M. RDPO #512 stated at approximately 6:30 P.M. on 11/12/24 the facility notified of the emergency flooding in the B hall shower room extending into the hallway and nurse's station area. The local water valve located in the B hallway shower was turned off which ceased the drain backup in the shower. At approximately 8:30 P.M. the drain in the B hallway shower began backing up again into the shower room and the hallway. At this time the decision was made to shut the main water valves off which completely ceased all drainage backups. The plumbing company was contacted and advised the facility they would be returning to the facility on [DATE] to address the drainage backup. The facility then made available emergency water sources and personal hygiene wipes for use to the staff and the residents. All the main water lines for the sprinkler system were still active for any potential emergencies that could occur. On 11/13/24 the plumbing company returned to the facility with the results of troubleshooting and use of cameras revealed the main blockage was located in the line around the B hallway shower room. This blockage was determined to be the same blockage which was identified and supposedly removed on 11/12/24. Once the blockage was fully pushed through the line to the main drain line, water was slowly restored resulting in several shut off valves were blown off due to the water pressure. The plumbing company repaired all shut off valves and water was restored to the facility. The blockage was fully pushed through the main line to the street line and was determined to be several wash cloths and other pieces of fabric debris which caused the blockage in the facility.
Interview on 11/18/24 at 10:30 A.M. with Certified Nursing Assistant (CNA) #335 revealed CNA #335 was not working during the water problems on 11/11/24 and 11/12/24. When CNA #335 returned to work on 11/14/24 B hallway shower room was not usable and the residents had to use the C hallway shower room for showers but the shower room was now back in use.
Interview on 11/18/24 at 10:45 A.M. with CNA #236 revealed the facility has had problems with the plumbing for a long time. CNA #236 stated there are residents which will get mad at the facility and have been known to flush non-flushable items down the toilets causing plumbing issues and water leaks. CNA #236 stated, while the facility had the plumbing company fixing the most recent plumbing problem, the water had to be turned off and the facility had passed out wipes, large bottles of water and smaller bottles of water to the staff and the residents to use during the period the water was turned off.
Interview on 11/14/24 at 3:15 P.M. with the Administrator confirmed the facility had experienced a plumbing failure on 11/11/24 and 11/12/24 causing water damage to the B hallway shower room. The Administrator stated the plumbing company had been contacted and subsequently came to the facility on [DATE] to investigate and fix the plumbing failure. The plumbing company had to return on 11/13/24 for continued drainage and flooding issues which were located and repaired. The Administrator stated the plumbing company had located a clog in the pipe which had been identified as wash cloths.
Review of the facility's policy titled, Maintenance Service dated 12/09 revealed, Maintenance is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at al times.
This deficiency represents non-compliance investigated under Complaint Number OH00159812.
Oct 2024
4 deficiencies
2 IJ (2 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility staff interviews, review of the fire investigation report, observation of facility vide...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility staff interviews, review of the fire investigation report, observation of facility video camera footage, review of the facility submitted Self-Reported Incident (SRI), and review of facility policy, the facility failed to ensure a resident was free from neglect when staff did not timely implement fire procedures when a mattress/bedding fire occurred in Resident #19's room. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, negative health outcomes and/or death when on 09/26/24 at 11:46 P.M. a fire occurred in Resident #19's room which ignited the resident's mattress/bedding on fire, activating the fire alarm and sprinkler system and facility staff did not attempt to immediately implement fire protocols to rescue, contain and/or extinguish the fire in Resident #19's room until 11:53 P.M. on 09/26/24. Resident #19 sustained burns to her legs, torso, and arm, was transferred to the hospital and admitted to the Surgical Care Intensive Care Unit (SICU) for treatment of extensive burns received on her legs, torso, and arm. Resident #19 was treated for acute respiratory failure with hypoxia and intubated with a moderate inhalation injury. This affected one (#19) resident who resided in Room B05 and placed an additional nine residents (Residents #11, #15, #16, #17, #18, #20, #21, #22, and #23), residing in the same smoke compartment as Resident #19 at potential risk for the likelihood of serious injury, impairment, negative health outcomes, and/or death, due to potential for the fire and smoke to spread throughout the hall. The facility census was 88.
On 10/10/24 at 2:47 P.M., the Administrator, Director of Nursing (DON), Corporate Nurse (CN) #309, and Regional Director of Operations (RDO) #334 were notified Immediate Jeopardy began on 09/26/24 when facility staff did not timely and appropriately implement fire safety protocols and procedures, in accordance with facility policy, to rescue residents, contain the fire, extinguish the fire, and evacuate residents who resided in the compartment where the fire was located. On 09/26/24 at 11:46 P.M., the fire alarm was activated and the fire doors shut. On 09/26/24 at 11:53 P.M., facility staff were observed, via video camera footage, to enter Resident #19's room with a fire extinguisher and Resident #19 was brought out of her room at 11:56:10 P.M. and at 11:57 P.M., Emergency Medical Services (EMS) took over care of Resident #19. Emergency Medical Services (EMS) transported Resident #19 to the hospital where she was admitted to the SICU for 35% Total Burn Surface Area (TBSA) burn, and status post escharotomy (a surgical procedure that involves cutting through burnt skin to release the eschar and relieve pressure) of the right lower extremity. Resident #19 was treated for acute respiratory failure with hypoxia and intubated with a moderate inhalation injury. The affected ten residents' (#11, #15, #16, #17, #18, #19, #20, #21, #22, and #23) who resided in the smoke compartment were the fire was located.
The Immediate Jeopardy was removed on 10/18/24 when the facility implemented the following corrective actions:
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On 09/26/24 at 11:46 P.M., the fire alarm sounded which transmits an alarm to the fire department of the fire.
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On 09/26/24 at approximately 11:46 P.M., the facility's incident investigation indicated Licensed Practical Nurse (LPN) #251 called 911 to report the incident of fire.
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On 09/26/24 from 11:50 P.M. through 11:52 P.M., residents are seen via facility video camera footage to be directed out of their rooms and attempting to make their way off the hallway.
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On 09/26/24 at 11:53 P.M., LPN #251 was observed via video footage to take a fire extinguisher into the resident's room B05, identified as Room B05. A subsequent interview with the nurse revealed she could see fire in the room, and she was able to extinguish the fire by utilizing the extinguisher, but was not able to rescue the resident due to the smoke and everything was wet (as a result of the activation of the sprinkler system). She stated that she could not see in the room, and she kept tripping on items. Video camera footage noted other staff were observed standing outside the door to Room B05. Two male residents are observed to be closing resident room doors concurrently to contain the fire.
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On 09/26/24 at 11:55 P.M., Columbus Police Officers are visible on the hallway and enter Room B05. LPN #251 and State Tested Nurse Aide (STNA) #248 were also in the room with Resident #19.
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On 09/26/24 at 11:56:10 P.M., Resident #19 was observed on the video footage being brought out of Room B05 in the bed and was pushed down the hallway by LPNs #251 and #444, and STNA #248 with Police Officers following.
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On 09/26/24 at 11:57 P.M., the care of Resident #19 was turned over to the emergency medical responders at this time.
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On 09/27/24 at 12:02 A.M., the facility had completed a head count of residents, and all 90 residents were accounted for.
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On 09/27/24 at 1:10 A.M., the Columbus Fire Department exited the facility, and a Fire Watch was initiated and completed by the Administrator and DON.
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On 09/27/24 at 1:15 A.M., Respiratory Assessments were initiated by Unit Manager/ LPN #225, and LPN #203 on Residents #17, #20, #18, #15, #21, #23, #22, #16, and #11, who resided in the same smoke compartment where the fire was located, with no adverse reactions noted. The assessments were completed on 09/27/24 at 3:10 A.M.
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On 09/27/24 at 1:00 A.M. through 3:00 A.M., cleaning of the fire debris in Room B05 and the adjacent hall area began by Maintenance Director #390 and Regional Environmental Services #805.
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On 09/27/24 at 3:00 A.M., all residents who lived in the smoke compartment where the fire occurred were temporarily moved to open rooms in the B and C halls.
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On 09/27/24 at 8:00 A.M., four sprinkler heads were replaced in Room B05 by Fire Safety Company #800 to maintain safety in the building and restore water to the facility.
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On 09/27/24 at 11:00 A.M., all 88 residents were interviewed for post incident safety, conducted by Admissions, Licensed Social Worker (LSW) #270 and Human Resource Director # 259 (Resident #19 was in the hospital and a male resident discharged Against Medical Advice on the morning of 09/27/24).
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On 09/27/24 at 12:00 P.M., the Fire Department inspected the facility and cleared the facility from Fire Watch. The facility was notified the residents could return to their original rooms as the facility was deemed safe by the fire department.
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On 09/27/24 at 12:00 P.M., the two fire extinguishers that were used and deployed during the fire were replaced by Maintenance Director #390 to ensure adequate tools for fire safety are available to the staff.
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On 09/27/24 at 1:00 P.M., all department managers were educated by the Regional Director of Clinical Services (RDCS) #810 on the Smoking Policy, Change in Condition Policy, Fire safety (RACE & PASS), and Abuse and Neglect Policy. Those receiving education were the Administrator, Admissions/Licensed Social Worker (LSW) # 270, Maintenance Director #390, Unit Manager LPN #225, Human Resources #259, Therapy Director #825, Business Office Manager #830, Activity Director #268, Dietary Manager #835, Medical Records/Central Supply #840, Assistant Director of Dietary #845, and Housekeeping Manager #850.
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On 09/27/24 at 1:21 P.M., an all-staff education was initiated by Department Managers and the DON for the facility's employees. The education was in person and by telephone/text covering Change in Condition Policy, Smoking Policy, Fire Safety (RACE & PASS) and Abuse and Neglect Policies. Staff were able to return/continue to work once training was completed. The education was completed on 09/27/24 at 7:52 P.M.
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On 09/27/24 beginning at 11:00 A.M. and completed by 3:06 P.M., all 88 resident rooms were searched by the Department Managers for smoking contraband. Non-permitted smoking articles were found in the rooms of Residents #33, #79, #82, #49, and #64, who were previously unsupervised smokers. This contraband was collected and further education provided to these residents by the Administrator and LSW #270.
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On 09/27/24 beginning at 10:45 A.M. and completed by 3:30 P.M., all 88 residents were assessed by Unit Manager LPN#225, Unit Manager LPN #579, and Registered Nurse (RN) #820 for a change in condition to assess for any changes in physical and mental condition, including distress from the incident. No residents were found to have a change in condition.
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On 09/27/24 at 4:00 P.M., a Fire Drill was conducted by Maintenance Director #390 without incident.
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On 09/27/24 at 4:13 P.M., the Fire Marshall was notified by the Administrator of the incident of fire via the Fire Marshall's electronic portal.
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On 09/27/24 beginning at 3:23 P.M. and completed by 4:45 P.M., a second Respiratory Assessment was initiated on Residents #17, #20, #18, # 15, #21, #23, #22, #16, and #11, who lived in the same smoke compartment where the fire occurred, by RN # 229, LPN # 251, LPN #444, and LPN #203 with no adverse reaction noted.
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On 09/27/24 at 6:15 P.M., a Quality Assurance and Performance Improvement (QAPI) meeting was held with the Administrator, RDCS #810, LSW # 270, Maintenance Director #390, Unit Manager LPN #225, Human Resources # 259, Therapy Director #825, Business Office Manager #830, Activity Director #268, Dietary Manager #835, Medical Records/Central Supply #840, Assistant Director of Dietary #845, Housekeeping Manager #850, and Medical Director #900. The following audits to be conducted:
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Resident Smoke Breaks- five times a week for four weeks, then one time a week for four weeks, completed by the DON.
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Room Sweeps for Smoking Materials- three times per week for four weeks and one time a week for four weeks, completed by the Departmental Managers.
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Fire Drills on Each Shift - weekly for eight weeks (7a-7p and 7p-7a), completed by Maintenance Director #390.
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Assess/Re-educate as needed - staff knowledge of Fire Safety RACE/PASS - weekly/per shift times eight weeks, completed by Maintenance Director #390.
Although the Immediate Jeopardy was removed on 10/18/24, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.
Findings Included:
Review of the medical record for Resident #19 revealed an admission date of 09/12/24. Diagnoses included chronic obstructive pulmonary disease, peripheral vascular disease, depression, anxiety, and suicidal ideation.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had a Brief Interview of Mental Status score of 15 (out of 15) which indicated she was cognitively intact. Resident #19 required setup assistance with meals and oral intake. Resident #19 was dependent on staff with personal hygiene, dressing, and transfers. Resident #19 was dependent on staff with using her manual wheelchair.
Review of the physician order dated 09/16/24 revealed Resident #19 had an order for five liters of oxygen per minute by nasal cannula, routine. Resident #19's oxygen was to be monitored every shift.
Review of the plan of care dated 09/13/24 revealed Resident #19 had mood problems related to agitation with hallucinations, suicidal ideations, and delirium. Interventions included to administer medication, assist the resident in positive coping skills, behavioral health consult, educate the resident and family regarding expectations of treatment, monitor and document risk for harm to self, suicidal plan, past attempts at suicide, possession of suicidal note, trying to harm self, refusing to eat or drink, sense of hopeless or helplessness, and impaired judgement or safety awareness. Resident #19 was to be monitored for mood patterns, anxiety, sad mood, behavior monitoring protocol, monitor increased anger, and observe for signs and symptoms of mania and hypomania, and increased irritability.
Review of Resident #19's medication administration record (MAR) for September 2024 revealed behaviors were assessed every shift and the resident was coded as not having any behaviors at the facility. Resident #19 had an order for Hydroxyzine (used to control anxiety and tension) 25 milligrams (mg), give 12.5 mg every eight hours as needed for 14 days dated 09/14/24. The MAR revealed the resident received the medication on 09/13/24 at 6:15 P.M., 09/18/24 at 4:04 P.M., 09/19/24 at 9:04 A.M, 09/21/24 at 8:39 A.M., 09/22/24 at 1:52 P.M., 09/23/24 at 10:09 A.M., 09/25/24 at 3:52 P.M., and on 09/26/24 at 10:23 P.M. All doses provided were documented as being effective.
Review of the Smoking-Safety Screen dated 09/16/24 revealed Resident #19 had been evaluated for smoking and safety. Resident #19 stated she smoked in the morning one to two cigarettes per day. Resident #19 could light her own cigarette, needed a smoking apron, had dexterity problem, no visual deficit, and had cognitive loss. Resident #19 needed the facility to store the lighter and cigarettes for safety. The care plan was updated for smoking safety. The decision by the interdisciplinary team was Resident #19 was safe to smoke with supervision.
Review of the plan of care dated 09/25/24 revealed Resident #19 was a smoker. The care plan was updated on 09/27/24 and indicated Resident #19 chooses not to follow smoking policy at times. Interventions included to instruct the resident about smoking risks and hazards, and about smoking cessation. Resident #19 was instructed about the facility policy on smoking, locations, times, and safety concerns. Monitor Resident #19's oral hygiene, observe clothing and skin for signs of cigarette burns, notify charge nurse immediately if it was suspected resident had violated facility smoking policy, resident required a smoking apron while smoking, and Resident #19 required supervision while smoking.
Review of the facility document titled Incident Investigation-Room [Resident #19's room] Fire dated 09/26/24 through 09/27/24 revealed the following: staff interviews and statements revealed their actions during the active incident and during the evacuation appeared consistent with the video surveillance. Two residents interviewed (Resident #08 and Resident #17) stated Resident #19 was yelling, which was normal in the evening for Resident #19. One resident reported shortly before the fire alarm activated, the resident was heard shouting, I'll show them. The statement seems to stand alone without sufficient context to determine its meaning. Interviews and video surveillance reveal the fire alarm sounded at approximately 11:45 P.M. on 09/26/24. Video shows staff responding appropriately using both the RACE and PASS method of dealing with an active fire. Staff used fire extinguishers to extinguish the flames. At approximately 11:46 P.M., emergency 9-1-1 was called. The local police arrived at the facility at 11:54 P.M. and the Fire Department and EMS arrived at 11:58 P.M. The local police and staff had already evacuated Resident #19 from her room. Resident #19 was examined by medics and transported to the hospital. The report stated Emergency Department notes provided helpful information in determining the origin of the fire. The notes state that the resident intentionally started the fire to get staff's attention. Where the resident obtained an instrument, i.e., matches, a lighter, etc. to ignite the fire cannot be determined. As a supervised smoker, the resident would have had her smoking material and paraphernalia collected at the time of her previous smoking session. An examination of the room [Resident #19] and the bed the resident was in was not determinative as to the source of ignition. The Administrator and Maintenance Director #390 closely examined the room and debris looking for a burned cigarette and/or a source of ignition. No cigarettes or lighters or matches were discovered in the debris. However, it can be noted that the bed was the origin of the fire. In fact, there appeared to be two separate ignition points. One point of origin appears to be on the resident's right-hand side of the bed at about the midpoint of the bed; the other point of origin (which looked to be the original point of origin) appeared at the right-side foot of the bed. The report listed the facilities conclusion as: facility staff responded appropriately at the time of the incident, ensuring the fire was extinguished, the residents and others were safely evacuated. Facility staff provided care to the resident prior to the incident. The resident started the fire intentionally and with knowledge that her actions could result in significant harm. The facility will continue to monitor other residents' for both physical and psycho social well-being. The facility will cooperate with the fire department in their investigation of the incident. The report was completed by the Administrator.
Review of the EMS report dated 09/27/24 revealed upon arrival to the facility, Resident #19 was alert and oriented and suffering from third degree burns to 15% of her lower left leg and lower right leg. Resident #19 had just been evacuated minutes before arrival. Resident #19 was quickly assessed and given 25 milligrams (mg) of Ketamine for pain and then transferred to the medic. Resident #19's condition was stable and transferred to Hospital #500's burn unit.
Review of the hospital document titled Rehabilitation Psychology Follow-Up Note dated 09/30/24 at 5:49 P.M. by Hospital Psychologist (HP) #499 revealed the examination was done related to mental status exam and humanistic interventions. HP #499 stated Resident #19 was alert and oriented, to person, place, time, and generally to situation. Resident #19 was being hospitalized due to burns. Resident #19 had difficultly providing accurate personal history, speech was normal rate, volume, and prosody (a word to describe the rate, rhythm, and melody of speech), but with word finding issues and frequent verbal preservation. Resident #19's mood was anxious; affect appropriate, and congruent. Eye contact at time intense and at other times she was observed staring off into space. Resident #19 asked to walk and later then swim and did not appreciate that there would be any barriers to these activities. Though content relevant to conversation and questioning but with off-topic responses and evident confusion. Delayed in responding to questions rather than most recent prompt. Resident #19 denied perceptual abnormalities, staring into space occasionally but denied any hallucinations when asked. Denied suicidally but endorsed setting a fire to get the attention. Resident #19 discussed that she was calling for help and thought she would set a fire to get help. Resident #19 discussed thinking she was somewhere else. Resident #19 stated the nursing home and funeral home interchangeably and also noted that she thought her son was in the next room at the time. She denied that this was an attempt to die or inflict intentional injury. She reported using lighter to set the fire. Resident #19 was aware of her burns and the association with her actions and the fire that was set.
Review of the hospital document titled Critical Care Attestation dated 10/01/24, by Critical Care Physician (CCP) #450 revealed Resident #19 had been admitted to hospital for 35% total Burn Surface Area (TBSA) burn, and status post escharotomy (a surgical procedure that involves cutting through burnt skin to release the eschar and relieve pressure) of the right lower extremity.
Review of the hospital document titled Lund [NAME] Flow Sheet (a tool useful in the management of burns for estimating TBSA) dated 10/01/24 revealed Resident #19 had the following burns: anterior trunk had 13% injury with 5% second degree burns, right lower arm had 3% injury with 2% second degree burns, right thigh had 9.5% injury with 2% second degree burns and 2% third degree burns with 4% total area, right leg was 7% third degree burn, left leg was 7% injury with 5% third degree burn, and right foot was 3.5% injury with 3.5% third degree burns. Resident #19 had injuries to head, neck, posterior trunk, right and left buttocks, right upper arm, left upper arm, left lower arm, right and left hand and left thigh that had suffered injury.
Interview on 10/02/24 at 10:05 A.M. with STNA #246 stated she did not know what happened to Resident #19 only that she had a fire in her room and was taken to the hospital with burns. STNA #246 stated she arrived at the facility to assist with evacuation at the facility due to the fire that night. STNA #246 stated she had recently received education on fire training on 09/27/24, including the use of a fire extinguisher, but stated she forgot what the fire acronyms RACE and PASS stood for.
Interview on 10/02/24 at 10:15 A.M. with STNA #223 verified they had been educated about fire evacuation, and using the fire extinguisher but did not know the date of the education. STNA #223 stated she does not know what she learned.
Interview on 10/02/24 at 10:20 A.M. with STNA #235 stated she was not sure about the fire, but that the next day she was educated on 09/27/24. The education included fire drills, using closest exit for evacuation, and to close all resident room doors in the area of the fire. STNA #235 stated she could recite what the acronym of RACE meant which was rescue, alarm, contain, and evacuate. STNA #235 stated she was not sure about PASS and its meaning.
