SANCTUARY AT WILMINGTON PLACE
Non profit - Corporation
63 Beds
AMERICAN HEALTH FOUNDATION
Data: November 2025
Trust Grade
40/100
#539 of 913 in OH
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Sanctuary at Wilmington Place has a Trust Grade of D, indicating below-average performance with some concerns about care quality. In terms of state ranking, it sits at #539 out of 913 facilities in Ohio, placing it in the bottom half, and #22 out of 40 in Montgomery County, meaning only a few local options are worse. The situation is worsening, with the number of reported issues increasing from 7 to 9 over the past year. While the facility has good RN coverage, exceeding 89% of Ohio facilities, staffing is a concern due to a high turnover rate of 79%, which is significantly above the state average. Specific incidents include a serious failure to provide necessary treatment for a resident's skin breakdown, leading to hospitalization, and another case where a resident did not receive pain medication despite reporting extreme pain, indicating serious gaps in care. Overall, while some aspects show strength, such as RN coverage and the absence of fines, the facility's significant challenges in staffing and care quality are concerning for families considering it.
- Trust Score
- D
- In Ohio
- #539/913
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 79% turnover. Very high, 31 points above average. Constant new faces learning your loved one's needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Ohio facilities.
- Skilled Nurses ✓ Good
- Each resident gets 53 minutes of Registered Nurse (RN) attention daily — more than average for Ohio. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 40 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Bottom 41%
Needs review
7 → 9 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 9 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
3-Star Overall Rating
Near Ohio average (3.2)
Meets federal standards, typical of most facilities
Staff Turnover: 79%
33pts above Ohio avg (46%)
Frequent staff changes - ask about care continuity
Chain: AMERICAN HEALTH FOUNDATION
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is very high (79%)
31 points above Ohio average of 48%
The Ugly 40 deficiencies on record
2 actual harm
Jun 2025
9 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and policy review, the facility failed to notify a resident's responsible part...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and policy review, the facility failed to notify a resident's responsible party/power of attorney (POA) of health changes. This affected one (#30) of the three residents reviewed for notification. The facility census was 59.
Findings include:
Review of the medical record of Resident #30 revealed an admission date of 04/12/24. Diagnoses included Parkinson's disease, anxiety, hypertension (HTN ), and glaucoma.
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #30 had severely impaired cognition. Resident #30's son was listed as the POA.
Review of a progress note dated 09/23/24 for Resident #30, revealed the resident had a change in condition due to the resident's oxygen saturation being low at 82 percent (%) and was wheezing. The physician was called and ordered for the resident to receive oxygen, a breathing treatment and a chest X-ray. There was no documented evidence of the resident's POA being notified.
Review of a progress notes dated 02/21/25 for Resident #30, revealed the resident was lethargic, and unable to awaken after receiving medications. There was no documented evidence of the resident's POA being notified.
Interview with Registered Nurse (RN) #59 on 05/22/24 at 3:00 P.M., verified there was no notification made to Resident #30's POA when the resident had changes in condition on 09/23/24 and 02/21/25.
Review of the facility policy titled Notification of Change dated 12/2024, revealed family should be notified of changes in physical, mental or psychosocial deterioration of residents.
This deficiency represents non-compliance investigated under Master Complaint Number OH00164992.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and staff interview, the facility failed to ensure an updated Pre-admiss...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and staff interview, the facility failed to ensure an updated Pre-admission Screening and Resident Review (PASARR) was completed. This affected one (#41) of the two residents reviewed for PASARR. The facility census was 59.
Findings include:
Review of the medical record for Resident #41 revealed an admission date of 01/06/23. Diagnoses included Dementia and Schizoaffective disorder bipolar type.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #41 had moderate cognitive impairment as evidenced by a Brief Interview Mental Status (BIMS) of eight.
Review of the medical record for Resident #41, revealed a PASARR was completed on 01/06/23, indicating Resident #41 had no indications of serious mental illness such as Schizophrenia, mood disorders, delusional disorders, panic or other severe anxiety disorders, somatic symptom disorders, personality disorders, or other psychotic disorders.
Further review of the medical record for Resident #41, revealed a diagnosis of schizoaffective disorder bipolar type was added on 11/21/23. There were no documented evidence an updated PASARR was completed.
Interview with Social Service Director (SSD) #70 on 05/29/25 at 3:52 P.M., confirmed the only PASARR Resident #41 had completed was dated for 01/06/23.
Review of the facility policy titled Resident Assessment, Coordination with PASARR Program, dated 12/2024, revealed 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 (ID) authority for a level II resident review.
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, staff interview, and policy review, the facility failed to timely develop and implement fall interventio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to timely develop and implement fall interventions to help reduce and/or eliminate falls. This affected one (#210) of the three residents reviewed for falls. The facility census was 59.
Findings include:
Review of the closed medical record for Resident #210 revealed an admission date of 02/11/25 and a discharge date of 02/16/25. Diagnoses included encephalopathy, altered mental status, Type Two diabetes mellitus (DM II) with hyperglycemia, depression, acute respiratory failure with hypoxia, chronic kidney disease, anemia, peripheral vascular disease, visual hallucinations, congestive heart failure (CHF), chronic atrial fibrillation, and obstructive sleep apnea (OSA).
Review of the admission Assessment initiated on 02/11/25 and completed on 02/16/25, revealed Resident #210 was at risk for falls. The interventions marked were to follow the facility's fall protocol and anticipate the resident's needs.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #210 was cognitively intact. Resident #210 was assessed to require setup assistance for eating and oral hygiene, substantial/maximal assistance with toileting, bathing, dressing, personal hygiene, and bed mobility, and was dependent for transfers.