Interview on 10/02/24 at 12:39 P.M. with STNA #214 revealed the fire alarm went off, and he looked at the fire panel to see Resident #19's room was on fire. STNA #214 stated he headed to Resident #19's room, and before arriving, Resident #17 came out of her room, and stated there was smoke coming out of the connecting bathroom door shared between her room and Resident #19's room. STNA #214 stated he touched the door to Resident #19's room and it was not hot then opened the door and looked into the room. STNA #214 stated Resident #19's room had pure black smoke in the room and no fire was seen. STNA #214 stated he could not see or go into the room due to all the smoke in the room had irritated his throat and he could not breath. STNA #214 stated he did not go into Resident #19's room. STNA #214 stated he knew the resident was in the room, and thought he heard her. STNA #214 stated he then turned around and went into two other residents' rooms to assist them in evacuation. STNA #214 stated he had in-service training for fire that included RACE and PASS.
Observation on 10/02/24 at 3:00 P.M. of the facility's video footage provided by the Administrator, DON, and CN #309 who reviewed the facility video dated 09/26/24 through 09/27/24 revealed a fire alarm started on 09/26/24 at 11:45 P.M. The video showed flashing fire alarms, and in the nurse's station at the beginning of the hall, the call light for Resident #19's room was not lit up. Resident #08 was seen assisting residents at the facility with closing doors, checking rooms, evacuating residents, and grabbing a fire extinguisher to hand to staff. At the end of the video Resident #19 was seen coming down the hall in her hospital bed with staff. The bed was burnt but not on fire. The Administrator stated there was no additional video footage of inside the fire doors to be able to see Resident #19's room after the fire doors closed at 11:45 P.M.
Interview on 10/03/24 at 10:09 A.M. with the Administrator stated the facility had performed respiratory assessments, head to toe assessments, and residents who smoked signed another smoking agreement. Residents who were smokers at the facility had room sweeps with their permission, one resident denied permission, Resident #08, and later then let facility staff sweep the room. The Administrator stated our system worked flawlessly, and our fire system had no problems.
Interview on 10/03/24 at 10:10 A.M. with the DON stated they had no issues identified after the fire. The DON stated we educated the residents again, and had them sign the smoking policy, and signed that they agreed not to keep their smoking products.
Interview on 10/03/24 at 11:24 A.M. with the Administrator revealed prior to 09/26/24, the facility would only educate residents at time of admission on the smoking policy, but staff were expected to know the policy and educate residents even after being admitted to the facility.
Review of additional camera footage provided to the survey agency on 10/08/24 from the facility revealed the camera footage contained multiple (four) camera's video feed and included the smoke compartment where Resident #19's room was located. The timeline of the following events was obtained from the provided camera's footage. The time was captured on Camera 7 footage and Camera 9 captured the hallway where Resident #19's room was located. The date of the footage is 09/26/24.
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At 11:50:29 P.M., STNA # 214, STNA #230 and LPN #444 were observed walking onto the hallway.
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At 11:50:34 P.M., the three staff are observed to walk past a fire extinguisher which was on the wall to their left. None of the staff picked up the extinguisher.
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At 11:50:43 P.M., STNA #214 was observed to open the door to Room B05, and black smoke was observed to come out of the room. The three staff were observed to flee from the room, STNA #230 and LPN #444 were observed to walk back up the hallway, and STNA #214 was observed to walk further down the hallway.
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At 11:50:44 P.M., STNA #230 and LPN #444 walked past the fire extinguisher hanging on the wall again which was now on their right side as they were coming back up the hallway. They did not attempt to pick up the extinguisher.
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At 11:50:46 P.M., STNA #230 and LPN #444 are observed to walk past Resident #17 who was observed in a wheelchair coming out of a resident room and into the hallway, neither staff member assisted Resident #17 in getting off the hallway where there was a room with black smoke coming out of the door, but the staff were seen to walk up the hallway off camera and leave Resident #17 attempting to move herself off the hallway on her own.
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At 11:50:55 P.M., Resident #17 was joined in the hallway by Resident #16 who was observed to walk out of a resident room which was just past the fire extinguisher hanging on the wall. Smoke was observed to continue to come into the hallway from Room B05 and no staff were observed on the hallway to assist residents, extinguish the fire, or contain the fire. The two residents are seen just congregating in the hallway.
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At 11:51:04 P.M., STNA # 214 was observed back at the end of the hallway and entered a room on the opposite side of the hallway from Room B05. Black smoke continues to come into the hallway form Room B05. No resident room doors have been shut and no other staff are observed on the hallway.
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At 11:51:20 P.M., STNA #230 and LPN #444 are observed to enter the hallway and direct Resident #16 and #17 off the hallway using hand gestures.
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At 11:51:24 P.M., STNA #230 and LPN #444 are observed on the hallway close to Room B05 but across the hall, the smoke in the hallway is thick and it is hard to see past the two staff. Neither of the staff grabbed the fire extinguisher off the wall as they walked down the hallway toward Room B05. No room doors were closed as the staff walked down the hallway.
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At 11:51:30 P.M., Resident #11 is visible sitting in a wheelchair in a room doorway two doors up the hallway on the same side of the hall as Room B05 across from STNA #230 and LPN #444 who are observed to be standing in the hallway, STNA #214 is visible at the end of the hallway, and smoke continues to fill the hallway. STNA #230 and LPN #444 are seen to turn and make their way back up the hallway past the fire extinguisher, without evacuating Resident #11 who was in the doorway. The staff did not attempt to shut any room doors or assist any residents to leave the hallway.
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At 11:51:34 P.M., STNA #214 was observed to stop at the doorway where Resident #11 is observed sitting in the wheelchair and raise his arm straight out toward the resident. Then the STNA is observed to continue to walk up the hallway, past the resident and past the fire extinguisher and exit the hallway. STNA #214 did not shut any resident room doors as he walked from one end of the hallway to the other end.
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At 11:51:45 P.M., Resident #21 is seen ambulating at the end of the hallway and Resident #15 was observed to be standing in a room doorway. The resident at the end of the hallway walks past Room B05 staying close to the other side of the hallway and LPN #444 was observed to wave the resident toward the fire door and off the hallway. The resident is no longer seen on camera and is off the hallway where the fire was.
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At 11:52:38 P.M., Resident #15 who was standing in the doorway was observed to exit his room walking with a walker and a hat on his head, and he exits the hallway with the fire.
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At 11:52:40 P.M., Resident #11 who was sitting in a wheelchair in his doorway is observed to wheel out of his room and into the hallway.
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At 11:52:43 P.M., LPN #251 was observed coming on the hallway where the fire is located, and grabbed the wheelchair of Resident #11 and moved him off the hallway at 11:52:53 P.M.
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At 11:52:54 P.M., LPN #251 was observed on the hall walking toward Room B05 carrying a fire extinguisher. LPN #251 was observed to enter Room B05 at 11:53 :09 P.M., exit the room at 11:53:14 P[TRUNCATED]
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, facility staff interviews, resident interviews, family interviews, review of a fir...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, facility staff interviews, resident interviews, family interviews, review of a fire drill report, review of emergency response reports, review of report of fire email communication, review of facility video camera footage, review of hospital records, review of the fire investigation report, and review of the facility policies for smoking and Oxygen Administration, the facility failed to ensure the residents environment remained as free from accident hazards as is possible when one resident (#19), who utilized oxygen therapy and who smoked cigarettes, possessed smoking materials, including cigarettes and a cigarette lighter, in her room. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, negative health outcomes and/or death when on 09/26/24 at 11:46 P.M. a fire occurred in Resident #19's room which ignited the resident's mattress/bedding on fire resulting in the resident sustaining severe burns to her legs, torso, and arm. Consequently, Resident #19 was transferred to the hospital and admitted to the Surgical Intensive Care Unit (SICU) for treatment of extensive burns received on her legs, torso, and arm. Resident #19 was treated for acute respiratory failure with hypoxia and intubated with a moderate inhalation injury. This affected one (#19) resident who resided in Room B05 and placed an additional nine residents (Residents #11, #15, #16, #17, #18, #20, #21, #22, and #23), residing in the same smoke compartment as Resident #19, at potential risk for the likelihood of serious injury, impairment, negative health outcomes, and/or death, due to the potential for the fire and smoke to spread throughout the hall. The facility identified a total of 50 residents currently residing in the facility who smoke (Residents #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #15, #16, #17, #20, #21, #22, #31, #32, #33, #34, #35, #37, #39, #40, #41, #42, #44, #45, #48, #49, #50, #52, #55, #57, #59, #61, #64, #67, #72, #74, #75, #77, #78, #79, #82, #86, #87, #88, #89, and #91). The total facility census was 88.
On 10/03/24 at 3:18 P.M., the Administrator, Director of Nursing (DON), Corporate Nurse (CN) #309, and Regional Director of Operations (RDO) #334 were notified Immediate Jeopardy began on 09/26/24 at 11:46 P.M. when Resident #19, who utilized oxygen therapy and had a lighter and smoking materials in her possession, started a fire in her room igniting her mattress/bedding. Resident #19 was assessed on 09/16/24 to require supervision with smoking and the resident's lighter and cigarettes were to be stored by the facility. The facility's smoking policy and smoking plan indicated residents were not allowed to store their smoking materials in their room. On 09/26/24 at 11:46 P.M., the fire alarm was activated and the fire doors shut at 11:56:10 P.M. Resident #19 was eventually brought out of her room and at 11:57 P.M., Emergency Medical Services (EMS) took over care of Resident #19. EMS transported Resident #19 to the hospital where she was admitted to the SICU for 35% Total Burn Surface Area (TBSA) burn, and status post escharotomy (a surgical procedure that involves cutting through burnt skin to release the eschar and relieve pressure) of the right lower extremity. Resident #19 was treated for acute respiratory failure with hypoxia and intubated with a moderate inhalation injury. The Fire Department's Investigation Report dated 09/26/24 revealed smoked and unsmoked cigarettes, cigarette pack, and a lighter were found near the original location of the bed. The conclusion was an accidental fire caused by smoking materials in close proximity to high concentration oxygen. Observation on 10/15/24 at 1:45 P.M. revealed there was a pile of debris next to the facility sidewalk in the courtyard area and it was the debris from Resident #19's room on 09/26/24. The debris included a lighter with scorch marks on it.
The Immediate Jeopardy was removed on 10/18/24 when the facility implemented the following corrective actions:
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On 09/26/24 at 11:46 P.M., the fire alarm sounded which transmits an alarm to the fire department of the fire.
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On 09/26/24 at approximately 11:46 P.M., the facility's incident investigation indicated Licensed Practical Nurse (LPN) #251 called 911 to report the incident of fire.
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On 09/26/24 from 11:50 P.M. through 11:52 P.M., residents are seen via facility video camera footage to be directed out of their rooms and attempting to make their way off the hallway.
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On 09/26/24 at 11:53 P.M., LPN #251 was observed via video footage to take a fire extinguisher into the resident's room, identified as Room B05. A subsequent interview with the nurse revealed she could see fire in the room, and she was able to extinguish the fire by utilizing the extinguisher, but was not able to rescue the resident due to the smoke and everything was wet (as a result of the activation of the sprinkler system). She stated she could not see in the room, and she kept tripping on items. Video camera footage noted other staff were observed standing outside the door to Room B05. Two male residents are observed to be closing resident room doors concurrently to contain the fire.
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On 09/26/24 at 11:55 P.M. per the video, Columbus Police Officers are visible on the hallway and enter Room B05. LPN #251 and State Tested Nurse Aide (STNA) #248 were also in the room with Resident #19.
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On 09/26/24 at 11:56:10 P.M., Resident #19 was observed on the video footage being brought out of Room B05 in the bed and was pushed down the hallway by LPNs #251 and #444, and STNA #248 with Police Officers following.
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On 09/26/24 at 11:56:14 P.M., the Columbus Fire Department is seen on video footage arriving at the facility in response to the 911 call and enter the facility and walk toward Room B05.
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On 09/26/24 at 11:57 P.M., the care of Resident #19 was turned over to the emergency medical responders at this time.
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On 09/27/24 at 12:02 A.M., the facility had completed a head count of residents, and all 90 residents were accounted for.
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On 09/27/24 at 1:10 A.M., the Columbus Fire Department exited the facility, and a Fire Watch was initiated and completed by the Administrator and DON.
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On 09/27/24 at 1:15 A.M., Respiratory Assessments were initiated by Unit Manager/LPN #225, and LPN #203 on Residents #17, #20, #18, #15, #21, #23, #22, #16, and #11, who resided in the same smoke compartment where the fire was located, with no adverse reactions noted. The assessments were completed on 09/27/24 at 3:10 A.M.
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On 09/27/24 at 1:00 A.M. through 3:00 A.M., cleaning of the fire debris in Room B05 and the adjacent hall area began by Maintenance Director #390 and Regional Environmental Services #805.
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On 09/27/24 at 3:00 A.M., all residents who lived in the smoke compartment where the fire occurred were temporarily moved to open rooms in the B and C halls.
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On 09/27/24 at 8:00 A.M., four sprinkler heads were replaced in Room B05 by Fire Safety Company #800 to maintain safety in the building and restore water to the facility.
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On 09/27/24 at 11:00 A.M., all 88 residents were interviewed for post incident safety, conducted by Admissions, Licensed Social Worker (LSW) #270 and Human Resource Director #259 (Resident #19 was in the hospital and a male resident discharged Against Medical Advice on the morning of 09/27/24).
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On 09/27/24 at 11:41 A.M., the facility smoking policy was reviewed and revised by [NAME] President of Clinical services #340 to make all smoking supervised and all smokers have to submit smoking articles to staff. The smoking process was updated to divide all smokers into two groups (A & B), residents are given two cigarettes for smoke break, and the staff smoking supervisor has the only lighter and lights all cigarettes during smoke breaks.
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On 09/27/24 at 12:00 P.M., the Fire Department inspected the facility and cleared the facility from Fire Watch. The facility was notified the residents could return to their original rooms as the facility was deemed safe by the fire department.
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On 09/27/24 at 12:00 P.M., the two fire extinguishers that were used and deployed during the fire were replaced by Maintenance Director #390 to ensure adequate tools for fire safety are available to the staff.
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On 09/27/24 at 1:00 P.M., all department managers were educated by the Regional Director of Clinical Services (RDCS) #810 on the Smoking Policy, Change in Condition Policy, and Fire Safety (RACE & PASS) Policy. Those receiving education were the Administrator, Admissions/Licensed Social Worker (LSW) #270, Maintenance Director #390, Unit Manager LPN #225, Human Resources #259, Therapy Director #825, Business Office Manager #830, Activity Director #268, Dietary Manager #835, Medical Records/Central Supply #840, Assistant Director of Dietary #845, and Housekeeping Manager #850.
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On 09/27/24 at 1:21 P.M., an all-staff education was initiated by Department Managers and the DON for the facility's employees. The education was in person and by telephone/text covering facility policies related to Change in Condition, Smoking, and Fire Safety (RACE & PASS). Staff were able to return/continue to work once training was completed. The education was completed on 09/27/24 at 7:52 P.M.
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On 09/27/24 at 1:30 P.M., the Administrator held a meeting with the 50 residents (Residents # 1,# 2, #3, #5, #7, #8, #9, #10, #11, #12, #15, #16, #17, #20, #21, #22, #31, #32, #33, #34, #35, #37, #39, #40, #41, #42, #44, #45, #48, #49, #50, #52, #55, #57, #59, #61, #64, #67, #72, #74, #75, #77, #78, #79, #82, #86, #87, #88, #89, and #91) who smoke to review and sign the revised Smoking Policy and smoking process, including smoke break times and groups A & B. All 50 Residents were educated, agreed, and signed the new smoking policy.
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On 09/27/24 beginning at 11:59 A.M. and completed by 1:44 P.M., smoking assessments began on all residents that currently smoke by Unit Manager LPN #579 and Unit Manager LPN #225 to ensure up to date assessments are in place for all smokers.
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On 09/27/24 beginning at 11:00 A.M. and completed by 3:06 P.M., all 88 resident rooms were searched by the Department Managers for smoking contraband. Non-permitted smoking articles were found in the rooms of Residents #33, #79, #82, #49, and #64, who were previously unsupervised smokers. This contraband was collected and further education provided to these residents by the Administrator and LSW #270.
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On 09/27/24 beginning at 10:45 A.M. and completed by 3:30 P.M., all 88 residents were assessed by Unit Manager LPN #225, Unit Manager LPN #579, and Registered Nurse (RN) #820 for a change in condition to assess for any changes in physical and mental condition, including distress from the incident. No residents were found to have a change in condition.
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On 09/27/24 at 4:00 P.M., a Fire Drill was conducted by Maintenance Director #390 without incident.
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On 09/27/24 at 4:13 P.M., the Fire Marshall was notified by the Administrator of the incident of fire via the Fire Marshall's electronic portal.
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On 09/27/24 beginning at 3:23 P.M. and completed by 4:45 P.M., a second Respiratory Assessment was initiated on Residents #17, #20, #18, #15, #21, #23, #22, #16, and #11, who lived in the same smoke compartment where the fire occurred, by RN #229, LPN # 251, LPN #444, and LPN #203 with no adverse reaction noted.
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On 09/27/24 at 6:06 P.M., the care plans of residents who were previously unsupervised smokers were revised to now being supervised smokers by Minimum Data Set (MDS) LPN #855.
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On 09/27/24 at 6:15 P.M., a Quality Assurance and Performance Improvement (QAPI) meeting was held with the Administrator, RDCS #810, LSW #270, Maintenance Director #390, Unit Manager LPN #225, Human Resources #259, Therapy Director #825, Business Office Manager #830, Activity Director #268, Dietary Manager #835, Medical Records/Central Supply #840, Assistant Director of Dietary #845, Housekeeping Manager #850, and Medical Director #900. The following audits to be conducted:
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Resident Smoke Breaks - five times a week for four weeks, then one time a week for four weeks, completed by the DON.
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Room Sweeps for Smoking Materials - three times per week for four weeks and one time a week for four weeks, completed by the Departmental Managers.
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Fire Drills on Each Shift - weekly for eight weeks (7a-7p and 7p-7a), completed by Maintenance Director #390.
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Assess/Re-educate as needed - staff knowledge of Fire Safety RACE/PASS - weekly/per shift times eight weeks, completed by Maintenance Director #390.
Although the Immediate Jeopardy was removed on 10/18/24, the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.
Findings include:
Review of the medical record for Resident #19 revealed an admission date of 09/12/24. Diagnoses included chronic obstructive pulmonary disease, peripheral vascular disease, depression, anxiety, and suicidal ideation.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had a Brief Interview of Mental Status score of 15 (out of 15) which indicated she was cognitively intact. Resident #19 required setup assistance with meals and oral intake. Resident #19 was dependent on staff with personal hygiene, dressing, and transfers. Resident #19 was dependent on staff with using her manual wheelchair.
Review of the physician order dated 09/16/24 revealed Resident #19 had an order for five liters of oxygen per minute by nasal cannula, routine. Resident #19's oxygen was to be monitored every shift.
Review of the plan of care dated 09/13/24 revealed Resident #19 had mood problems related to agitation with hallucinations, suicidal ideations, and delirium. Interventions included to administer medication, assist the resident in positive coping skills, behavioral health consult, educate the resident and family regarding expectations of treatment, monitor and document risk for harm to self, suicidal plan, past attempts at suicide, possession of suicidal note, trying to harm self, refusing to eat or drink, sense of hopeless or helplessness, and impaired judgement or safety awareness. Resident #19 was to be monitored for mood patterns, anxiety, sad mood, behavior monitoring protocol, monitor increased anger, and observe for signs and symptoms of mania and hypomania, and increased irritability.
Review of Resident #19's medication administration record (MAR) for September 2024 revealed behaviors were assessed every shift and the resident was coded as not having any behaviors at the facility. Resident #19 had an order for Hydroxyzine (used to control anxiety and tension) 25 milligrams (mg), give 12.5 mg every eight hours as needed for 14 days dated 09/14/24. The MAR revealed the resident received the medication on 09/13/24 at 6:15 P.M., 09/18/24 at 4:04 P.M., 09/19/24 at 9:04 A.M., 09/21/24 at 8:39 A.M., 09/22/24 at 1:52 P.M., 09/23/24 at 10:09 A.M., 09/25/24 at 3:52 P.M., and on 09/26/24 at 10:23 P.M. All doses provided were documented as being effective.
Review of the Smoking-Safety Screen dated 09/16/24 revealed Resident #19 had been evaluated for smoking and safety. Resident #19 stated she smoked in the morning one to two cigarettes per day. Resident #19 could light her own cigarette, needed a smoking apron, had dexterity problem, no visual deficit, and had cognitive loss. Resident #19 needed the facility to store the lighter and cigarettes for safety. The care plan was updated for smoking safety. The decision by the interdisciplinary team was Resident #19 was safe to smoke with supervision.
Review of the plan of care dated 09/25/24 revealed Resident #19 was a smoker. The care plan was updated on 09/27/24 and indicated Resident #19 chooses not to follow smoking policy at times. Interventions included to instruct the resident about smoking risks and hazards, and about smoking cessation. Resident #19 was instructed about the facility policy on smoking, locations, times, and safety concerns. Monitor Resident #19's oral hygiene, observe clothing and skin for signs of cigarette burns, notify charge nurse immediately if it was suspected resident had violated facility smoking policy, resident required a smoking apron while smoking, and Resident #19 required supervision while smoking.
Review of the facility document titled Incident Investigation-Room [Resident #19's room] Fire dated 09/26/24 through 09/27/24 revealed the following: staff interviews and statements revealed their actions during the active incident and during the evacuation appeared consistent with the video surveillance. Two residents interviewed (Resident #08 and Resident #17) stated Resident #19 was yelling, which was normal in the evening for Resident #19. One resident reported shortly before the fire alarm activated, the resident was heard shouting, I'll show them. The statement seems to stand alone without sufficient context to determine its meaning. Interviews and video surveillance reveal the fire alarm sounded at approximately 11:45 P.M. on 09/26/24. Video shows staff responding appropriately using both the RACE and PASS method of dealing with an active fire. Staff used fire extinguishers to extinguish the flames. At approximately 11:46 P.M., emergency 9-1-1 was called. The local police arrived at the facility at 11:54 P.M. and the Fire Department and EMS arrived at 11:58 P.M. The local police and staff had already evacuated Resident #19 from her room. Resident #19 was examined by medics and transported to the hospital. The report stated Emergency Department notes provided helpful information in determining the origin of the fire. The notes state that the resident intentionally started the fire to get staff's attention. Where the resident obtained an instrument, i.e., matches, a lighter, etc. to ignite the fire cannot be determined. As a supervised smoker, the resident would have had her smoking material and paraphernalia collected at the time of her previous smoking session. An examination of the room [Resident #19] and the bed the resident was in was not determinative as to the source of ignition. The Administrator and Maintenance Director #390 closely examined the room and debris looking for a burned cigarette and/or a source of ignition. No cigarettes or lighters or matches were discovered in the debris. However, it can be noted that the bed was the origin of the fire. In fact, there appeared to be two separate ignition points. One point of origin appears to be on the resident's right-hand side of the bed at about the midpoint of the bed; the other point of origin (which looked to be the original point of origin) appeared at the right-side foot of the bed. The report listed the facilities conclusion as: facility staff responded appropriately at the time of the incident, ensuring the fire was extinguished, the residents and others were safely evacuated. Facility staff provided care to the resident prior to the incident. The resident started the fire intentionally and with knowledge that her actions could result in significant harm. The facility will continue to monitor other residents' for both physical and psycho social well-being. The facility will cooperate with the fire department in their investigation of the incident. The report was completed by the Administrator.
Review of the witness statement from Resident #17 dated 09/27/24 revealed she was in her room on the evening of 09/26/24. Resident #17 stated it was a little before midnight. Resident #17 was waiting for the midnight movie to come on her television when she started to hear Resident #19 in her room next door, yelling Help, Help. Resident #17 thought nothing of this as Resident #19 generally does yell out in the evenings. Resident #19 started to rattle the side rail of her bed, as well. Resident #17 heard Resident #19 say I'll show them. Resident #17 stated when she moved around in her room, she saw smoke coming out from under her bathroom door. Resident #17 then stated she heard the fire alarm go off. Resident #17 went to the hall to yell for help.
Review of the witness statement from Resident #08 dated 09/27/24 revealed he was lying in his bed and heard yelling. Resident #08 stated someone was banging on the wall. Resident #08 stated the fire alarm then went off and he saw smoke. Resident #08 ran to get the fire extinguisher and handed it to the nurse. Resident #08 stated the sprinkler system was going off in the room. Resident #08 could not see anything due to the smoke. Resident #08 saw staff coming, and the local police showed up.
Review of the witness statement from STNA #248 dated 09/27/24 revealed there was an alarm on 09/26/24 at 11:45 P.M. RN #229 came to C station to ask him to hurry, and they needed help to get Resident #19 out of her room. STNA #248 stated he immediately went down to Resident #19's room and saw smoke and heard Resident #19 screaming. STNA #248 entered the room and was unable to see anything. STNA #248 managed to get hold of the bed, pushed everything out of his way, and pulled Resident #19 out of the room. The bed was then pushed out of the building. Resident #19 was taken to the hospital.
Review of the witness statement by LPN #251 dated 09/27/24 revealed the fire alarm sounded, then looked at the fire panel to see the location of fire. LPN #251 ran to the room of Resident #19 where the fire was located. Resident #08 handed her the fire extinguisher. Resident #19's room was full of smoke, and the water sprinklers were on. LPN #251 stated she could not see anything, but the fire was on the foot of Resident #19's bed. LPN #251 stated she used the fire extinguisher and yelled for help to get the woman out of the room. LPN #251 stated she called 9-1-1 to report the fire in Resident #19's room.
Review of the Fire Department's Investigation Report dated 09/26/24 revealed smoked and unsmoked cigarettes, cigarette pack, and a lighter were found near the original location of the bed. The conclusion was an accidental fire caused by smoking materials in close proximity to high concentration oxygen.
Review of the EMS report dated 09/27/24 revealed upon arrival to the facility, Resident #19 was alert and oriented and suffering from third degree burns to 15% of her lower left leg and lower right leg. Resident #19 had just been evacuated minutes before arrival. Resident #19 was quickly assessed and given 25 milligrams (mg) of Ketamine for pain and then transferred to the medic. Resident #19's condition was stable and transferred to Hospital #500's burn unit.
Review of the hospital document titled Rehabilitation Psychology Follow-Up Note dated 09/30/24 at 5:49 P.M. by Hospital Psychologist (HP) #499 revealed the examination was done related to mental status exam and humanistic interventions. HP #499 stated Resident #19 was alert and oriented, to person, place, time, and generally to situation. Resident #19 was being hospitalized due to burns. Resident #19 had difficultly providing accurate personal history, speech was normal rate, volume, and prosody (a word to describe the rate, rhythm, and melody of speech), but with word finding issues and frequent verbal preservation. Resident #19's mood was anxious; affect appropriate, and congruent. Eye contact at time intense and at other times she was observed staring off into space. Resident #19 asked to walk and later then swim and did not appreciate that there would be any barriers to these activities. Though content relevant to conversation and questioning but with off-topic responses and evident confusion. Delayed in responding to questions rather than most recent prompt. Resident #19 denied perceptual abnormalities, staring into space occasionally but denied any hallucinations when asked. Denied suicidally but endorsed setting a fire to get the attention. Resident #19 discussed that she was calling for help and thought she would set a fire to get help. Resident #19 discussed thinking she was somewhere else. Resident #19 stated the nursing home and funeral home interchangeably and also noted that she thought her son was in the next room at the time. She denied that this was an attempt to die or inflict intentional injury. She reported using lighter to set the fire. Resident #19 was aware of her burns and the association with her actions and the fire that was set.
Review of the hospital document titled Critical Care Attestation dated 10/01/24, by Critical Care Physician (CCP) #450 revealed Resident #19 had been admitted to hospital for 35% TBSA burn, and status post escharotomy of the right lower extremity.
Review of the hospital document titled Lund [NAME] Flow Sheet (a tool useful in the management of burns for estimating TBSA) dated 10/01/24 revealed Resident #19 had the following burns: anterior trunk had 13% injury with 5% second degree burns, right lower arm had 3% injury with 2% second degree burns, right thigh had 9.5% injury with 2% second degree burns and 2% third degree burns with 4% total area, right leg was 7% third degree burn, left leg was 7% injury with 5% third degree burn, and right foot was 3.5% injury with 3.5% third degree burns. Resident #19 had injuries to head, neck, posterior trunk, right and left buttocks, right upper arm, left upper arm, left lower arm, right and left hand and left thigh that had suffered injury.
Interview on 10/02/24 at 10:01 A.M. with STNA #240 revealed Resident #19 was not sure what happened to her. STNA #240 stated Resident #19 had set her bed on fire. STNA #240 stated Resident #19 must have had her lighter in her room but was not sure. Sometimes residents at the facility keep their smoking paraphernalia.
Interview on 10/02/24 at 10:05 A.M. with STNA #246 stated she did not know what happened to Resident #19 only that she had a fire in her room and was taken to the hospital with burns. STNA #246 stated she arrived at the facility to assist with evacuation of residents at the facility due to the fire that night. STNA #246 stated she had recently received education on fire training on 09/27/24, including the use of a fire extinguisher, but stated she forgot what the fire acronyms RACE and PASS stood for.
Interview on 10/02/24 at 10:15 A.M. with STNA #223 stated sometimes the smoking products do not get returned by the residents. STNA #223 stated she does not know what she learned in the fire training.
Interview on 10/02/24 at 10:20 A.M. with STNA #235 stated she was not sure about the fire, but that the next day she was educated on 09/27/24. The education included fire drills, using closest exit for evacuation, and to close all resident room doors in the area of the fire.
Interviews on 10/02/24 at 10:28 A.M. with the Administrator stated Resident #19 was alert and oriented, supervised smoker, and lit the mattress on fire. At 10:50 A.M., the Administrator showed a picture of Resident #19's burned hospital bed. The hospital bed had a burned area at the foot of the bed on the right lower side of the bed on the top surface of the mattress that was black, charred, and debris was peeled away and attached to bed. The right-side middle area of the bed at the handrail was burned in large circle that was about 12 inches in diameter. The Administrator stated he reviewed the facility's video footage for dates 09/26/24 and 09/27/24 that showed staff was in providing routine care to Resident #19.
Interviews on 10/02/24 at 11:55 A.M. with Resident #03, at 12:00 P.M. with Resident #12, at 3:00 P.M. with Resident #89, at 3:38 P.M. with Resident #22 and at 5:00 P.M. with Resident #08 confirmed before the facility had the fire incident on 09/26/24, the facility staff was not monitoring the residents closely in taking cigarettes and lighters away from residents. The five residents all confirmed they were allowed to keep smoking materials with them and not hand them in to the facility. Resident #22 stated Resident #19 was known to keep her materials including a lighter in her room. Resident #08 stated Resident #19 had family in to visit her on 09/26/24 and he heard them fighting about something. Resident #08 stated Resident #19 was yelling and upset.
Interview on 10/02/24 at 12:39 P.M. with STNA #214 stated the fire alarm went off, and then looked at the fire panel to identify Resident #19's room was on fire. STNA #214 headed to Resident #19's room, and before arriving, Resident #17 came out of her room, and stated there was smoke coming out of her door from the connecting bathroom to Resident #19's room. STNA #214 touched the door, and it was not hot then opened the door and looked into the room. STNA #214 stated Resident #19's room had pure black smoke in the room and no fire was seen. STNA #214 stated he could not see or go into the room due to all the smoke in the room as it irritated his throat, and he could not breathe. STNA #214 verified he did not go into Resident #19's room. STNA #214 stated the staff was supposed to collect all the smoking products, but sometimes residents keep their smoking products on them.
Observation on 10/02/24 at 3:00 P.M. of the facility's video footage provided by the Administrator, DON, and CN #309 who reviewed the facility video dated 09/26/24 through 09/27/24 revealed a fire alarm started on 09/26/24 at 11:45 P.M. The video showed flashing fire alarms, and in the nurse's station at the beginning of the hall, the call light for Resident #19's room was not lit up. Resident #08 was seen assisting residents at the facility with closing doors, checking rooms, evacuating residents, and grabbing a fire extinguisher to hand to staff. At the end of the video Resident #19 was seen coming down the hall in her hospital bed with staff. The bed was burnt but not on fire. The Administrator stated there was no additional video footage of inside the fire doors to be able to see Resident #19's room after the fire doors closed at 11:45 P.M.
Review of the facility interview dated 10/03/24 with the Administrator, Regional Director of Operations (RDO) #334, and the daughter of Resident #19 stated they had interviewed the daughter who provided additional information for [TRUNCATED]
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, observation of facility video footage, review of the facility submitted Self-R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, observation of facility video footage, review of the facility submitted Self-Reported Incident (SRI), and facility policy review, the facility failed to report an incident of potential neglect when the facility failed to timely implement fire protocol regarding rescuing residents, containing the fire and extinguishing and evacuating residents. This affected one Resident (#19) who had a fire in her room on 09/26/24 and had the potential to affect the other nine residents (Resident #11, #15, #16, #17, #18, #20, #21, #22, and #23) living in the same smoke compartment as Resident #19. The total facility census was 88.
Findings included:
Review of Resident #19's medical record revealed the resident was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, peripheral vascular disease, depression, anxiety, and suicidal ideation.
Review of physician order dated 09/16/24 revealed Resident #19 had an order for oxygen at five liters per minute via nasal cannula, routine. Resident #19's oxygen was to be monitored every shift.
Review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #19 had a Brief Interview of Mental Status (BIMS) score of 15 (out of 15) indicating the resident was cognitively intact. Resident #19 required setup assistance with meals and oral intake. Resident #19 was dependent on staff for personal hygiene, bathing, toileting, putting on and off shoes, dressing upper and lower body, and transfers. Resident #19 was dependent on staff for use of her manual wheelchair.
Review of plan of care 09/25/24 revealed that Resident #19 was a smoker, and did not follow the smoking policy at times. Interventions included instruct the resident about smoking risks, hazards, and about smoking cessation. Resident #19 was instructed about the facility policy on smoking, locations, times, and safety concerns. Monitor Resident #19's oral hygiene, observe clothing and skin for signs of cigarette burns, and notify charge nurse immediately if it was suspected resident had violated facility smoking policy. Resident #19 required a smoking apron, and supervision while smoking.
Review of the EMS report dated 09/27/24 revealed on arrival to the facility, Resident #19 was alert and oriented and suffering from third degree burns to 15% of her lower left leg and lower right leg. Resident #19 had just been evacuated minutes before arrival. Resident #19 was quickly assessed and given 25 milligrams (mg) of ketamine for pain and the transferred to the medic. Resident #19's condition was stable and transferred to Hospital #500's burn unit.
Interview on 10/02/24 at 12:39 P.M. with State Tested Nursing Assistant (STNA) #214 revealed the fire alarm went off, and he looked at fire panel to see Resident #19 room was on fire. STNA #214 stated he headed to Resident #19 room, and before arriving, Resident #17 came out of her room, and stated there was smoke coming out of the connecting bathroom door shared between her room and Resident #19's room. STNA #214 stated he touched the door to Resident #19's room and it was not hot and he opened and looked into the room. STNA #214 stated Resident #19's room had pure black smoke in the room and no fire was seen. STNA #214 stated he could not see or go into the room due to all the smoke in the room had irritated his throat and he could not breath. STNA #214 stated he did not go into Resident #19's room. STNA #214 stated he knew the resident was in the room, and thought he heard her. STNA #214 stated he then turned around and went into two other residents' rooms to assist them in evacuation. STNA #214 stated he had in-service training for fire that included RACE and PASS.
Review of the additional camera footage provided to the survey agency on 10/08/24 from the facility revealed camera footage contained multiple camera's video feed and included the smoke compartment where Resident #19's room was located. The timeline of the following events was obtained from the provided camera's footage. The time was captured on Camera 7 footage and Camera 9 captured the hallway where Resident #19's room was located. The date of the footage is 09/26/24.
•
At 11:50:29 P.M., State Tested Nursing Assistant (STNA) # 214, #230 and Licensed Practical Nurse (LPN) #444 were observed walking onto the hallway.
•
At 11:50:34 P.M., the three staff are observed to walk past a fire extinguisher which was on the wall to their left. None of the staff pick up the extinguisher.
•
At 11:50:44 P.M., STNA #230 and LPN #444 walked past the fire extinguisher hanging on the wall again which was now on their right side as they were coming back up the hallway. They did not attempt to pick up the extinguisher.
•
At 11:50:46 P.M., STNA #230 and LPN #444 are observed to walk past Resident #17 who was observed in a wheelchair coming out of a resident room and into the hallway, neither staff member assisted Resident #17 in getting off the hallway where there was a room with black smoke coming out of the door, but the staff were seen to walk up the hallway off camera and leave Resident #17 attempting to mover herself off the hallway on her own.
•
At 11:50:55 P.M., Resident #17 was joined in the hallway by Resident #16 who was observed to walk out of a resident room which was just past fire extinguisher hanging on the wall. Smoke was observed to continue to come into the hallway from room B05 and no staff was observed on the hallway to assist residents, extinguish the fire, or contain the fire. The two residents are seen just congregating in the hallway.
•
At 11:51:04 P.M., STNA # 214 was observed back at the end of the hallway and entered a room on the opposite side of the hallway from B05. Black smoke continues to come into the hallway form room B05. No resident room doors have been shut and no other staff are observed on the hallway.
•
At 11:51:20 P.M., STNA #230 and LPN #444 are observed to enter the hallway and direct Resident #16 and #17 off the hallway off the hallway using hand gestures.
•
At 11:51:24 P.M., STNA #230 and LPN #444 are observed on the hallway close to room B05 but across the hall, smoke is thick is observed on the hallway and it is hard to see past the two staff. Neither staff grabbed the fire extinguisher off the wall as they walked down the hallway toward room B05. No room doors were closed as the staff walked down the hallway.
•
At 11:51:30 P.M., Resident #11 is visible sitting in a wheelchair in a room doorway two doors up the hallway on the same side of the hall as B05 across from STNA #230 and LPN #444 who are observed to be standing in the hallway, STNA #214 is visible at the end of the hallway, and smoke continues to fill the hallway. STNA #230 and LPN #444 are seen to turn and make their way back up the hallway past the fire extinguisher, without evacuating Resident #11 who was in the doorway. The staff did not attempt to shut any room doors or assist any residents to leave the hallway.
•
At 11:51:34 P.M., STNA #214 was observed to stop at the doorway where the Resident #11 is observed sitting in the wheelchair and raise his arm straight out toward the resident. Then the STNA is observed to continue to walk up the hallway, past the resident and past the fire extinguisher and exit the hallway. STNA #214 did not shut any resident room doors as he walked from one end of the hallway to the other end.
•
At 11:51:45 P.M., Resident #21 is seen ambulating at the end of the hallway and Resident #15 was observed to be standing in a room doorway. The resident at the end of the hallway walks past room B05 staying close to the other side of the hallway and LPN #444 was observed to wave the resident toward the fire door and off the hallway. The resident is no longer seen on camera and is off the hallway where the fire was.
•
At 11:52:38 P.M., Resident #15 who was standing in the doorway was observed to exit his room walking with a walker and a hat on his head, he exits the hallway with the fire.
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At 11:52:40 P.M., Resident #11 who was sitting in a wheelchair in his doorway is observed to wheel out of his room and into the hallway.
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At 11:52:43 P.M., LPN #251 was observed coming on the hallway where the fire is located, and grabbed the wheelchair of Resident #11 and moved him off the hallway at 11:52:53 P.M.
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At 11:52:54 P.M., LPN #251 was observed on the hall walking toward room B05 carrying a fire extinguisher. LPN #251 was observed to enter Room B05 at 11:53 :09 P.M., exit the room at 11:53 :14 P.M., reenter the room at 11:53:15 P.M. and re-exit the room by herself at 11:53: 30 P.M.
•
At 11:53:44 P.M., Resident #8 and Resident #21 are observed on the hallway shutting room doors, staff are observed standing outside room B05, and smoke is observed filling the hallway.
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At 11:55:29 P.M., The Columbus Police Officers are visible on the hallway and enter room B05. LPN #251 and STNA # 248 were also in the room with Resident #19.
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At 11:56:10 P.M., Resident #19 was brought out of room B05 and down the hall by LPN #251 and #444, STNA #248 with Police Officers following.
Interview and observation of facility video camera footage with Regional Director of Operations (RDO) #334 on 10/09/24 at 2:00 P.M. confirmed the facility did not follow their policy and procedures regarding fire safety and they did not rescue the resident in the room where the fire occurred timely and the facility staff did not implement the fire procedures and take a fire extinguisher to the room and attempt to extinguish the fire. He confirmed multiple staff walked past a fire extinguisher hanging on the wall and did not attempt to pick up the extinguisher and the staff did not evacuate other resident on the hallway where the fire was located or shut the room doors to contain the fire.
Interview with RDO #334 on 10/10/24 at approximately 10:15 A.M. confirmed the facility had not submitted a self-reported incident regarding the incident of fire on 09/26/24 and the facility's staff response to the fire on 09/26/24.
Review of the facility submitted SRI dated 10/10/24 revealed after a review of the facility's video surveillance on 10/09/24, related to a fire incident on 09/26/24 at approximately 11:46 P.M., the Administrator launched an investigation for Neglect due to staff response to the fire. The Summary of Incident and Investigation noted the following:
On 9/26/2024 at approximately 11:45 P.M., the facility fire alarm was activated. Staff on the A/B hall observed the fire panel and noted the fire to be in Room B-5. A review of the facility's video surveillance showed facility staff viewing the fire panel and immediately proceeding to Room B-5. The video footage shows that the door to B-5 was closed, and smoke was coming from under the door. A facility STNA opened the door and noted the Resident's bed to be the source of the smoke/fire. The facility sprinkler system had activated. The door to Room B-5 was left open while staff retrieved a fire extinguisher and returned to the room and sprayed the contents of the fire extinguisher on the source of the fire. Simultaneously, additional staff were observed on the surveillance video executing R (Rescue), A (Alarm -- already activated), C (Contain), and E (Evacuate). The Resident in B-5 was evacuated from the room and the building at 11:56 PM. Written statements from involved staff members confirms that all facility staff performed emergency procedures properly according to facility policy. The facility Administrator has been and continues to be in contact with the Columbus Division of Police, the Columbus Fire Department, and the [NAME] County Prosecutors Office to pursue criminal charges against the Resident.
The facility Conclusion/Disposition Section of the SRI with a completion date of 10/17/24, indicated the evidence was inconclusive and Abuse, Neglect or Misappropriation is not suspected, and the SRI was Unsubstantiated. On 10/18/24, an Addendum was added to the SRI by the Administrator and indicated the following: Upon further review, the facility is substantiating a finding of neglect.
Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 11/01/2019 revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of resident, or misappropriation of resident property, including injuries of unknown origin. The facility staff should immediately report all such allegations to the Administrator/designee and to the Ohio Department of health in accordance with the procedures in this policy. In cases where a crime was suspected, staff should also report the same to local law enforcement in accordance the facility's crime reporting policy. The failure of the facility, its employees, or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Ohio Department of Health will be notified by using the online Enhanced Information Dissemination and Collection system.
This deficiency represents non-compliance investigated under Master Complaint Number OH00158457, Complaint Number OH00158364, and Complaint Number OH00158347.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, review of facility camera footage, observation, review of a job description, review o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, review of facility camera footage, observation, review of a job description, review of the facility Self-Reported Incident (SRI), and facility policy review, the facility failed to be administered in a manner that enabled the facility to utilize available resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This included failure to prevent neglect of residents by staff during a fire that occurred on 09/26/24, failure to ensure residents utilizing oxygen therapy were not able to possess lighters and smoking materials unsupervised, failure to timely and appropriately implement emergency procedures, when a fire occurred in Resident #19's room and ignited the resident's mattress/bedding on fire which ultimately activated the sprinkler system, including: rescuing residents in and near the fire, containing the fire from potentially spreading, alerting emergency personnel timely, and attempting to extinguish the fire. The incident was also not documented on the facility's incident log as an incident with resultant injuries. Additionally, when the Administrator submitted the SRI dated 10/10/24, after a review of the facility's video surveillance on 10/09/24, related to a fire incident on 09/26/24, the Administrator launched an investigation for neglect due to staff response to the fire, and the conclusion was unsubstantiated on 10/17/24 indicating the evidence was inconclusive and facility staff performed emergency procedures properly according to facility policy. On 10/18/24, an Addendum was added to the SRI by the Administrator and indicated upon further review, the facility is substantiating a finding of neglect. This affected one (#19) resident who resided in Room B05 and placed an additional nine residents (#11, #15, #16, #17, #18, #20, #21, #22, and #23), residing in the same smoke compartment as Resident #19 at potential risk due to the potential for the fire and smoke to spread throughout the hall. The facility identified a total of 50 residents currently residing in the facility who smoke (Residents #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #15, #16, #17, #20, #21, #22, #31, #32, #33, #34, #35, #37, #39, #40, #41, #42, #44, #45, #48, #49, #50, #52, #55, #57, #59, #61, #64, #67, #72, #74, #75, #77, #78, #79, #82, #86, #87, #88, #89, and #91). The facility census was 88.
Findings include:
Review of the facility document titled Job Description and Performance Standards dated 04/22/24 revealed the Administrator had started a position as Administrator at the facility. The purpose of this position was to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet residents' needs in compliance with federal, state, and local requirements.
Interview with the Administrator on 10/03/24 at 10:30 A.M. revealed they did not identify any issues related to the smoking incident when Resident #19 had a fire to her bed on 09/26/24. The Administrator stated the resident has the right to light herself on fire if she chose to and the resident has the right to have cigarettes and lighter on self if she chooses to.
During the complaint and partial extended survey, observations, record review, staff interviews, and policy review, resulted in concerns related to the operation of the facility including but not limited to abuse and neglect, fire safety, and implementing their smoking policy and plan. The facility failed to provide evidence that administrative staff had effective systems in place to timely identify abuse and quality of care concerns.
1. Resident #19's smoking and safety screen dated 09/16/24 revealed Resident #19 needed the facility to store lighter and cigarettes.
On 09/26/24 at 11:45 P.M., a fire was started on Resident #19's bed. Resident #19 was sent to the hospital and sustained 35 percent (%) burns on her body. Resident #19 was admitted to the Surgical Care Intensive Care Unit (SICU) for treatment of extensive burns received on her torso, extremities and face. The patient was noted to be in excruciating pain. Resident #19 was treated for acute respiratory failure with hypoxia and was intubated with a moderate inhalation injury.
1a. The facility did not timely report an allegation of injury of unknown origin and/or potential neglect involving Resident #19's fire in her room resulting in burns to her body to the State Survey Agency.
Interview on 10/09/24 at 2:00 P.M. with Regional Director of Operations (RDO) #334 confirmed the facility did not report an allegation of injury of unknown origin and/or neglect involving Resident #19 to the State Survey Agency.
1b. The facility did not complete a thorough investigation of the fire in Resident #19's bed. The facility did not identify the source of the fire and determine the timeline of events that occurred after the fire started. The facility did not identify there was a delay in staff's response to the fire until 10/08/24.
Review of the facility document titled Incident Investigation-Room [Resident #19's room] Fire dated 09/26/24 through 09/27/24 revealed the following: staff interviews and statements revealed their actions during the active incident and during the evacuation appeared consistent with the video surveillance. Two residents interviewed (Resident #08 and Resident #17) stated Resident #19 was yelling, which was normal in the evening for Resident #19. One resident reported shortly before the fire alarm activated, the resident was heard shouting, I'll show them. The statement seems to stand alone without sufficient context to determine its meaning. Interviews and video surveillance reveal the fire alarm sounded at approximately 11:45 P.M. on 09/26/24. Video shows staff responding appropriately using both the RACE (Rescue, Alert/Alarm, Contain, Extinguish) and PASS (Pull, Aim, Squeeze, Sweep) method of dealing with an active fire. Staff used fire extinguishers to extinguish the flames. At approximately 11:46 P.M., emergency 9-1-1 was called. The local police arrived at the facility at 11:54 P.M. and the Fire Department and EMS arrived at 11:58 P.M. The local police and staff had already evacuated Resident #19 from her room. Resident #19 was examined by medics and transported to the hospital. The report stated Emergency Department notes provided helpful information in determining the origin of the fire. The notes state that the resident intentionally started the fire to get staff's attention. Where the resident obtained an instrument, i.e., matches, a lighter, etc. to ignite the fire cannot be determined. As a supervised smoker, the resident would have had her smoking material and paraphernalia collected at the time of her previous smoking session. An examination of room [Resident #19] and the bed the resident was in was not determinative as to the source of ignition. The Administrator and Maintenance Director #390 closely examined the room and debris looking for a burned cigarette and/or a source of ignition. No cigarettes or lighters or matches were discovered in the debris. However, it can be noted that the bed was the origin of the fire. In fact, there appeared to be two separate ignition points. One point of origin appears to be on the resident's right-hand side of the bed at about the midpoint of the bed; the other point of origin (which looked to be the original point of origin) appeared at the right-side foot of the bed. The report listed the facilities conclusion as: facility staff responded appropriately at the time of the incident, ensuring the fire was extinguished, the residents and others were safely evacuated. Facility staff provided care to the resident prior to the incident. The resident started the fire intentionally and with knowledge that her actions could result in significant harm. The facility will continue to monitor other residents' for both physical and psycho social well-being. The facility will cooperate with the fire department in their investigation of the incident. The report was completed by the Administrator.
The facility did not review all available camera footage in the hallway of Resident #19's room when completing their investigation, the facility only reviewed the camera footage down the long hallway and the footage did not show Resident #19's room after the fire doors closed. This camera footage was shown to the State Survey Agency on 10/02/24 at 3:00 P.M. The Administrator stated there was no additional video footage of inside the fire doors to be able to see Resident #19's room after the fire doors closed at 11:45 P.M. on 10/02/24 at 3:00 P.M. The State Survey Agency requested a copy of the camera footage of the fire and on 10/08/24, the facility provided camera footage that included all hallways of the facility including the hallway where Resident #19's door was located. The camera footage of Resident #19's room after the fire doors closed showed there was a delay in the staff's response to rescue Resident #19 and the other residents in the hallway of the fire. Regional Director of Operations #334 explained the Administrator was unaware the facility had this video footage of Resident #19's hallway on 10/08/24 at 11:00 A.M.
Interview on 10/03/24 at 10:09 A.M. with the Administrator and DON revealed the facility in response to the fire performed respiratory assessments and head to toes assessments on other facility residents. The smoking policy was updated and the residents who smoked were divided into two groups, group A and B. The residents who smoke at the facility were educated on the policy update and signed a new smoking agreement. Residents' room sweeps were completed. The DON stated they had no issues identified after the fire. They changed their smoking set up to group A and B which started on 09/27/24. The smokers were educated on the changes, the policy, they signed the new policy and agreed to not keep their smoking materials with them or in their room. The Administrator stated their system worked flawlessly, and their fire system had no problems.
Observation and interview on 10/15/24 at 1:45 P.M. with Maintenance Director #390 and Corporate Nurse #309 revealed there was a pile of debris next to the facility sidewalk in the courtyard area where the smokers [NAME] was located. The debris contained insulation, broken ceiling tiles, a resident air mattress that had burn marks on it, a resident call light cord, a phone charging cord, several pop bottles, some burnt fabric, melted and disfigured room blinds and a lighter with scorch marks on it. Maintenance Director #390 stated the fire department put the debris outside on the night of the fire 09/26/24. Maintenance Director #390 verified it was the debris from Resident #19's room, and when the lighter was pointed out, Maintenance Director #390 and Corporate Nurse #309 both verified, they saw the lighter with the burned marks from the fire in the items removed form Resident #19's room.
1c. The facility did not implement their smoking plan and smoking policy prior to 09/27/24.
Review of the facility document titled Smoking Plan dated 04/04/23 revealed during the hours the receptionist was in the facility, the following will occur: your cigarettes will be kept with the receptionist. The paraphernalia will need to be turned back into the receptionist, and you will need to get it from the receptionist when you are wanting to go out. Any resident found with their smoking paraphernalia (including cigarettes or lighters) will lose all rights to go out independently as you pose a risk to the safety of all other residents in the facility. Smoking was to occur under the sheltered smoking.
Review of the facility's undated policy titled Smoking Policy-Residents' revealed all residents will have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. All residents will be required to follow supervised smoking. Residents may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision. The facility maintains the right to confiscate smoking articles found in violation of our smoking policies. The policy was updated on 09/27/24 to include Smoking was only permitted in designated resident smoking areas, which are located outside of the building. Oxygen use was prohibited in smoking areas. All residents shall have the direct supervision of a staff member, family member, visitor or volunteer, or worker at all time while smoking. All residents are required to follow supervised smoking.
Interviews on 10/02/24 at 11:55 A.M. with Resident #3, at 12:00 P.M. with Resident #12, at 3:00 P.M. with Resident #89, at 3:38 P.M. with Resident #22 and at 5:00 P.M. with Resident #8 confirmed before the facility had the fire incident on 09/26/24, the facility staff was not monitoring the residents closely in taking cigarettes and lighters away from residents. The five residents confirmed they were allowed to keep smoking materials with them and not hand them in to the facility. Resident #22 stated Resident #19 was known to keep her materials including a lighter in her room. Resident #8 stated Resident #19 had family in to visit her on 09/26/24 and he heard them fighting about something. Resident #8 stated Resident #19 was yelling and upset.
Interview on 10/02/24 at 12:39 P.M. with State Tested Nursing Assistant (STNA) #214 stated the residents at the facility do keep smoking products on them sometimes.
Review of the Fire Department's Investigation Report dated 09/26/24 revealed smoked and unsmoked cigarettes, cigarette pack, and a lighter were found near the original location of the bed. The conclusion was an accidental fire caused by smoking materials in close proximity to high concentration oxygen.
1d. Review of the facility's fall and incident log dated from 09/26/24 through 10/02/24 revealed Resident #19 was not documented as an incident with injury on the log.
Interview on 10/02/24 at 10:28 A.M. with the Administrator verified Resident #19 was not listed on the facility's fall and incident log provided to the survey team. The Administrator stated he was not sure why her incident was not listed on the fall and incident log.
1e. Review of the facility document titled Emergency Preparedness dated 07/17/24 revealed only forty-five employees were educated. The education included managing oxygen in nursing homes, oxygen therapy, oxygen safety, RACE (Rescue, Alarm, Contain, Extinguish), and PASS( Pull (pull the pin to discharge the extinguisher), Aim (Point the nozzle at the base of the fire), Squeeze (Squeeze the handle to release the extinguishing agent), and Sweep (Sweep the nozzle from side to side at the base of the first until it's out). [NAME] President of Clinical Services #310 verified there was only 45 employees at the Emergency Preparedness and Safety Management training on 10/15/24 at 3:16 P.M.
Interview on 10/02/24 at 10:01 A.M. with State Tested Nursing Assistant (STNA) #240 stated she was recently educated on fire safety but could not remember the training.
Interview on 10/02/24 at 10:05 A.M. with STNA #246 stated she had education on fire on 09/27/24. STNA #246 stated she forgot what the fire acronyms RACE and PASS stood for.
Interview on 10/02/24 at 10:20 A.M. with STNA #235 stated she was educated on fire safety on 09/27/24. The education included fire drills, closest exit for evacuation, all doors to close for the fire. STNA #235 stated she could recite what the acronym of RACE meant. STNA #235 stated she was not sure about PASS and the meaning for it.
Interview on 10/09/24 at 2:54 P.M. with STNA #214 verified he did not follow RACE during the fire incident involving Resident #19. STNA #214 verified he never rescued the resident or closed the door to contain the fire.
Interview on 10/09/24 at 3:27 P.M. with STNA #230 verified she did not go into Resident #19's room when the fire started to rescue Resident #19. STNA #230 stated she knew Resident #19 was in her room. STNA #230 verified she did not use the fire extinguisher and did not close Resident #19's door to her room. STNA #230 stated she knew what RACE meant but forgot what PASS meant. STNA #230 stated she was educated after the fire. STNA #230 stated she did follow RACE and did rescue other residents, but not Resident #19.
Observation on 10/09/24 at 11:30 A.M. with RDO #334 of Video #9 (the camera footage of Resident #19's hallway after the fire started) revealed the facility staff had passed the fire extinguisher and were not shutting the resident's doors to contain the fire, and rescuing Resident #19 who was laying in her bed, while the fire was burning. Resident #19 was not rescued timely by staff at the facility.
Interview on 10/09/24 at 2:00 P.M. with RDO #334 confirmed the facility did not follow their policy and procedures regarding fire safety, they did not rescue the resident in the room where the fire occurred timely, and the facility staff did not implement the fire procedures and take a fire extinguisher to the room and attempt to extinguish the fire. He confirmed multiple staff walked past a fire extinguisher hanging on the wall, did not attempt to pick up the extinguisher and the staff did not evacuate other residents on the hallway or shut the room doors to contain the fire.
Interview on 10/15/24 at 4:30 P.M. with Corporate Nurse (CN) #309 stated Maintenance Director #390 was auditing staff for fire training and reviewing the acronyms for RACE and PASS with several employees who still do not remember the meaning. CN #309 verified the facility had 112 employees on the staff identifier list.
This deficiency represents non-compliance investigated under Master Complaint Number OH00158457, Complaint Number OH00158364, and Complaint Number OH00158347.
Aug 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
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 record review, observation, and interview, the facility failed to ensure fall interventions were in place. This affecte...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure fall interventions were in place. This affected one (Resident #22) of three residents reviewed for falls. The facility census was 94.
Findings include:
Record review revealed Resident #22 admitted to the facility on [DATE] with diagnoses including seizures, delirium, hemiplegia and hemiparesis following cerebral infarction, edema, major depression, hyperlipidemia, and mild cognitive impairment.
Review of a Morse Fall Scale assessment completed on 07/17/24 revealed Resident #22 was at high risk for falling.
Review of the care plan revealed Resident #22 required assistance of one to two staff for transfers and was at risk for falls related to an unsteady gait with fall interventions including but not limited to bright colored tape to call light, defined perimeter mattress, non-skid footwear, fall mat to right side of bed, bed in lowest position, and keeping call light in reach.
Observation on 08/16/24 at 1:05 P.M. revealed Resident #22 was resting in bed. The bed was not in the lowest position, she did not have non-skid footwear on, the call light was not in reach and did not have bright colored tape as a visual cue. Interview with Licensed Practical Nurse (LPN) #124 confirmed observations and stated Resident #22 did not like to wear socks to bed and she had been eating lunch so her bed was not in the lowest position. LPN #124 confirmed the head of bed could be elevated with the bed in lowest position.
Review of a policy titled, Falls - Clinical Protocol, dated 09/2012 revealed facility staff will identify pertinent interventions to try to prevent subsequent falls and to address the risks of falling. The staff will monitor and document the individuals response to the fall interventions intended to reduce falling or the consequences of falling.
This deficiency represents non-compliance investigated under Complaint Number OH00156353.
Jul 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on medical record review, observation, staff interview and review of the facility policy the facility failed to maintain proper infection control measures during medication administration. This ...
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Based on medical record review, observation, staff interview and review of the facility policy the facility failed to maintain proper infection control measures during medication administration. This affected two (Residents #22) of four residents observed for medication administration. The facility also failed to implement enhanced barrier precautions (EBP) when appropriate. This one resident (Resident #28) of three residents reviewed for isolation precautions. The facility census was 95 residents.
Findings include:
1.Review of the medical record for Resident #22 revealed an admission date of 05/05/23 with diagnoses of respiratory failure and muscle weakness. Resident #22 was dependent on staff for activities of daily living (ADL) tasks including medication administration and had moderate cognitive impairment.
Review of the physician orders for Resident #22 dated July 2023 revealed orders for the following medications to be given in the morning: Tylenol, Baclofen, Colace, folic acid, multivitamin, Zoloft, thiamine, vitamin D3, Gabapentin.
Observation on 07/23/24 at 8:15 A.M. of medication administration for Resident #22 per Registered Nurse (RN) #345 revealed the nurse dispensed the following oral medications into a cup: Tylenol 325 milligrams (mg) two tablets totaling 650 mg, Baclofen 10mg one tablet, Colace 100 mg one gel capsule, folic Acid 1 mg one tablet, multivitamin one tablet, Zoloft 25 mg one tablet, thiamine 100 mg one tablet, vitamin D3 1000 units two tablets. RN #345 then unlocked the narcotic drawer to retrieve the nerve Gabapentin 300 mg two tablets. RN #345 removed the medication card for Gabapentin and dispensed the two capsules into her left hand and then placed the two capsules into the medication cup sitting on top of the medication cart.
Interview on 07/23/24 at 8: 20 A.M. with RN #345 confirmed she dispensed Resident #22's Gabapentin capsules into her bare hand and placed them in the cup for administration to the resident. RN #345 further confirmed she should not have touched the resident's oral medications with her bare hands.
Review of the facility policy titled Administering Medications dated 12/01/12 revealed staff should follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications.
2. Review of the medical record for Resident #28 revealed an admission date of 04/27/24 with diagnoses including protein calorie malnutrition, high blood pressure, depression, and muscle weakness. Resident #28 required assistance from staff to complete ADLs and had intact cognition.
Review of the physician orders for Resident #28 revealed an order dated 07/09/24 to cleanse a wound to the coccyx with Dakin's solution and pack with Dakin's solution-soaked gauze and cover with a border dressing twice daily and as needed. Resident #28 had no orders for EBP.
Observation on 07/23/24 at 9:04 A.M. of wound care to the coccyx for Resident #28 per RNs #222 and #328 revealed the nurses did not don gowns prior to completing the dressing change. There was a three-drawer container with personal protective equipment (PPE) located in the resident's room outside of the bathroom door.
Interview on 07/23/24 at 9:10 A.M. with RN #222 confirmed residents are placed on EBP for various conditions including indwelling urinary catheters, intravenous (IV) devices, dialysis ports, ostomies, and open wounds/pressure ulcers.
Interview on 07/23/24 at 9:27 A.M. with the Director of Nursing (DON) confirmed there was not an order implemented for EBP related to Resident #28's open coccyx wound. The DON further confirmed Resident #28 should have had an order for enhanced barrier precautions due to the open coccyx wound and nurses should don gowns prior to performing dressing changes to the resident's coccyx wound.
Review of the facility policy titled Enhanced Barrier Precautions dated 04/01/24 revealed (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with open wounds regardless of the wounds' multi-drug resistant organism (MDRO) colonization or infection status.
This deficiency represents noncompliance investigated under Complaint Number OH00155639.
Jun 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, policy review, and interview, the facility failed to assist one female resident with shavin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, policy review, and interview, the facility failed to assist one female resident with shaving her face. This affected one resident (#44) of three residents reviewed for activities of daily living (ADLs). The facility census was 87.
Findings include:
Record review revealed Resident #44 admitted to the facility on [DATE] with diagnoses including other sequela of cerebral infarction, hemiplegia and hemiparesis following cerebrovascular disease affecting left dominant side, depression, chronic obstructive pulmonary disease, and type II diabetes.
Review of an admission minimum data set (MDS) completed on 06/03/24 revealed Resident #44's cognition was intact, she did not refuse care, and was dependent on staff for personal hygiene including combing hair, shaving, applying makeup, washing face and hands.
Observation and interview on 06/21/24 at 12:13 P.M. with Resident #44 revealed she had not been shaved since her admission because there were no supplies. Resident #44 stated an aide was bringing in supplies the following day and would shave her as part of her shower day routine. Resident #44 stated it bothered her to have facial hair and it was embarrassing. During the interview, Resident #44 was observed to have inch long, gray whiskers across her cheeks and chin.
Interview on 06/21/24 at 1:17 P.M. with Director of Nursing (DON) confirmed Resident #44 did have long facial hair across her cheeks and chin. The DON stated when asked, Resident #44 was not bothered by facial hair.
Review of a policy titled Shower/Tub Bath (dated October 2010) revealed staff should assist with dressing and grooming as needed.
This deficiency represents non-compliance investigated under Complaint Number OH00154376.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
Based on observation, record review, interview, and photographs, the facility was not maintained in a clean, homelike environment and was not in good repair. This affected all 87 residents residing in...
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Based on observation, record review, interview, and photographs, the facility was not maintained in a clean, homelike environment and was not in good repair. This affected all 87 residents residing in the facility. The census was 87.
Findings include:
Review of Resident Council Meeting minutes dated 06/06/24 revealed room B27's sink had been broken for three months. Grievance sheet dated 06/12/24 revealed the sink was repaired on 06/14/24.
Observations on 06/21/24 during the initial tour of the facility with Administrator present to confirm revealed the following:
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10 A.M. a missing transition strip to the dining room, the door frame was dirty and chipped, the dining room had peeling wallpaper, splatter marks throughout the dining room walls, two rusting ceiling vents with dust across the ceiling near the vents.
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10:03 A.M. the door to the therapy gym was chipping and jagged with a sharp edge, the wallpaper near the trashcan in the therapy gym was peeling and stained brown.
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10:05 A.M. on the C hallway revealed room C10's floor was dirty with mud and tire marks from a motorized wheelchair and the wall outside C19 was streaked with brown.
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10:07 A.M. on the B hallway revealed room B34's bathroom door was splattered with a brown substance, the vent above the door to room B26 was rusted, and the floor near B16 was covered with debris.
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10:25 A.M. the downstairs counseling space drywall was off half of the far wall with dirty brick exposed.
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10:30 A.M. the downstairs staff lounge was closed and off limits due to renovations occurring after a concern was identified related to a water leak and black mold-like substance.
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10:40 A.M. room A19 had linens on the floor and the floor outside the central shower room had grooves in the tile and was uneven.
Interview with the Administrator on 06/21/24 at 1:54 P.M. confirmed the photographs received were the off-limits downstairs staff lounge. Administrator stated repairs had begun and he could provide documentation.
Review of an undated email from Administrator to OSHA revealed employees working in the basement of the facility are exposed to slip, trip, and fall hazards resulting from leaking pipes that leave sections of the tiled floor routinely covered with water. It was discovered the floor drain in the facility's laundry room was clogged, the maintenance assistant used an electric floor drain snake to clear the drain line. Employees throughout the facility are exposed to potential health hazards related to the untreated accumulation of mold. This allegation was investigated and determined a storage room with limited access to employees has water damage from the leak. All water damaged items were removed, damaged drywall and tile flooring were removed. Once the source of the water leak has been identified and remediated, the floor will be covered in an epoxy floor paint and the walls will be treated for the mold-like substance and painted with Kilz paint. Supplies were purchased and are on site.
Review of a receipt dated 06/11/24 at 2:02 P.M. revealed Columbus Leak Detection LLC received payment to determine the location of the leak.
Review of a text message dated 06/18/24 at 9:30 A.M. provided by Administrator revealed Columbus Leak Detection LLC would be available to repair issues on 06/27/24 and services would include backfill hole and pouring concrete once leak was fixed.
A policy for maintaining the facility in a safe, sanitary manner was requested and not provided.
This deficiency represents non-compliance investigated under Complaint Number OH00154570.
Apr 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
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 review of the facility policy, the facility failed to ensure medications we...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure medications were administered without significant errors. This affected one (Resident #96) of three residents reviewed for medications. The facility census was 91.
Findings include:
Review of the medical record for Resident #96 revealed an admission date of 01/11/24, with diagnoses including seizure disorder, chronic obstructive pulmonary disease (COPD), and dependence on respirator(ventilator).
Review of the comprehensive Minimum Data Set (MDS) assessment for Resident #96 dated 01/17/24 revealed the resident was cognitively impaired and was dependent on staff for all activities of daily living (ADLs).
Review of the care plan for Resident #96 dated 01/12/24 revealed the resident had a seizure disorder. Interventions included to give seizure medication as ordered by doctor and to monitor for side effects and effectiveness.
Review of physician orders for Resident #96 revealed an order dated 02/03/24 valproic acid solution (anti-seizure medication) 10 milliliters (ml) per gastrostomy tube (g-tube) three times per day at 9:00 A.M., 1:00 P.M., and 9:00 P.M.
Review of the progress notes for Resident #96 revealed the resident was discharged to the hospital on [DATE] and was readmitted to the facility on [DATE].
Review of the readmission orders for Resident #96 dated 02/14/24 revealed an order for valproic acid solution 10 ml per g-tube three times per day at 9:00 A.M., 1:00 P.M., and 9:00 P.M.
Review of the Medication Administration Record (MAR) for Resident #96 dated February 2024 MAR revealed the resident did not receive valproic acid solution ordered on 02/14/24 through 02/29/24.
Review of the MAR for Resident #96 dated March 2024 revealed the resident did not receive valproic acid solution as ordered on 03/01/24 through 03/13/24. The resident was readmitted to the hospital on [DATE].
Review of the hospital report for Resident #96 dated 03/16/24 revealed the resident was admitted to the hospital on [DATE] with a diagnosis of seizure activity. Further review of the report revealed the resident's valproic acid solution was discontinued though the reasoning for the discontinuation was unclear.
Review of the facility incident report regarding Resident #96 dated 03/18/24 timed at 4:51 P.M. revealed the resident returned from the hospital on [DATE], and the admitting nurse did not enter the order for valproic acid solution into the electronic medical record (EMR.) Resident #96 did not receive valproic acid solution from 02/14/24 through 03/13/24. On 03/14/24 the resident was sent to the hospital for seizure-like activity. The hospital staff noticed valproic acid solution was not on Resident #96's medication list. The facility notified Resident #96's physician of the medication error (resident did not receive valproic acid as ordered from 02/14/24 to 03/13/24) on 03/18/24 at 4:00 P.M.
Interview on 04/01/24 at 12:15 P.M. with the Director of Nursing (DON) confirmed Resident #96 did not receive valproic acid solution as ordered on 02/14/24 through 03/13/24. The DON confirmed Resident #96 did not receive her medication due to a transcription error in which the readmitting nurse on 02/14/24 failed to enter the medication order in the EMR.
Review of the facility policy titled Medication and Treatment Orders revised July 2016. revealed medications must be administered as ordered by the physician.
This deficiency represents noncompliance investigated under Complaint Number OH00152209.
Mar 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
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 ensure the contact information for the practitioner r...
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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 ensure the contact information for the practitioner responsible for the care of the resident, resident representative information, advanced directives information, all special instructions or precautions for ongoing care and all other necessary information to ensure a safe and effective transition of care was communicated to the receiving health care institution or provider upon transfer/discharge. This affected three (Residents #90, #91, and #92) out of three residents reviewed for hospitalization. The facility census was 85.
Findings include:
1. Review of Resident #90's medical record revealed an admission date of [DATE] with diagnoses which included respiratory failure, tracheostomy, dependence on respirator (ventilator), history of Covid-19, type two diabetes mellitus, congestive heart failure, and hypertension. Resident #90 was discharged to the hospital on [DATE].
Review of Resident #90's progress notes, dated [DATE], revealed at 3:40 A.M., Resident #90 coded and a code blue was called. Chest compressions were started. 911 was called and 911 took over compressions when they arrived. When Emergency Medical Services (EMS) got a pulse, they took Resident #90 to the emergency room. Resident #90's family, MedOne, and the Director of Nursing were notified.
Review of the medical record for Resident #90 revealed there was no evidence the following information was provided to the receiving health care institution or provider when Resident #90 transferred/discharged to the hospital on [DATE]: contact information for the practitioner responsible for the care of the resident, resident representative information, advanced directives information, all special instructions or precautions for ongoing care and all other necessary information to ensure a safe and effective transition of care.
2. Review of Resident #91's medical record revealed an admission date of [DATE] with diagnoses which included acute and chronic respiratory failure, Chronic Obstructive Pulmonary Disease, paranoid schizophrenia, end stage renal disease dependent on renal dialysis, depression, anxiety, and congestive heart failure.
Review of Resident #91's progress notes, dated [DATE], revealed the nurse entered the Resident #91's room and called the resident by his name with no response. No chest movement was noted and the nurse was unable to find a carotid pulse. The nurse pushed the call button, yelled code blue, and immediately initiated cardio-pulmonary resuscitation (CPR). 911 was called and 911 arrived at the facility at approximately 1:10 P.M. EMS obtained a faint pulse and transported the resident to the emergency department at that time. The physician was informed of the situation and Resident #91's power of attorney was informed of the change to the residents status.
Review of the medical record for Resident #91 revealed there was no evidence the following information was provided to the receiving health care institution or provider when Resident #91 transferred/discharged to the hospital on [DATE]: contact information for the practitioner responsible for the care of the resident, resident representative information, advanced directives information, all special instructions or precautions for ongoing care and all other necessary information to ensure a safe and effective transition of care.
3. Review of Resident #92's medical record revealed an admission date of [DATE] with diagnoses which included peripheral vascular disease, respiratory failure, heart disease, hypertension, and dementia.
Review of Resident #92's progress note dated, [DATE] at 10:59 A.M., revealed the aide notified the nurse Resident #92 did not eat breakfast. Resident #92 was mumbling words when the nurse went in to talk to Resident #92. The nurse assessed Resident #92 and Resident #92's blood pressure was 71 over 45, oxygen saturation was 56%, pulse was 14, and temperature was 97.3 degrees fahrenheit. The nurse practitioner was notified and gave a new order for one time prednisone 40 milligrams, intravenous fluid one liter at 100 milliliters/hour, chest x-ray, and a covid and flu test. The nurse immediately administered the prednisone but couldn't get fluids running and Resident #92 started turning purple so Resident #92 was sent out (to the hospital).
Review of the medical record for Resident #92 revealed there was no evidence the following information was provided to the receiving health care institution or provider when Resident #92 transferred/discharged to the hospital on [DATE]: contact information for the practitioner responsible for the care of the resident, resident representative information, advanced directives information, all special instructions or precautions for ongoing care and all other necessary information to ensure a safe and effective transition of care.
Interview on [DATE] at 2:55 P.M. with Regional Director of Clinical Support #420 verified there was no evidence in Resident #90, Resident #91, and Resident #92's medical record that contact information for the practitioner responsible for the care of the resident, resident representative information, advanced directives information, and all special instructions or precautions for ongoing care as well as all other necessary information to ensure a safe and effective transition of care was communicated to the receiving facility when they were transferred/discharged to the hospital.
This deficiency represents non-compliance investigated under Complaint Number OH00151847.
Nov 2023
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, the facility failed to ensure resident representatives were notified of medication changes. This affected one (Resident #1) out of three residents r...
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Based on medical record review and staff interview, the facility failed to ensure resident representatives were notified of medication changes. This affected one (Resident #1) out of three residents reviewed for medications. The census was 91.
Findings include:
Review of the medical record for Resident #1 revealed an initial admission date of 10/10/23 with diagnoses including but not limited to chronic respiratory failure with hypoxia, end stage renal disease, dependence on dialysis, tracheostomy, gastrostomy, type one diabetes mellitus, and seizures.
Review of Resident #1's acute care hospital discharge instructions revealed orders, dated 10/10/23, for Keppra (medication used to control seizures) 100 milligrams (mg)/milliliter (ml) with the special instructions to give five ml via peg-tube twice daily and Keppra 100 mg/ml with special instructions to give 2.5 ml via peg-tube daily every Tuesday, Thursday and Saturday.
Review of Resident #1's physician orders, dated 10/11/23, revealed an order for Keppra 100 mg/ml with special instructions to give 2.5 ml via peg-tube daily every Tuesday, Thursday and Saturday as well as an order for Keppra 100 mg/ml with special instructions to give five ml every Monday, Wednesday and Friday.
Interview on 11/07/23 at 5:18 P.M., with Licensed Practical Nurse (LPN) #174 revealed new orders were obtained for Resident #1's Keppra. LPN #174 verified there was no documented evidence Resident #1's power of attorney was notified of the changes to the Keppra.
This deficiency represents non-compliance investigated under Complaint Number OH00147337.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
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 record review and staff interview, the facility failed to develop a recapitulation of a resident's stay when the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and staff interview, the facility failed to develop a recapitulation of a resident's stay when the resident had a planned discharge. This affected one (Resident #93) out of one sampled resident who had a planned discharge to the community. The census was 91.
Findings include:
Review of the closed medical record for Resident #93 revealed an initial admission date of 08/15/23 with diagnoses including acute and subacute endocarditis, cerebral infarction, congestive heart failure, psychoactive substance abuse, hypertension, chronic viral hepatitis C, edema, diarrhea, gastro-esophageal reflux disease, muscle wasting, generalized muscle weakness, depression and pain. Resident #93 was discharged home with her daughter on 09/16/23.
Review of the plan of care, dated 08/16/23, revealed Resident #93 would have a discharge plan. Interventions included all discharges were to be documented as well as document all discussions with family and resident regarding discharge plans.
Review of Resident #93's comprehensive Minimum Data Set (MDS) assessment, dated 08/22/23 revealed Resident #93 had no cognitive impairment.
Review of Resident #93's medical record revealed no evidence a recapitulation of Resident #93's stay was provided to Resident #93 or her resident representative upon discharge home on [DATE].
Interview on 10/17/23 at 10:05 A.M., with the Director of Nursing (DON) verified the facility did not provide a recapitulation of Resident #93's stay upon discharge on [DATE].
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on medical record review, staff interview, and facility policy review, the facility failed to routinely assess pressure ulcers as well as ensure wound assessments included a description of the w...
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Based on medical record review, staff interview, and facility policy review, the facility failed to routinely assess pressure ulcers as well as ensure wound assessments included a description of the wound. This affected three (#48, #92, and #93) out of three residents reviewed for pressure ulcers. Additionally, the facility failed to initiate treatment for a pressure ulcer in a timely manner. This affected one (#92) out of three residents reviewed for pressure ulcers. The census was 91.
Findings include:
1. Review of the medical record for Resident #92 revealed an initial admission date of 05/19/23 with a latest readmission date of 08/27/23. Resident #92's diagnoses included but were not limited to end stage renal disease (ESRD), diabetes mellitus, vascular dementia, dependence on renal dialysis, seizures, muscle wasting, and congestive heart failure.
Review of the plan of care, dated 05/22/23, revealed Resident #92 was at risk for skin breakdown related to decreased mobility. Interventions included encourage Resident #92 to float heels as tolerated, house barrier cream with each episode of incontinence, observe skin for redness or open areas, notify the nurse, pressure reducing/relieving cushion to wheelchair, pressure reducing/relieving mattress, turn and reposition every two hours as tolerated. On 08/28/23, an intervention for Prevalon boots to be worn while in bed was added.
Review of the nursing admit/readmit assessment, dated 08/27/23, revealed Resident #92 was readmitted to the facility with multiple pressure ulcers. Resident #92 was admitted with a stage two pressure ulcer to the left buttocks measuring 1.5 centimeters (cm) by 0.5 cm by 0.1 cm, as well as three stage two pressure ulcers to the right buttocks which measured 1.5 cm by 0.5 cm by 0.1 cm, 1.5 cm by 0.5 cm by 0.1 cm, and 1.5 cm by 0.5 cm by 0.1 cm. Additionally, there was an unstageable pressure ulcer to the left heel measuring 4.0 cm by 5.0 cm by 0.21 cm. The assessment contained no description of the wounds.
Review of the weekly wound observation and clarification of wounds, dated 09/04/23, revealed Resident #92 had a suspected deep tissue injury (SDTI) to the right heel measuring 4.3 cm by 4.7 cm. The wound was described as 100% dry reabsorbing purple non-blanching tissue. The treatment was for skin prep and leave open to air.
Review of the weekly wound observation and clarification of wounds, dated 09/04/23, revealed Resident #92's stage two pressure ulcer to the left buttocks had worsened to a stage three pressure ulcer and measured 2.5 cm by 3.0 cm with the depth being unable to be determined. The wound was described as being 20% granulation and 80% intervening. The treatment was to cleanse the wound with soap and water and apply zinc oxide cream.
Review of Resident #92's medical record revealed no documented evidence the Stage III pressure ulcer to the sacrum and the SDTI to the right heel were assessed during the week of 09/11/23.
Review of the plan of care, dated 09/12/23, revealed Resident #92 had a pressure ulcer or potential for pressure ulcer development related to right heel and sacral pressure ulcers. Interventions included administer medications as ordered, administer treatments as ordered and monitor for effectiveness, educate the resident/family/caregivers as to causes of skin breakdown including transfer/positioning requirements, importance of taking care during ambulation/mobility, good nutrition and frequent repositioning, follow facility policies/protocols for the prevention/treatment of skin breakdown, monitor nutritional status, provide diet as ordered, monitor and record intake, monitor/document/report as needed any changes in skin status, obtain and monitor lab/diagnostic work as needed, provide supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing, treat pain as per orders prior to treatment/turning and weekly treatment documentation to include measurement of each area of skin breakdown's (width, length, depth, type of tissue and exudate).
Review of the Resident #92's weekly skin assessment, dated 09/18/23, revealed the assessment indicated the stage III pressure ulcer to the sacrum measured 6.8 cm by 5.7 cm and the SDTI to the right heel measured 3.0 cm by 3.2 cm. The assessment contained no description of the wound and did not indicate if the wounds had improved, declined or remained unchanged.
Review of Resident #92's weekly skin assessment, dated 09/25/23, revealed Resident #92 had a pressure ulcer to the front of the right knee and front of the left knee. The wound to the right knee measured 3.0 cm by 2.0 cm and the wound to the left knee measured 2.0 cm by 2.0 cm. The assessment failed to identify the stage or description of the wound.
Review of Resident #92's weekly skin assessment, dated 09/28/23, revealed Resident #92 had a pressure ulcer to the front of the right knee and front of the left knee. The assessment failed to identify the stage, measurements or description of the wound. A treatment was implemented on 09/28/23 to cleanse the left knee with normal saline, apply zinc and cover with an island dressing daily. Additionally, a treatment was implemented on 09/28/23 to cleanse the right knee with normal saline, apply hydrogel and cover with an island dressing.
Review of Resident #92's medical record revealed no documented evidence a treatment for the pressure ulcers to the left and right knee was implemented when identified on 09/25/23. Further review of the medical record revealed a treatment for the pressure ulcers to the left and right knee were not implemented until 09/28/23.
Interview on 10/16/23 at 10:51 A.M., with the Director of Nursing (DON) verified a comprehensive weekly wound assessments was not completed for Resident #92 during the week of 09/11/23. Additionally, the DON verified the nursing admit/readmit assessment did not include a description of Resident #92's wounds and the wound assessment on 09/18/23 as well as the wound assessments for the right and left knee wounds on 09/25/23 and 09/28/23 did not include a description of the wounds. The DON also verified Resident #92's left and right knee pressure ulcers were identified on 09/25/23 but a treatment was not initiated until 09/28/23.
2. Review of the medical record for Resident #48 revealed an initial admission date of 03/02/23 with diagnoses including but not limited to ESRD, depression, diabetes mellitus, atrial fibrillation, cardiac pacemaker, dependence on dialysis, ileostomy status, hyperlipidemia, and chronic sinusitis.
Review of Resident #48's plan of care, dated 03/03/23, revealed Resident #48 had a pressure ulcer or potential for pressure ulcer development. Interventions included administer medications as ordered, administer treatments as ordered, follow facility policy/protocols for prevention/treatment of skin breakdown, monitor for signs/symptoms of infection, monitor nutritional status, serve diet as ordered, monitor intake and record, monitor/document/report as needed any changes in skin status (appearance, color, wound healing, signs/symptoms of infection, wound size and stage), obtain and monitor lab/diagnostic work as ordered, teach resident/family importance of changing positions for prevention of ulcers, provide required supplement, protein, amino acids, vitamins and minerals as ordered to promote wound healing, treat pain per orders and weekly treatment documentation to include measurement of each area of skin breakdown, width, length, depth, type of tissue and exudate.
Review of the initial weekly wound observation tool dated 03/06/23 revealed Resident #48 was admitted with a stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) pressure ulcer to the sacrum measuring 5.9 cm by 4.2 cm by 4.6 cm. The wound bed was described as 90% granulation and 10% bone. The facility implemented the treatment of Dakins solution, zinc and cover with ABD pad.
Review of Resident #48's quarterly Minimum Data Set (MDS) assessment, dated 07/01/23, revealed Resident #48 had no cognitive behavior. The assessment indicated Resident #48 was at risk for skin breakdown and had one unhealed stage IV pressure ulcer present on admission. The facility implemented a pressure reducing device to bed/chair, pressure ulcer/injury care, application of nonsurgical dressings, applications of ointments/medications other than to feet and application of dressing to feet.
Review of the weekly wound observation tools revealed Resident #48's stage IV pressure ulcer to the sacrum was not assessed on 03/20/23, 05/29/23, 09/11/23 and 09/18/23.
Review of the most recent wound assessment, dated 10/16/23, revealed the stage IV pressure ulcer to the sacrum measured 5.4 cm by 3.8 cm by 2.4 cm. The wound was described as 70% granulation tissue and 30% intervening skin. The wound was determined to have improved and was healing.
Interview on 10/17/23 at 12:56 P.M., with the DON verified Resident #48's stage IV pressure ulcer to the sacrum was not assessed on 03/20/23, 05/29/23, 09/11/23 and 09/18/23.
3. Review of the medical record for Resident #93 revealed an initial admission date of 08/15/23 with diagnoses including but not limited to acute and subacute endocarditis, cerebral infarction, congestive heart failure, hypertension, chronic viral hepatitis C, edema, and muscle wasting.
Review of the nursing admit/readmit assessment, dated 08/16/23, revealed Resident #93 was admitted to the facility with multiple pressure areas including one suspected deep tissue injury (SDTI) to the right great toe measuring 3.0 cm by 2.0 cm with no description of the wound, a SDTI to the right heel measuring 3.8 cm by 4.0 cm and described as a blister, a stage III pressure ulcer to the left outer ankle measuring 1.5 cm by 1.5 cm by 0.5 cm with no description of the wound, a stage III pressure ulcer to the middle of the back measuring 6.0 cm by 3.0 cm by 1.0 cm with no description of the wound, a stage IV pressure ulcer to the sacrum measuring 4.0 cm by 4.0 cm by 7.6 cm with no description of the wound and a stage I to the bilateral heels measuring 6.0 cm by 6.0 cm with no description of the wound.
Review of the plan of care, dated 08/16/23, revealed Resident #93 was at risk for skin breakdown related to decreased mobility. Interventions included apply lotion/moisture barrier cream as needed, encourage resident to wear Prevalon boots while in bed for prevention and protection, encourage to float heels as tolerated, house barrier cream with each episode of incontinence, observe skin for redness or open areas, notify nurse, pressure reducing/relieving cushion to wheelchair, pressure reducing/relieving mattress, skin assessment as needed, supplements as ordered, and turn and reposition every two hours as tolerated.
Review of the initial assessment, dated 08/21/23, of the unstageable pressure ulcer to Resident #93's back revealed the wound measured 1.7 cm by 1.7 cm and was described as being 100% slough.
Review of the initial assessment, dated 08/21/23, of the SDTI to Resident #93's right medial heel revealed the wound measured 0.4 cm by 0.5 cm and was described as 100% scabbed.
Review of the resident's comprehensive MDS assessment, dated 08/22/23, revealed the resident had no cognitive impairment. The assessment indicated the resident was at risk for skin breakdown and had three unstageable pressure ulcers that were present on admission to the facility. The facility implemented the interventions of pressure ulcer/injury care and applications of ointment/medications other than to feet.
Review of the plan of care, dated 08/25/23, revealed Resident #93 had a pressure ulcer or potential for pressure ulcer development. Interventions included administer medications as ordered, administer treatments as ordered, follow facility policy/protocols for the prevention/treatment of skin breakdown, if the resident refuses treatment then confer with the resident, interdisciplinary team (IDT) and family to determine why and try alternative methods to gain compliance, monitor nutritional status, serve diet as ordered, monitor intake and record, monitor/document/report as needed any changes in skin status (appearance, color, wound healing, signs/symptoms of infection, wound size and stage), obtain and monitor lab/diagnostic work as ordered, teach resident/family importance of changing positions for prevention of ulcers, provide required supplement, protein, amino acids, vitamins and minerals as ordered to promote wound healing, treat pain per orders and weekly treatment documentation to include measurement of each area of skin breakdown, width, length, depth, type of tissue and exudate.
Review of Resident #93's medical record revealed no documented evidence the resident's pressure ulcers were assessed on 08/28/23.
Review of the weekly wound observation, dated 09/11/23, revealed the unstageable pressure ulcer to Resident #93's back measured 1.5 cm by 1.5 cm and was described as being 100% dry scab.
Interview on 10/17/23 at 12:56 P.M. with the DON verified Resident #93's pressure ulcers were not assessed on 08/28/23 and the assessment of Resident #93's wounds on 08/16/23 did not include a description of all of the wounds.
Review of the facility policy titled Pressure Ulcers/Skin Breakdown,dated 03/2014, revealed the nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure ulcers. In addition the nurse shall describe and document/report the following, full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue, pain assessment, resident's mobility status, current treatment, including support surfaces and all active diagnoses.
This deficiency represents non-compliance investigated under Master Complaint Number OH00147762 and Complaint Numbers OH00147337 and OH00147122.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on closed record review and staff interview, the facility failed to ensure there was a receipt of disposition for narcotic pain medication upon discharge from the facility. This affected one (Re...
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Based on closed record review and staff interview, the facility failed to ensure there was a receipt of disposition for narcotic pain medication upon discharge from the facility. This affected one (Resident #93) out of one resident reviewed for planned discharge. The census was 91.
Findings include:
Review of the closed medical record for Resident #93 revealed an initial admission date of 08/15/23 with diagnoses including acute and subacute endocarditis, cerebral infarction, congestive heart failure, psychoactive substance abuse, hypertension, chronic viral hepatitis C, edema, diarrhea, gastro-esophageal reflux disease, muscle wasting, generalized muscle weakness, depression and pain. Resident #93 was discharged home with her daughter on 09/16/23.
Review of Resident #93's comprehensive Minimum Data Set (MDS) assessment, dated 08/22/23, revealed Resident #93 had no cognitive impairment.
Review of the resident's progress note dated 09/16/23 at 3:45 P.M. revealed the resident was discharged home at 2:30 P.M. The resident was provided discharge instructions and a list of their orders and a supply of medications. The resident signed for her Methadone (narcotic medication).
Review of Resident #93's medical record revealed there was no narcotic count sheet to indicate the disposition of Resident #93's Methadone.
Interview on 10/17/23 at 10:05 A.M., with the Director of Nursing (DON) verified the facility had no disposition records for Resident #93's Methadone.
Aug 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observations and staff interviews, the facility failed to ensure a clean and comfortable living environment. This affected five (#10, #32, #33 and #34) of 85 residents residing in the facilit...
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Based on observations and staff interviews, the facility failed to ensure a clean and comfortable living environment. This affected five (#10, #32, #33 and #34) of 85 residents residing in the facility. The census was 85.
Findings include:
Observation during a tour of the facility, on 08/10/23 from 10:10 A.M. to 10:30 A.M., revealed a strong urine-like odor in the hallway of rooms of Resident #10, #22, #32, #33 and #34. Observation of Resident #32's room confirmed the strong odor emanates from her room.
Observation and interview on 08/10/23 at 12:55 P.M., with Unit Manager #100 confirmed there was a urine odor in the hallway in front of the Resident #10, #32, #33 and #34's rooms.
Observation and interview on 08/10/23 at 4:00 P.M., with Housekeeping Supervisor #104 and Administrator verified the urine odor in the hallway outside of Resident #10, #32, #33 and #34 rooms. The Administrator confirmed the odor emanates from Resident #32's room. The housekeeper Supervisor #104 explained the rooms are cleaned frequently and it is the responsibility of her staff to indicate if a deep cleaning is needed.
Observations on 08/14/23 from 10:15 A.M. to 10:30 A.M. revealed the following:
Resident #22's room was observed to have an area above the entry way on ceiling measuring approximately 10-inch (in) by10 in. area brown with three dime size black substance in the middle. Interview with Housekeeper #110, at the time of the observation, verified the area on the ceiling.
Resident#30's room was observed to have an area, above the room entry way on the ceiling, measuring approximately 14 in. x 14 in. of brown water-stained substance. Interview with Housekeeper #110, at the time of the observation, verified the area on the ceiling.
Resident #32's room was observed to have an area, above the entry on the ceiling, a brown like substances that formed a circle on ceiling with a square like pattern of several black dots. Interview with Housekeeper #106, at the time of the observation, verified the area on the ceiling.
Room B-04 was empty and observed to have an area, above the door on ceiling, measuring two circles approximately 8 in. in diameter, with a brown ring with black like substance around it in clusters. Interview with Housekeeper #106, at the time of the observation, verified the area on the ceiling.
This deficiency represents the noncompliance investigated under Complaint Number OH00145333.
Apr 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
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interviews, and review of facility policy and procedure, the facility failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure appropriate care and treatment to a resident with a new wound. Actual harm occurred to Resident #3 when Resident #3's wound was treated without a physician order, the physician was not notified of the new wound, the wound worsened into a stage three pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed.) and currently an unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar), and the open wound was exposed to possible infections when it was placed on an unsanitary pillow. This affected one (Resident #3) of three residents reviewed for wounds. The facility identified 20 residents with wounds. The facility census was 88.
Findings include:
Review of the medical record for Resident #3 revealed an admission date of 01/06/23. Diagnoses included congestive heart failure, depression, muscle wasting atrophy, pulmonary embolism, and abnormalities of gait and mobility. Review of the quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed Resident #3 had intact cognition and he required extensive assistance of two staff for bed mobility and transfers and he required extensive assistance of one staff for toilet use, personal hygiene, and dressing. Resident #3 was at risk for pressure ulcers, but he had no current pressure issues.
Review of Resident #3's pressure ulcer risk assessment dated [DATE] revealed the resident was at high risk for the development of pressure ulcers.
Review of the care plan dated 01/09/23 revealed Resident #3 had a pressure ulcer and/or potential for pressure ulcer development related to decreased mobility and a left heel wound had resolved with interventions to administer medications and treatments as ordered, follow facility policies/protocols for the prevention/treatment of skin breakdown, monitor/document/report as needed any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size, and stage, and weekly wound documentation to include measurement of each area of skin breakdowns width, length, depth, type of tissue and exudate.
Review of Resident #3's physician orders revealed on 02/28/23, an order to apply zinc to Resident #3's left heel and leave open to air every day. There was also a physician order dated 01/06/23 to encourage and attempt to float heels while in bed every shift.
Review of Resident #3's skin assessment dated [DATE] (and signed/locked on 04/20/23 at 11:24 A.M.) revealed the resident had a reddened area on the left heel measuring 5.0 centimeters (cm) long by 3.0 cm wide with no drainage or odor. There was no change in treatment orders or plan of care and no evidence the physician was notified of the new reddened area from 04/17/23 to 04/19/23.
Review of Resident #3's skin assessment dated [DATE] revealed the resident had a stage three pressure ulcer to the left heel, acquired on 04/17/23. It measured 4.0 cm in length by 3.8 cm wide by 0.1 cm in depth with no odor, 10% slough, a moderate amount of serosanguinous drainage, and the peri wound tissue was macerated. The resident's family and physician were notified, and there was a new order to cleanse with normal saline, pat dry, apply nickel thick medihoney to wound bed then cover with cut to fit calcium alginate, cover with ABD and wrap with kerlix daily.
Review of the nursing note dated 4/20/23 at 11:23 A.M. revealed Resident #3 was noted with a treatment in place to the left lower extremity heel. Upon investigation of the wound, it was found that the nurse assessed the area on 04/17/23 and implemented a treatment (although no new physician order from 04/17/23 to 04/19/23). The nurse also worked yesterday (04/19/23) and placed/changed the treatment. The wound was measured and staged this shift (04/20/23), the physician was notified of the wound and a message was left for the family, but the resident was his own responsible party and was made aware of his updated status. The resident will be seen on wound rounds Monday (04/24/23). The resident's heels were floated upon assessment. The resident was to have feet washed as he refused a shower at this time. Laboratory orders, air mattress, prostat (a high protein supplement), and prevalon boots (protects the heels) were implemented after speaking with the physician.
Review of Resident #3's skin assessment dated [DATE] revealed the resident had an unstageable pressure ulcer to his left heel. The wound had 60% slough, 15% granulation tissue, and 25% intervening skin, it had no odor or signs of infection and the wound measured 5.1 cm by 5.9 cm with an undetermined depth. It stated the Wound CNP was notified on 04/24/23 and she stated the wound was unavoidable. The assessment indicated the slough from the wound was mechanically debrided and she changed the order to pack the wound with medihoney and cover with an ABD pad and wrap with kerlix daily.
Observation and interview on 04/20/23 at 9:29 A.M. with Registered Nurse (RN) #114 revealed Resident #3 had a yellow/green/brown soiled undated kerlix wrapped around his left heel and his heels were slightly elevated with a blue pillow that did not have a pillowcase. RN #114 removed the soiled kerlix and an odor was present on the kerlix. RN #114 rested the resident's open wound on the blue pillow that the resident's soiled dressing had been sitting on. RN #114 stated she knew the dressing was changed by night shift last night though there was no date on the dressing, she stated there was no odor on the wound yesterday, and the order was for it to have zinc and a kerlix dressing.
Observation on 04/20/23 at 9:47 A.M. with Licensed Practical Nurse/Unit Manager (LPN/UM) #115 and RN #117 revealed they were going to complete Resident #3's dressing change. They confirmed the open wound had been lying on the soiled pillow prior to their dressing change. LPN #115 held the resident's left leg up while RN #117 cleansed the area with normal saline and gauze, applied medihoney with calcium alginate, covered it with an ABD pad, and wrapped the area with kerlix. After the dressing change was completed, LPN #115 sat the residents' newly covered/dressed heel on the soiled pillow, she then obtained a cleaning solution and wiped the pillow clean, applied a pillowcase to the pillow, and elevated the resident's heels from the bed.
Interview on 04/20/23 at 12:30 P.M. with RN #114 confirmed she sat the open wound on the soiled pillow. She also stated on 04/17/23 when she noticed the new wound, it was just red, unopened, non-odorous, and it measured 5.0 cm by 3.0 cm per her assessment. She stated the resident had a wound there previously that had healed, and she thought he was still being seen by the wound care team, and verified she failed to notify the physician about the new red area, and she also failed to notify her colleagues (nurses and aides) that she had found that the resident had a new wound forming.
Interview on 04/20/23 at 10:14 A.M. with the Director of Nursing (DON) revealed on 04/17/23, RN #114 identified that there was a new wound on Resident #3. The DON confirmed she was not notified of the wound, and she found out about it when the surveyor found out about it. She stated she believed Resident #3 had a heel wound that healed on 02/27/23 and on 03/01/23, there was a new order for zinc and open to air as a preventative measure. She confirmed the kerlix was not part of the zinc order. Additionally, at 11:05 A.M., the DON stated she spoke to RN #114 again, she said on 04/17/23 RN #114 found the wound, but she thought the resident was still being seen on wound rounds so she did not tell the physician. She said she put the kerlix on yesterday (04/19/23) because it was now open and starting to have drainage. The DON stated she measured it today as a stage three pressure ulcer.
Interview on 04/24/23 at 9:08 A.M. with Wound Certified Nurse Practitioner (CNP) #130 revealed when she observed Resident #3's wound today (04/24/23), it was an unstageable pressure wound with slough, she debrided it today, and started him on just medihoney. She stated she was here weekly, she comes early on Mondays, but she was not notified of Resident #3's wound from Monday (04/17/23) through today (04/24/23). She revealed the staff notified her about it today (04/24/23). She stated the wound was larger because there was one big open area and one small open area, so she included them both in one measurement. She revealed if slough was present, it was unstageable since you cannot determine the depth, though staging was difficult. She stated nurses can stage if they feel comfortable, and she can educate them on how to stage and they do pretty well, but if it was staged wrong, she will say error in staging and she will document what it really was. Wound CNP #130 stated Resident #3's wound measured 5.1 cm by 5.9 cm with no depth since unstageable, but 30% of that was skin, 15% was granulation tissue, and 55% was slough, there was moderate serous drainage, with no signs or symptoms of infection. She stated her new order was going to be for Medihoney, ABD and kerlix daily.
The subsequent interview on 04/24/23 at 11:46 A.M. with Wound CNP #130 and the DON revealed the CNP stated Resident #3's heel wounds were unavoidable, he digs his heels into the bed, and he will scooch himself down. They stated the resident got an air mattress and has heel boots now. The CNP stated the DON's assessment of the wound on 04/20/23 was accurate, even with the slough present, it was only 10% and you could still see some of the wound bed, so it was a technical stage three pressure ulcer. The CNP stated it was her company's policy to stage anything with slough as unstageable, though now the slough was at 55% today (04/24/23) so it would be unstageable for sure as there was a lot more slough than there was on 04/20/23. The DON stated the resident also may have possible peripheral vascular disease which could contribute to wound deterioration or growth .
Review of the facility policy titled Wound Care, dated October 2010, revealed the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. It stated staff should place a disposable cloth next to the resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. It also stated after the wound is dressed, mark the tape with initials, time, and date, and apply it to the dressing.
Review of the facility policy titled, Prevention of Pressure Ulcers/Injuries, dated July 2017, revealed the residents will have a comprehensive skin assessment upon admission and the skin would be inspected daily when performing care or assisting with personal care or activities of daily living, including identifying signs of developing pressure injuries and inspecting pressure points (including heels). The policy stated staff were to evaluate, report and document potential changes in skin.
This deficiency represents non-compliance investigated under Master Complaint Number OH00142188 and Complaint Number OH00142173.
Mar 2023
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility failed to complete quarterly care conferences for residents....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility failed to complete quarterly care conferences for residents. This affected two (Residents #16 and #18) of two residents reviewed for care plans. The facility census was 87.
Findings include:
1. Review of the medical record for Resident #16 revealed an admission date of 04/12/22. Diagnoses included chronic obstructive pulmonary disease (COPD), schizoaffective disorder, type two diabetes mellitus, depression, mood disorder, and atrial fibrillation.
Review of the Medicare Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 had moderate cognitive impairment evidenced by a Brief Interview for Mental Status (BIMS) score of nine. Resident #16 was assessed to require two-person extensive assistance with transfers, one-person extensive assistance with dressing, toileting, and bathing, and was independent with eating.
Review of the care plan dated 07/20/22 revealed Resident #16 had hemiplegia/hemiparesis. Interventions included to assist with activities of daily living (ADLs), Bowel/bladder program to improve or maintain continence as needed, staff to give medications as ordered, staff to obtain and monitor lab/diagnostic work as ordered, and physical therapy (PT), occupational therapy (OT), and speech therapy (ST) to evaluate and treat as ordered.
Review of the care conferences for 2022 revealed Resident #16 had no documentation of care conferences being completed in 2022.
Interview on 03/15/23 at 11:02 A.M. with Social Services Director #203 revealed she did not have documentation showing Resident #16 received care conferences.
2. Review of the medical record for Resident #18 revealed an admission date of 10/22/20. Diagnoses included type two diabetes mellitus, hypertension, schizoaffective disorder, major depressive disorder, bipolar disorder, and generalized anxiety.
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. This resident was assessed to require two-person extensive assistance with transfers, one-person extensive assistance with dressing, toileting, and bathing, and supervision with eating.
Review of the care plan dated 02/07/23 revealed Resident #18 had hemiplegia/hemiparesis related to history of stroke. Interventions included assist with ADLs as needed. Bowel and bladder program to improve or maintain continence as needed. Give medications as ordered. Obtain and monitor lab/diagnostic work as ordered. PT, OT, and ST evaluate and treat as ordered.
Review of the care conferences for 2022 and 2023 for Resident #18 revealed only two care conferences completed, but no dates were noted to confirm when they were completed.
Interview on 03/15/23 at 11:02 A.M. with Social Services Director #203 revealed she did not have documentation showing Resident #18 received care conferences.
Review of the facility policy titled, Resident Participation - Assessment/Care Plans, dated December 2016 revealed the resident and his or her representative were encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. The resident and his or her legal representative were encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
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, hospital staff interview, and staff interview, the facility failed to ensure...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, hospital staff interview, and staff interview, the facility failed to ensure a resident attended scheduled medical appointments. This affected one (Resident #71) of three residents reviewed for medical appointments. The census was 87.
Findings include:
Resident #71 was admitted to the facility on [DATE]. Diagnoses included venous insufficiency, peripheral vascular disease, lymphedema, type II diabetes, atherosclerosis, cardiomyopathy, atherosclerotic heart disease, hypertension, heart failure, and other psychoactive substance.
Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #71 was cognitively intact.
Review of Resident #71's hospital records dated 05/19/22, revealed the resident was admitted to the facility for therapy and follow-up services related to a right lower leg wound.
Review of Resident #71's progress notes revealed he complained of shortness of breath on 02/13/23, 02/27/23, and 03/07/23. Further review revealed the resident was monitored and ordered various in-facility tests, but he was not sent out to the hospital or any other specialist. Resident #71 had appointments scheduled for vascular surgeon follow up on 06/15/22, 10/12/22, 10/18/22, 11/02/22, 11/08/22, and 12/15/22. He attended appointments on 06/15/22 and 10/18/22, but an appointment that was scheduled for 12/15/22, was to be re-scheduled due to transportation issues.
Review of Resident #71's physician orders and transportation reminders, dated 12/30/22 and 02/08/23, revealed he was to have follow up vascular surgeon appointments, but there was no documentation to support he attended these appointments. Additionally, there was no other documentation to support he was scheduled for or attended any other specialist appointments.
Interview on 03/13/23 at 2:30 P.M. with Resident #71 verified he missed many vascular follow-up and heart doctor appointments. Resident #71 reported appointments were missed due to transportation issues.
Interview on 03/16/23 at approximately 1:00 P.M. with Hospital Staff #700 confirmed Resident #71 had missed many scheduled appointments related to follow-up vascular surgeon care, and newly scheduled heart/cardiac physician appointments related to his shortness of breath. The following appointments were scheduled for his vascular surgeon follow-ups, but he was either a no-show or they were not attended: 06/01/22, 06/08/22, 09/14/22, 12/30/22, 01/04/23, and 02/08/23. Resident #71 had the following cardiac appointments scheduled to determine the cause of his shortness of breath, and they were not attended: 03/06/23, 03/08/23, and 03/13/23. Hospital Staff #700 confirmed Resident #71 attended appointments on 06/15/22 and 10/18/22, with no signs his health was declining, or his right lower leg condition was declining. Hospital Staff #700 reiterated the resident did not attend a vast majority of scheduled appointments to ensure his health remained stable.
Interview on 03/16/23 at 1:30 P.M. with Director of Nursing (DON) confirmed the facility could not provide evidence to support Resident #71 attended the missed appointments.
This deficiency represents non-compliance investigated under Complaint Number OH00141025.
Oct 2019
18 deficiencies
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
Based on review of the medical record and staff interview, the facility failed to notify the physician of high blood glucose results per physician parameters. This affected one (#14) of five residents...
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Based on review of the medical record and staff interview, the facility failed to notify the physician of high blood glucose results per physician parameters. This affected one (#14) of five residents reviewed for unnecessary medications. The facility census was 91.
Findings include:
Review of the medical record for Resident #14 revealed an admission date of 03/23/19 with diagnoses including diabetes mellitus type two.
Review of the physician's orders included an order for Humalog Solution 100 unit/milliliter, inject as per sliding scale. The order stated if blood glucose was 401 or above, give 10 units and notify physician.
Review of the medication administration record (MAR) for 09/2019 revealed on 09/06/19 at 7:30 A.M., the resident's blood glucose was 435, at 11:30 A.M., it was 462, and on 09/10/19 at 11:30 A.M., it was 463. The MAR for 10/2019 revealed on 10/01/19 at 7:00 A.M. blood glucose was 560 and 10/03/19 at 7:00 A.M. was 407.
Review of the progress notes revealed no evidence the physician was notified of the blood glucose levels above 401 per physician's order.
Interview with Licensed Practical Nurse (LPN) Unit Manager #3 on 10/08/19 at 10:53 A.M. confirmed there was no evidence the facility had notified the physician of the high blood glucose levels noted above.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on staff interview, record review and review of facility's self-reported incidents (SRIs), the facility failed to implement its written abuse policies when it did not thoroughly investigate an a...
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Based on staff interview, record review and review of facility's self-reported incidents (SRIs), the facility failed to implement its written abuse policies when it did not thoroughly investigate an allegation of abuse by Resident #139. This affected one (Resident #139) of two residents reviewed for abuse. The facility census was 91.
Findings include:
Record review of Resident #139 revealed an admission date of 09/18/19 with pertinent diagnoses of: major depressive disorder, neuropathy and cerebrovascular disease.
Review of the facility's Self Reported Incident control number 181490, dated 10/03/19, revealed Resident #139 stated a male resident had tried to kiss her and pulled her hair back. The resident stated on a separate occasion the male resident tried to put his hand up her shirt.
Review of the facility's investigation for the abuse allegation on 10/09/19 revealed there was no statement from Resident #139, no statement from the alleged perpetrator, no statement from staff, and a piece of paper signed by the Director of Nursing (DON) stating she interviewed four witnesses from 10/04/19 to 10/08/19 and they denied ever seeing abuse of Resident #139.
Interview with the DON on 10/09/19 at 2:30 P.M. verified this was her complete abuse investigation for Resident #139. The DON verified there was no statement from Resident #139, no statement from the alleged perpetrator, no statement from staff, and a piece of paper signed by the Director of Nursing (DON) stating she interviewed four witnesses from 10/04/19 to 10/08/19 and they denied ever seeing abuse of Resident #139.
Review of the facility's abuse policy and procedure titled abuse, neglect, exploitation, and misappropriation, dated 10/27/17, revealed the person investigating the incident should generally take the following actions: Interview the resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family members); and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident. If there are no direct witnesses, then the interviews may be expanded. For example, to cover all employees on the unit, or, as appropriate, the shift. Obtain a statement from the resident, if possible, the accused, and each witness.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on staff interview and review of facility's self-reported incidents, the facility failed to thoroughly investigate an allegation of abuse by Resident #139. This affected one (Resident #139) of t...
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Based on staff interview and review of facility's self-reported incidents, the facility failed to thoroughly investigate an allegation of abuse by Resident #139. This affected one (Resident #139) of two residents reviewed for abuse. The facility census was 91.
Findings include:
Record review of Resident #139 revealed an admission date of 09/18/19 with pertinent diagnoses of: major depressive disorder, neuropathy and cerebrovascular disease.
Review of the admission Minimum Data Set (MDS) assessment, dated 09/25/19, revealed Resident #139 was cognitively intact. The resident required extensive assistance for bed mobility, transfer, dressing, locomotion on and off unit, and toilet use.
Review of the facility's Self Reported Incident control number 181490, dated 10/03/19, revealed Resident #139 stated a male resident had tried to kiss her and pulled her hair back. The resident stated on a separate occasion the male resident tried to put his hand up her shirt.
Review of the facility's investigation for the abuse allegation on 10/09/19 revealed there was no statement from Resident #139, no statement from the alleged perpetrator, no statement from staff, and a piece of paper signed by the Director of Nursing (DON) stating she interviewed four witnesses from 10/04/19 to 10/08/19 and they denied ever seeing abuse of Resident #139.
Interview with the DON on 10/09/19 at 2:30 P.M. verified this was her complete abuse investigation for Resident #139. The DON verified there was no statement from Resident #139, no statement from the alleged perpetrator, no statement from staff, and a piece of paper signed by the Director of Nursing (DON) stating she interviewed four witnesses from 10/04/19 to 10/08/19 and they denied ever seeing abuse of Resident #139.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
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 complete a Preadmission Screening and Resident Review...
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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 complete a Preadmission Screening and Resident Review (PASARR) for all newly admitted residents. This affected one (Resident #47) of one residents reviewed for PASRR. The census was 91.
Findings Include:
Record review for Resident #47 revealed the resident was admitted to the facility on [DATE]. Diagnoses upon admission included generalized anxiety disorder, bipolar disorder and schizoaffective disorder.
Review of Resident #47's medical records revealed she had the following diagnoses at the time of admission that should be captured on a PASARR application were generalized anxiety disorder, bipolar disorder and schizoaffective disorder. In addition to the diagnoses that should have been captured by a PASARR application, he was deemed a long term care resident, meaning he would be in the facility for more than 30 days. Finally, in review of all medical records, there was no evidence that the PASARR application was completed.
Interview with Regional Director #104 on 10/09/19 at 10:45 A.M. confirmed the facility did not complete the PASARR application for Resident #47 and they should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #46 revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, sensorineural hearing loss, low vision right eye, muscle weakness, nicotine dependence, dementia and dysphagia. Review of his Brief Interview for Mental Status (BIMS) score, dated 07/30/19, revealed he was moderately cognitively impaired.
Review of the progress notes revealed the resident was an active smoker. On 05/14/19, during a care conference, it was determined that he was going to be an unsupervised smoker with the use of a smoking apron.
Review of the resident's care plan revealed there were guidelines for his smoking and how to be safe. The care plan was not updated to reflect the resident should use a smoking apron.
Interview with the Director of Nursing (DON) and Regional Director #104 on 10/09/19 at 9:36 A.M. and 9:40 A.M. confirmed the intervention of a smoking apron was not added as an intervention until 10/07/19 and it should have been added at the time the intervention was put into place on 05/14/19.
Review of the facility policy titled Smoking Policy - Residents, dated December 2016, revealed any smoking-related privileges, restrictions and concerns shall be noted on the care plan.
Based on review of the medical record, review of facility policy and staff interview, the facility failed to develop a care plan for monitoring a resident with a surgical site to the tongue and develop appropriate interventions for a resident determined to be a safety risk with smoking and in need a smoking apron for safety interventions. This affected two (#46 and #189) of 38 residents reviewed for care plans.
Findings include
1. Review of the medical record for Resident #189 revealed an admission date of 09/27/19 with diagnoses to include malignant neoplasm of border of the tongue. The hospital records dated 09/23/19 revealed the resident had a glossectomy prior to admission to the facility and sutures were in place.
Review of the admission assessment, dated 09/27/19, stated the tongue was pink in color. There was no assessment or mention of the glossectomy or sutures. Review of the progress notes and physician's orders revealed no monitoring or further assessment of the tongue/surgical site.
Review of the resident's baseline care plan, dated 09/28/19, revealed it was incomplete and it did not address the resident's recent surgery for glossectomy with sutures in place. The care plan did not address any monitoring or care to be provided regarding the glossectomy.
An interview on 10/07/19 at 1:31 P.M. with the Director of Nursing verified there was no care plan for what the nurses should observe/assess for in care and/or follow up of the tongue surgery.
Review of the facility's policy titled Comprehensive Assessment and Care Delivery Process, dated December 2016, revealed comprehensive assessments, care planning, the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on staff interview and record review, the facility failed to follow a physician order when they did not educate Resident #26 when he refused tube feedings. This affected one (Resident #26) of tw...
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Based on staff interview and record review, the facility failed to follow a physician order when they did not educate Resident #26 when he refused tube feedings. This affected one (Resident #26) of two residents reviewed for tube feeding. The facility identified 10 residents receiving tube feedings. The facility census was 91.
Findings include:
Record review of Resident #26 revealed an admission date of 11/14/15. Diagnoses included chronic obstructive pulmonary disease, alcoholic liver disease, cerebral infarction, gastrostomy, nicotine dependence and epilepsy.
Review of a physician order, dated 07/02/19, revealed the resident may refuse bolus feedings, document refusals with education, make Medical Doctor aware every shift. A physician order, dated 08/27/19, revealed the diet order was nothing by mouth. On 09/13/19, an order for tube feedings Jevity 1.5 (a enteral tube feed formula) give 480 milliliters four times a day for dietary management.
Review of the medication administration record from 08/01/19 to 08/31/19 revealed Resident #26 refused his tube feedings on 08/15/19, 08/16/19, 08/20/19, and three times on 08/29/19. There was no documentation about education or that the medical doctor was aware of the refusals of his tube feeding.
Interview with the Director of Nursing (DON) on 10/09/19 at 2:30 P.M. verified there was no education or medical doctor aware notes completed for Resident #26 when he refused his tube feedings on 08/15/19, 08/16/19, 08/20/19, and on 08/29/19.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, the facility failed to have an adequate nutritional assessment for all residents. This affected one (Resident #54) of two residents reviewed for nut...
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Based on medical record review and staff interview, the facility failed to have an adequate nutritional assessment for all residents. This affected one (Resident #54) of two residents reviewed for nutrition. The facility identified two residents who had unplanned significant weight loss or gain. The facility census was 91.
Findings include:
Review of the medical record for Resident #54 revealed an admission date of 03/22/19 with diagnoses to include bilateral above knee amputations, end stage renal disease with dialysis dependence, protein-calorie malnutrition and type one diabetes mellitus.
Review of the nutrition/weight progress note, dated 07/18/19, revealed current weight was 103 pounds on 07/01/19. This was a 13 pound weight loss and a 11.2% significant weight loss times six months, and it was undesirable, and the weight loss was related to amputations and being in and out of hospital at that time.
Review of the nutrition/weight progress note, dated 10/08/19 at 7:13 P.M., revealed the resident's current weight was 97.4 pounds on 10/08/19 from 09/02/19 to 10/03/19 he lost three pounds and three percent undesirable weight weight loss. The resident's Body Mass Index (BMI) (a measure of body fat in adults) was 15.7.
Interview with Registered Dietician (RD) #200 on 10/09/19 at 12:30 P.M. stated he used the residents actual weight and multiplied it by 25-30 grams/kilogram (gm./kg.) to equal his estimated energy needs. He stated the computer calculates it from his old height of 66 inches. Resident has had both legs amputated and was no longer 66 inches tall. He stated the last amputation was around January of 2019. The RD verified he did not adjust the BMI with the resident's bilateral amputations and verified his progress notes were not accurate due to the amputations. He stated he wanted him to be somewhere in the 20-25 range for BMI but states if he uses his new height it would be a false reading and would be high at around 80. He stated his weight was stable but stated he goes by his actual weight right now and old height. He stated he thinks he was underweight right now which was why he had liberalized his diet two times a week. He stated he didn't know his new height but he bets it was 38 inches, but he didn't use the new height.
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, record review, staff interview and review of the facility's policy, the facility failed to follow physician's orders for nasogastric (NG) tube feeding and confirm placement of th...
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Based on observation, record review, staff interview and review of the facility's policy, the facility failed to follow physician's orders for nasogastric (NG) tube feeding and confirm placement of the tube prior to administration of the enteral feeding. This affected one (Resident #189) of one resident reviewed for tube feeding.
Finding include:
Review of the medical record for Resident #189 revealed an admission date of 09/27/19 and diagnoses to include malignant neoplasm of border of tongue, enterocolitis due to clostridium difficile, tracheostomy status and dependence on renal dialysis.
Review of the physician's orders, dated 10/2019, revealed the orders included to administer Nepro (a tube feed formula) 290 milliliters (ml.) bolus five times a day per the NG tube. Check NG tube placement via air bolus every shift. Administer the free water flush of 20 ml. before and after each bolus feed.
Review of the Medication Administration Record (MAR) revealed the tube feeding, order for 20 ml before and after each bolus feeding five times a day was given incorrectly as the nurses were documenting the resident was receiving only 20 ml. five times a day instead of the 40 ml. that was ordered and also hadn't received the tube feeding on nine occasions so far this month on 10/01/19 at 10:00 A.M., 10/03/19 at 10:00 A.M., 2:00 P.M. and 6:00 P.M., 10/05/19 at 6:00 A.M. and 10:00 A.M., 10/06/19 at 6:00 A.M. , 10/07/19 2:00 P.M., 6:00 P.M. and 10:00 P.M. due to refusal or being out of the facility. There was no evidence the physician was aware of the tube feeding not being given as prescribed or if extra feeding was needed to ensure he was getting enough calories and fluids.
Observation on 10/08/19 at 3:00 P.M. revealed Licensed Practical Nurse (LPN) #79 provided NG tube feeding to Resident #189. The nurse flushed the NG tube via gravity with a 60 milliliter (ml.) syringe with 20 ml. water. She did not check for placement prior to flushing the tube. She was asked by the surveyor about checking placement of the tube prior to administering the water and she confirmed she had not done this and asked the unit manager, LPN #3 to go get her stethoscope. She then checked for placement via air bolus after obtaining her stethoscope but did not check residual. She administered the Nepro 290 ml. via gravity using the 60 ml. syringe. She then flushed the tube with 300 ml. of water per gravity after administration of the Nepro feeding. The surveyor asked LPN #79 if the resident was supposed to get 300 ml. water flush after the tube feeding and she confirmed after looking at the orders, the order was for 20 ml. of water before the feeding and 20 ml. after the feeding and not the 300 ml. she administered. The resident stated they usually flush it with 150 ml. and getting the 300 ml. made his stomach hurt.
Interview with the Director of Nursing on 10/08/19 at 4:00 P.M. revealed sometimes residents have orders they may refuse medications and they would not notify the physician in this case because the physician wouldn't want notified of the refusals. She confirmed the resident did not get his tube feeding on nine occasions and there was no evidence anyone had notified the physician the resident wasn't getting the recommended calories and fluids he needed.
Review of the facility's policy titled Confirming Placement of Feeding Tubes, last revised 03/2015, revealed the purpose of the procedure was to ensure proper placement of the feeing tube to prevent aspiration during feedings. Wash hand and apply clean gloves, observed for a change in the external tube length marked at the time of the initial insertion, observe for change in residual volume. If feeding has been interrupted for a few hours, observe and check the pH of the aspirate (nasogastric, gastric, jejunoostomy tubes). If the above suggests improper tube positioning do not administer feeding or medication, notify the charge nurse or physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, medical record review, resident and staff interview and policy review, the facility failed to ensure Resident #191 was suctioned upon request in a timely manner. In addition, a s...
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Based on observation, medical record review, resident and staff interview and policy review, the facility failed to ensure Resident #191 was suctioned upon request in a timely manner. In addition, a sterile technique wasn't used for tracheostomy care and there wasn't an emergency trach at the bedside for Resident #189. This affected two (#189 and #191) of three residents reviewed for respiratory care. The facility identified six residents who were provided tracheostomy care. The census was 91.
Findings include:
1. Medical record review revealed an admission date of 10/01/19. Diagnoses included quadriplegia and spinal cord injury. Review of the admission Minimum Data Set (MDS) assessment revealed he was moderately cognitively impaired.
Review of the care plan, dated 10/04/19, revealed the resident had a tracheostomy related to impaired breathing mechanics and spinal cord injury. Interventions were to suction as necessary.
Observation and interview with Resident #191 on 10/06/19 at 5:36 P.M. revealed he was lying in bed in no distress, he had his untouched dinner tray in front of him on the bedside table and he stated he didn't want to eat unless he got suctioned, because he was afraid he would choke on his saliva. He stated he had been waiting to be suctioned for about an hour. At 6:01 P.M., no one had come into the room to suction him and Licensed Practical Nurse (LPN) #47 knocked on the door and asked if she could take the dinner tray and walked down the hallway. At 6:15 P.M., the surveyor intervened and went down to the nursing station and spoke with Registered Nurse (RN) #98 and she stated LPN #47 had been sent to the room to suction the resident but was told to come back to the room. The surveyor stated no one sent her away, but she asked for his tray and not to suction him. At 6:20 P.M. the RN said could someone else suction the resident since she had personal problems going on at the time she needed to take care of. She stated LPN #47 would be into the room to suction him. At 6:25 P.M., Resident #191 was finally suctioned with no concerns.
2. Review of the medical record for Resident #189 revealed an admission date of 09/27/19 and diagnoses to include malignant neoplasm of border of tongue, enterocolitis due to clostridium difficile, end stage renal disease, tracheostomy status and dependence on renal dialysis.
Review of the physician's orders for October 2019 revealed an order for tracheostomy care daily, Shiley #6, disposable removed and dispose of inner cannula, place with new inner cannula.
Review of the Treatment Administration Record revealed to complete tracheostomy care daily and as needed. Shiley #6 disposable. Remove and dispose of inner cannula. Replace new inner cannula every day shift. Change tracheostomy ties weekly on Sunday.
Observation on 10/08/19 at 3:00 P.M. of Licensed Practical Nurse (LPN) #79 revealed she washed her hands, opened the tracheostomy kit after placing a towel on the bedside table. She donned the sterile gloves. She opened the tracheostomy ties package that was not sterile with her sterile gloves and placed it into the tray in the kit. She then used her sterile gloves to open three packages of 4 x 4 gauze sponges and put them in the sterile kit. She then moved the tracheostomy ties and gauze pads to a different part of the tray using sterile gloves and removed a basin tray within the kit and placed it on the towel. She didn't change the sterile glove throughout the procedure. She removed the soiled tracheostomy ties with her gloved hands. The unit manager, LPN #3 helped her place the new ties using clean gloves but not sterile gloves. She poured hydrogen peroxide in the tray using sterile gloves and opened many single use normal saline tubes into another tray. She then removed the inner cannula and placed it in the tray with the hydrogen peroxide. She used a brush contained within the kit to clean the inside and outside of the tracheostomy cannula. She placed it into the normal saline to rinse it. She then dried the inside of the cannula with a gauze sponge by pushing it into the cannula. Sterile pipe cleaners were not used. She then replaced the inner cannula without difficulty. The resident tolerated the procedure well. The nurse was asked if there was an emergency tracheostomy tube at the bedside and she looked through everything and stated there was not one available at the bedside. On 10/08/19 at 4:00 P.M., the Director of Nursing confirmed the nurse had not completed the tracheostomy care per the procedure and maintaining sterile field. She also confirmed the nurse cleaned the inner cannula and replaced it when the physician's order was for disposable cannula to be disposed of and a new one used to reduce the risk of infection.
Review of the facility's policy and procedure for Tracheostomy Care, last revised 08/2013, revealed general guidelines, 1. Aseptic technique must be used.: a. during cleaning and sterilization of reusable tracheostomy tubes, b. during all dressing changes until the tracheostomy wound has granulated (healed) and c. during tracheostomy tube changes, either reusable or disposable. 2. Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must be used during aseptic procedure. 4. Tracheostomy tubes should be changes as ordered and as needed (at least monthly). 5. Tracheostomy care should be provided as often as needed, at least once daily for old established tracheotomies and at least every eight hours for residents with unhealed tracheotomies. 6. A replacement tracheostomy tube must be available at the bedside at all times. 7. A suction machine, supply of suction catheter, exam and sterile gloves and flush solutions must be available at the bedside at all times. 1. Open tracheostomy cleaning kit, set up supplies on sterile filed, maintaining sterile field, pour equal parts hydrogen peroxide and normal saline in one compartment of opened kit. Pour normal saline in another compartment. Open four gauze pads and saturate with hydrogen peroxide, open two gauze pads and saturate with antiseptic solution, open two gauze pads and saturate with sterile saline, open two gauze pads and keep dry. Put on sterile gloves, secure the outer neck plate with non-dominant gloved hand, gently remove inner cannula rotating counterclockwise while lifting away from the resident, soak the cannula in hydrogen peroxide saline mixture. Clean with brush, rinse with saline and dry with pipe cleaners. Remove and discard gloves into appropriate receptacle, wash hands and put on fresh gloves. Replace the cannula carefully and lock in place. ensure there is an emergency tracheostomy set up at the resident's bedside. Site and stoma care, apply clean gloves, clean the stoma with two peroxide-soaked gauze pads using a single sweep for each side. Rise the stoma with saline-soaked gauze pads using a single week for each side. Wipe with dry gauze using a single sweep for each side. Disinfect the stoma with the antiseptic-soaked gauze pads using a single sweep for each side, allow to air dry or wipe with clean dry gauze. Remove neck ties and replace with clean ones. Apply fenestrated gauze pad around the insertion site. Remove gloves and discard into appropriate receptacle, wash hands, document procedure, condition of site and resident response.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
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 address pharmacy recommendations and physician respon...
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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 address pharmacy recommendations and physician responses to pharmacy recommendations in a timely manner. This affected one resident ( #88) of five reviewed for unnecessary medications. The facility census was 91.
Findings include:
Medical record review revealed Resident #88 was admitted to the facility on [DATE] with the following diagnoses, schizophrenia, insomnia, mood disorder, bipolar disorder, major depressive disorder and anxiety disorder.
Review of the pharmacy recommendations for February 2019 and April 2019 revealed they could not be located in the medical records.
A pharmacy recommendation made in 08/2019 revealed there was a gradual dose reduction recommendation for Valium two milligrams (mg.) twice daily to one mg. twice daily. The physician agreed with the recommendation and signed the document on 08/22/19. Review of the Medication Administration Record (MAR) and physician orders revealed the implementation of the recommendation to reduce the Valium was not implemented until 08/30/19. The resident received Valium two mg., twice daily from 08/22/19 to 08/30/19 when she should have been receiving Valium one mg., twice daily.
Interview with Regional Director #105 on 10/08/19 at 2:30 P.M. confirmed that when a physician reviews a pharmacy recommendation and decides to write a new order based on that recommendation, the facility was to implement that new order immediately; not eight days later.
Interview with Regional Director #104 and Director of Nursing on 10/09/19 at 9:58 A.M. confirmed they were missing the pharmacy recommendations in February and April 2019 for Resident #88. Also, they confirmed the recommendation in November 2018 was addressed until May 2019
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, the facility failed to provide appropriate follow up for monitoring a resident on sliding scale insulin and parameters set by the physician to notif...
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Based on medical record review and staff interview, the facility failed to provide appropriate follow up for monitoring a resident on sliding scale insulin and parameters set by the physician to notify the physician of high blood glucose levels. This affected one resident (#14) of five reviewed for unnecessary medications. The facility census was 91.
Findings include:
Review of the medical record for Resident #14 revealed an admission date of 03/23/19 with diagnosis of diabetes type 2.
Review of Resident #14's physician's orders included an order for Humalog Solution (insulin) 100 unit/milliliter, inject as per sliding scale. The order revealed if the resident's blood glucose was 401 or above, give 10 units and notify the physician.
Review of Resident #14's Medication Administration Record (MAR) for 09/19 revealed on 09/06/19 at 7:30 A.M. the resident's blood glucose was 435, at 11:30 A.M. it was 462, and on 09/10/19 at 11:30 A.M. it was 463. The MAR for 10/19 revealed on 10/01/19 at 7:00 A.M. the resident's blood glucose was 560 and on 10/03/19 at 7:00 A.M. it was 407.
Review of Resident #14's progress notes revealed no evidence the physician was notified of the blood glucose levels above 401 to receive further guidance from the physician, per physician's order.
Interview with Licensed Practical Nurse (LPN) Unit Manager #3 on 10/08/19 at 10:53 A.M. confirmed there was no evidence the facility had notified the physician of the high blood glucose levels noted above.
Interview with Certified Nurse Practitioner (CNP) #150 on 10/08/19 at 1:20 P.M. revealed he could not remember if had been contacted of Resident #14's blood glucose levels being over 401. However, said if it wasn't documented, it wasn't done.
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** 2. Medical record review for Resident #33 revealed she was admitted to the facility on [DATE] with diagnoses including diabetes ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident #33 revealed she was admitted to the facility on [DATE] with diagnoses including diabetes and Non-Alzheimer's disease.
Review of quarterly Minimum Data Assessment (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired.
Review of physician orders for Resident #33 revealed an order for Seroquel (anti-psychotic) daily on 06/05/19. There was no evidence of any documentation to support the use of the Seroquel. le (AIMS) dated 09/26/19.
Interview with the DON on 10/09/19 at 9:38 A.M. confirmed there was no documentation to justify the use of the Seroquel ordered on 06/05/19. The DON confirmed the only Abnormal Involuntary Movement Scale (AIMS) that had been completed was on 09/26/19, and one should have been completed in June 2019.
Based on medical record review, staff interview, and facility policy review, the facility failed to provide adequate monitoring for the use of psychotropic medications for two residents (#54 and #33) of five reveiwed for unnecessary medications. The facility census was 91.
Findings include:
1. Review of the medical record for Resident #54 revealed an admission date of 03/22/19 with a diagnosis added on 05/16/19 of Schizoaffective Disorder.
Review of a pharmacy recommendation dated 04/11/19 revealed the resident was on Abilify (antipsychotic). The recommendation to the physician revealed to circle and document the approved diagnosis to justify the use of the Abilify. The physician circled Schizoaffective Disorder on 05/16/19. There was no evidence in the medical record prior to the diagnosis being circled, the resident had any documentation/assessment completed regarding the Schizoaffective Disorder.
Interview on 10/08/19 at 4:00 P.M. with the Director of Nursing (DON) confirmed there was no physician assessment of the resident, or notes, and/or documentation of any signs or symptoms or behaviors to justify adding the Schizoaffective Disorder to justify the use of Abilify for Resident #54.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and facility policy review, the facility failed to notify the Office of the Stat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and facility policy review, the facility failed to notify the Office of the State Long-Term Care Ombudsman regarding residents being discharged from the facility. This affected five (Resident 33, #58, #61, #65 and #85) of five residents discharges reviewed. The facility census was 91.
Findings Include:
1. Record review for Resident #58 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hypotension, acute kidney failure, atrial fibrillation and fluid overload.
The medical record revealed the resident was discharged to home on [DATE]. There was no documentation to support the Office of the State Long-Term Care Ombudsman was notified of Resident #58's discharge.
2. Record review for Resident #65 revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified sequelae of cerebral infarction, end stage renal disease, renal osteodystrophy, seizures, specific developmental disorder of motor function, Methicillin resistant staphylococcus aureus, pressure ulcer of the right buttock and left buttock, chronic respiratory failure with hypoxia, unspecified mycosis, chronic respiratory failure, embolism and thrombosis or right axillary vein, tracheostomy status, gastrostomy status, and dependence on renal dialysis.
The medical record revealed he was discharged to the hospital on [DATE]. There was no documentation to support the Office of the State Long-Term Care Ombudsman was notified in a timely manner of Resident #65's discharge.
3. Record review for Resident #85 revealed the resident was admitted to the facility on [DATE]. Diagnoses included persistent vegetative state, sepsis, chronic respiratory failure, atrial fibrillation, front temporal dementia, congestive heart failure, dependence on renal dialysis, tracheostomy status and end stage renal dialysis.
The medical record revealed he was discharged to the hospital on [DATE]. There was no documentation to support the Office of the State Long-Term Care Ombudsman was notified in a timely manner of Resident #85's discharge.
Interview with Business Office Manager (BOM) #13 on 10/08/19 at 3:15 P.M. confirmed they have not sent notifications to the Office of the State Long-Term Care Ombudsman for Resident #58, Resident #65 and Resident #85's facility discharges.
4. Medical record review for Resident #33 revealed an admission date of 04/05/19. Diagnoses included cancer and chronic kidney disease.
The medical record revealed the resident went out to the hospital on [DATE] and returned to the facility on [DATE].
Review of the facility's notice of transfer/discharge form, dated 09/21/19, revealed there wasn't any documentation the form was given to the resident at the time of transfer or the Office of the State Long-Term Care Ombudsman was notified.
Interview with Business Office Manager (BOM) #13 on 10/08/19 at 9:58 A.M. verified the form didn't go with the resident at the time of transfer to the hospital and confirmed the State Ombudsman was not notified for the transfer either.
Review of the facility's undated policy titled Bed-Holds and Returns revealed prior to a transfer, written information will be given to the resident and the details of the transfer.
5. Record review of Resident #61 revealed an admission date of 12/03/18. Diagnoses included congestive heart failure and chronic obstructive pulmonary disease.
The medical record revealed the resident was admitted to the hospital on [DATE].
Review of the facility's notice of transfer and discharge, dated 06/17/19, revealed a sheet stating that the hospital liaison delivered the transfer and discharge paperwork to the resident at the hospital. There was no documented instance of the facility notifying the State Ombudsman of the transfer to the hospital.
Interview with Business Office Worker #13 on 10/08/19 at 10:49 A.M. verified that she did not notify the State Ombudsman when Resident #61 was transferred or discharged to the hospital.
Review of the facility's policy titled Bed Hold and Transfer revealed nothing specific about notifying the Office of the State Long-Term Care Ombudsman for discharges from the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to provide evidence a written b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to provide evidence a written bed hold notification was given to the residents and/or resident representative when they went to the hospital. This affected four (Resident #33, #61, #65 and #85) of four residents reviewed for hospitalizations. The facility census was 91.
Findings include:
1. Record review for Resident #65 revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified sequelae of cerebral infarction, end stage renal disease, renal osteodystrophy, seizures, specific developmental disorder of motor function, Methicillin resistant staphylococcus aureus, pressure ulcer of the right buttock and left buttock, chronic respiratory failure with hypoxia, unspecified mycosis, chronic respiratory failure, embolism and thrombosis or right axillary vein, tracheostomy status, gastrostomy status, and dependence on renal dialysis.
The medical record revealed the resident was discharged to the hospital on [DATE]. There was no documentation to support a written copy of the bed hold policy and procedures was given to the resident and/or their representative.
2. Record review for Resident #85 revealed the resident was admitted to the facility on [DATE]. Diagnoses included persistent vegetative state, sepsis, chronic respiratory failure, atrial fibrillation, front temporal dementia, congestive heart failure, dependence on renal dialysis, tracheostomy status and end stage renal dialysis.
The medical record revealed the resident was discharged to the hospital on [DATE]. There was no documentation to support a written copy of the bed hold policy and procedures was given to the resident and/or their representative.
Interview with Business Office Manager (BOM) #13 on 10/08/19 at 9:58 A.M. confirmed they did not give Resident #65 and Resident #85 written notification of the facility's bed hold policy/procedure at the time of discharge. She also confirmed that if a resident was discharged on the weekend, they do not give the resident/representative written bed hold documentation because she was not in the facility on the weekends.
4. Medical record review for Resident #33 revealed an admission date of 04/05/19. Diagnoses included cancer and chronic kidney disease.
The medical record revealed Resident #33 went out to the hospital on [DATE] and returned to the facility on [DATE].
Review of bed-hold authorization and notification form, dated 09/23/19, revealed there wasn't a signature of the resident/representative being notified in writing of the facility's bed hold policy and procedure. There was an asterisk next to the line and written in, the social worker at the hospital notified the resident of the bed hold authorization and notification.
Interview with Business Office Manager (BOM) #13 on 10/08/19 at 9:58 A.M. verified she didn't work weekends and if the resident went out to the hospital on the weekend, which Resident #33 did, she would notify the social worker at the hospital to have them notify the resident of the bed hold authorization and bed hold notification.
5. Record review of Resident #61 revealed an admission date of 12/03/18 with diagnoses including congestive heart failure and chronic obstructive pulmonary disease.
The medical record for Resident #61 revealed an admission to the hospital on [DATE].
Review of a notice of transfer and discharge form dated 06/17/19 revealed a sheet stating that the hospital liaison delivered the transfer and discharge paperwork to the resident at the hospital.
Interview with Business Office Worker #13 on 10/08/19 at 10:49 A.M. verified that she was unsure if the resident ever got the discharge notice since it was not signed and she did not deliver it.
Review of the facility's policy titled Bed Hold and Transfer revealed prior to transfers or therapeutic leaves, residents or resident representatives will be informed in writing of the bed hold and return policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide a copy of the baseline care plan to the resid...
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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 a copy of the baseline care plan to the resident or representative in a timely manner. This affected four (Resident #47, #189, #191 and #193) of five newly admitted residents reviewed for care plans. The facility census was 91.
Findings include:
1. Record review for Resident #47 revealed the resident was admitted to the facility on [DATE]. Diagnoses included urinary tact infection, muscle weakness, morbid obesity, cerebral infarction, suicidal ideations, bipolar disorder, generalized anxiety disorder, dementia, major depressive disorder, insomnia, legal blindness, hyperlipidemia, other frontotemporal dementia, bradycardia, osteoarthritis, frontal lobe and executive function deficit following cerebral infarction, history of falling, hypertension, and schizoaffective disorder.
Review of the acknowledgement of documents revealed there was no evidence the care plan was shared with the resident and/or resident representative.
Interview with Director of Nursing (DON) on 10/09/19 at 1:45 P.M. confirmed there was no documentation to support the care plan was reviewed and a copy was given to the resident or representative. She confirmed she can not guarantee a copy was given.
2. Medical record review for Resident #193 revealed an admission of 10/01/19. Diagnoses included osteoporosis with current pathological fracture for the left femur with infection.
Review of the admission Minimum Data Set (MDS) assessment, dated 10/08/19, revealed the resident was cognitively intact.
Review of the Acknowledgement of Documents form, dated 10/01/19, for Resident #193 revealed it was silent for a 48-hour baseline care plan being received by the resident.
Interview with the Director of Nursing on 10/08/19 at 11:30 P.M. verified the baseline care plan wasn't given to the the resident.
3. Medical record review for Resident #191 revealed an admission date of 10/01/19. Diagnoses included quadriplegia and spinal cord injury.
Review of the Acknowledgement of Document form, dated 10/01/19, revealed there wasn't a 48-hour baseline care plan provided to the resident and/or resident's representative.
Interview with the Director of Nursing on 10/08/19 at 11:30 P.M. verified the baseline care plan wasn't given to the the resident.
4. Review of the medical record for Resident #189 revealed an admission date of 09/27/19 with diagnoses to include malignant neoplasm of border of tongue, enterocolitis due to clostridium difficile, end stage renal disease, hypertension, opioid dependence, tracheostomy, dependence on renal dialysis and history of malignant neoplasm of bladder.
Review of the physician's orders revealed the resident was on contact isolation for clostridium difficile, required tube feeding via nasogastric tube for nutrition, tracheostomy, Jackson Pratt drain, and a Hemovac to left thigh. The record also indicated the resident has partial glossectomy and had sutures to the tongue in place.
Review of the care plan revealed it was initiated on 09/28/19. There was no evidence the care plan was given to or signed by the resident after admission.
Review of the acknowledgement of document form, dated 09/27/19, revealed there was no evidence the care plan was shared with the resident.
Interview with Licensed Practical Nurse (LPN) #79 on 10/07/19 at 2:53 P.M. confirmed the baseline care plan was not signed by the resident. She stated when they go over the care plan with the resident they have them sign the acknowledgement of documents and she was unable to find any evidence the care plan was given to the resident after admission.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
2. Observation on 10/06/19 at 12:15 P.M. of lunch being provided on the B hall revealed STNA #69 placed a dirty tray left over from breakfast on the lunch cart with trays still needing to be passed. T...
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2. Observation on 10/06/19 at 12:15 P.M. of lunch being provided on the B hall revealed STNA #69 placed a dirty tray left over from breakfast on the lunch cart with trays still needing to be passed. The old breakfast tray was placed directly above a clean lunch tray that still needed to be passed to a resident.
Interview on 10/06/19 at 12:20 P.M. with STNA #69 confirmed the dirty tray from breakfast had been placed back on the tray cart directly above a resident's lunch tray that still needed taken to the resident.
Based on observation, staff interview, and facility policy review, the facility failed to ensure prepared food trays transported on the food cart did not come into contact with dirty food trays. This had the potential to affect one resident (#15) on the B hall. The facility further failed to ensure all food/food items were stored and served safely. This had the potential to affect 85 residents of the facility who received food from the kitchen. The facility identified six residents (#45, #85, #26, #37, #67, and #189) who did not receive food from the kitchen. The facility census was 91.
Findings include:
1. Observation on 10/08/19 at 11:10 A.M. revealed a scoop was laying inside the container of food thickener.
Interview with Dietary Supervisor #57 on 10/08/19 at 11:53 A.M. confirmed the scoop was inside the container of food thickener. He also confirmed it should not have been stored in there.
2. Observation on 10/08/19 from 11:35 A.M. to 11:52 A.M. revealed [NAME] #55 had gloves on. While she had gloves on, she touched the unclean counter top and the food thermometer. She then picked up two chicken breasts from the serving tray to take the temperature. She did not change her gloves prior to touching the chicken. After completing the food temperatures, she took off her gloves and washed her hands. She then started serving trays. With her gloves on, she touched the dirty countertop, the handle of the utensils, the plates, and the plastic wrap that was covering the food on the tray line. She then touched two hamburger buns with the same gloved hand, touched the plastic bag that was holding a turkey sandwich, touched the stove, turned the knob of the stove to ignite the burner which was dirty with caked grease, then she touched the bread of the turkey sandwich to grill it.
Interview with Dietary Supervisor #57 on 10/08/19 at 11:52 A.M. confirmed the above observations. The Dietary Supervisor revealed [NAME] #55 should have washed her hands and changed her gloves.
Review of facility policy titled, Food Receiving and Storage, dated July 2014 revealed nothing in the policy regarding changing of gloves or keeping scoops out of food products.
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
Based on observation, review of Centers for Disease Control (CDC) guidelines, and staff interview, the facility failed to ensure medications were dated properly. This had the potential to affect all 9...
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Based on observation, review of Centers for Disease Control (CDC) guidelines, and staff interview, the facility failed to ensure medications were dated properly. This had the potential to affect all 91 residents who resided in the facility.
Findings include:
Observation of the medication room on the A hall in the refrigerator on 10/08/19 at 2:18 P.M. revealed there were two opened bottles of tuberculin (TB), undated and no expiration date on the label. Also, there was an opened vial of Heparin (blood thinner) not dated of opening and or an expiation date. The vial of Heparin was being stored in a TB box.
Interview with the Unit Manager (UM) #46 on 10/08/19 at 2:20 P.M. verified the TB and Heparin was opened and not dated. She further verified the Heparin was being stored in a TB box.
Review of information from the CDC, dated 03/01/13 revealed the tuberculin label should indicate the expiration date. If it's been opened more than 30 days or the expiration date has passed, the vial should be thrown away and a new vial used. When you open a new vial, write the date and your initials on the label to indicate when the vial was opened and who opened it.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure Personal Protective Equipment (PPE) was used before entering one resident (#193)...
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Based on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure Personal Protective Equipment (PPE) was used before entering one resident (#193) of one reviewed for contact isolation and infection control. The facility census was 91.
Findings include:
Medical record review for Resident #193 revealed an admission of 10/01/19 with diagnoses including osteoporosis with current pathological fracture for the left femur, with infection. The resident was noted to be cognitively intact.
Review of care plan dated 10/06/19 for Resident #193 revealed the resident was on contact isolation for Methicillin Staphylococcus Aureus (MRSA) in the wound. Interventions were to instruct family/visitors/caregivers to wear disposable gown and gloves during physical contact with resident. Discard in appropriate receptacle and wash hands before leaving room.
Observation of State Tested Nursing Aide (STNA) #72 on 10/06/19 at 10:13 A.M. revealed she was in the room with the resident without a gown or gloves on her hands.
Interview with STNA #72 on 10/06/19 at 10:18 A.M. revealed she went in Resident #72's room to provide care and confirmed she was not aware the resident was on contact isolation.
Review of facility policy titled Isolation undated, revealed to implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident's care items in the resident's environment. The policy further revealed to wear gloves upon entering the room and remove before leaving the room. Also wear a disposable gown into the room and remove it upon exiting the room.
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
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), 1 harm violation(s), $205,182 in fines, Payment denial on record. Review inspection reports carefully.
- • 49 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $205,182 in fines. Extremely high, among the most fined facilities in Ohio. Major compliance failures.
- • Grade F (6/100). Below average facility with significant concerns.
Bottom line: Trust Score of 6/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Capital City Gardens Rehabilitation And Nursing Ce's CMS Rating?
CMS assigns CAPITAL CITY GARDENS REHABILITATION AND NURSING CE an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Ohio, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Capital City Gardens Rehabilitation And Nursing Ce Staffed?
CMS rates CAPITAL CITY GARDENS REHABILITATION AND NURSING CE's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 54%, compared to the Ohio average of 46%. RN turnover specifically is 78%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Capital City Gardens Rehabilitation And Nursing Ce?
State health inspectors documented 49 deficiencies at CAPITAL CITY GARDENS REHABILITATION AND NURSING CE during 2019 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 46 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Capital City Gardens Rehabilitation And Nursing Ce?
CAPITAL CITY GARDENS REHABILITATION AND NURSING CE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GARDEN HEALTHCARE GROUP, a chain that manages multiple nursing homes. With 104 certified beds and approximately 89 residents (about 86% occupancy), it is a mid-sized facility located in COLUMBUS, Ohio.
How Does Capital City Gardens Rehabilitation And Nursing Ce Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, CAPITAL CITY GARDENS REHABILITATION AND NURSING CE's overall rating (2 stars) is below the state average of 3.2, staff turnover (54%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Capital City Gardens Rehabilitation And Nursing Ce?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Capital City Gardens Rehabilitation And Nursing Ce Safe?
Based on CMS inspection data, CAPITAL CITY GARDENS REHABILITATION AND NURSING CE has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Ohio. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Capital City Gardens Rehabilitation And Nursing Ce Stick Around?
CAPITAL CITY GARDENS REHABILITATION AND NURSING CE has a staff turnover rate of 54%, which is 8 percentage points above the Ohio average of 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 Capital City Gardens Rehabilitation And Nursing Ce Ever Fined?
CAPITAL CITY GARDENS REHABILITATION AND NURSING CE has been fined $205,182 across 2 penalty actions. This is 5.8x the Ohio average of $35,131. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Capital City Gardens Rehabilitation And Nursing Ce on Any Federal Watch List?
CAPITAL CITY GARDENS REHABILITATION AND NURSING CE 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.