Review of an Incident Report dated 02/15/25, revealed the nurse heard a loud noise, and Resident #210 was found on the floor between the wall and bed. The resident was assessed and noted to have a skin tear on the left elbow, which was treated, and the resident was assisted back to the bed.
Review of the care plan initiated 02/16/25, revealed Resident #210 was at risk for falls related to other lack of coordination, difficulty walking, morbid obesity, osteomyelitis, and peripheral vascular disease. Interventions included analyze previous resident falls to determine whether a pattern/trend can be addressed, anticipate and meet the resident's needs, ensure the resident's call light is within reach and encourage the resident to use it for assistance as needed, follow the facility's fall protocol, and have commonly used articles within easy reach.
Interview on 06/02/25 at 4:25 P.M. with MDS Coordinator #59, revealed the admission Assessment transfers over to the care plan when completed, and verified there were no fall interventions care planned for Resident #210 until 02/16/25.
Review of the undated facility policy titled Fall Prevention Program revealed the nurse would initiate fall interventions on the resident's baseline care plan.
This deficiency represents non-compliance investigated under Complaint Number OH00162762.
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, observation, staff interview, and policy review, the facility failed to ensure oxygen tubing was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure oxygen tubing was changed as ordered. This affected one (#05) of the two residents reviewed for oxygen therapy. The facility census was 59.
Findings include:
Review of the medical record for Resident #05 revealed an admission date of 02/01/22 with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and a history of pulmonary embolism.
Review of a physician order for Resident #05 dated 10/27/22, revealed the resident was ordered to have oxygen applied continuously at two liters per minute (LPM) via nasal cannula at bedtime. An additional physician order dated 08/17/23, revealed for staff to change the oxygen tubing weekly on Sundays.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #05 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14.
Observation of Resident #05's room on 05/28/25 at 12:31 P.M., revealed an oxygen concentrator next to the bed with oxygen tubing dated 05/11/25. Interview with Resident #05 during the observation, revealed she wears oxygen at bedtime.
Interview on 05/28/25 at 12:36 PM with Certified Nursing Assistant (CNA) #106 verified the date on Resident #05's oxygen tubing being 05/11/25.
Review of the facility policy titled Oxygen Administration, dated 2025, revealed the staff shall perform hand hygiene and apply gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include changing oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
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 policy review, the facility failed to ensure medications wer...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, and policy review, the facility failed to ensure medications were administered by the nurse who prepared the medications. This affected one (#15) of the seven residents investigated for medication administration. This had the potential to affect all twelve Residents (#08, #11, #15, #20, #21, #22, #25, #28, #31, #32, #38, and #47) on 200-hall. The facility census was 59.
Findings include:
Review of the medical record for Resident #15 revealed an admission date of 04/22/25. Diagnoses included chronic obstructive pulmonary disease (COPD), cerebral infarction (stroke) and dementia.
Review of the five-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 had moderate cognitive impairment. Resident was dependent on staff for medications.
Observation of medication administration on 05/27/25 from 5:06 P.M. through 5:09 P.M. with Licensed Practical Nurse (LPN) #53, revealed LPN #53 pulled and prepared medications from the medication cart for Resident #15. LPN #53 handed the medicine cup of medications to LPN #42, who took the medications into the resident's room and administered them to Resident #15.
Interview on 05/27/25 at 5:09 P.M. with LPN #53, verified she pulled and prepared medications for Resident #15 and handed the medications to LPN #42 to administer to the resident. LPN #53 stated the nurse who prepared the medications should be the same one who administered them.
Interview on 05/27/25 at 5:14 P.M. with LPN #42, verified she administered medications to Resident #15 that LPN #53 prepared.
Review of the undated facility policy titled Medication Administration policy, revealed medications are administered by licensed nurses in accordance with standards of practice and then the nurse signs the medication administration record after administration.
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, staff interview, and interview with contracted pharmacy staff, the facility failed to implement ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and interview with contracted pharmacy staff, the facility failed to implement pharmacy recommendations agreed upon by the facility's physician. This affected one (#15) of the five residents reviewed for unnecessary medications. The facility census was 59.
Findings include:
Review of the medical record for Resident #15 revealed an admission date of 04/22/25 with diagnoses of dementia, chronic obstructive pulmonary disease (COPD), cerebral infarction (stroke).
Review of a New admission Review by the contracted pharmacy dated 04/25/25, revealed a recommendation by the pharmacist for the ordered Lidocaine Patch (topical pain medications applied in a patch) as needed (PRN) every twelve hours to be changed to one Lidocaine patch daily. Additional recommendations included discontinuing Oxybutynin (for overactive bladder) and change Xarelto (anticoagulant) to Eliquis (anticoagulant). The physician reviewed the recommendations (undated) and ordered the Lidocaine Patch to be changed to apply one patch daily, discontinue Xarelto and start Eliquis five milligrams (mg) two times daily.
Further review of the medical record for Resident #15, revealed the pharmacy recommendations dated 04/25/25, were never implemented after the facility physician approved the changes.
Review of the five-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 had moderate cognitive impairment. Resident was dependent on staff for medications.
Interview on 05/29/25 at 9:02 A.M. with Minimum Data Set (MDS) Nurse #59, verified the pharmacy recommendations dated 04/25/25 were approved by the physician and the facility never implemented the orders. MDS Nurse #59 stated Resident #15 was receiving Hospice services, and they should have addressed the pharmacy's recommendations.
Interview on 05/29/25 at 11:27 A.M. with the Director of Nursing (DON), verified the facility did not have any documentation related to the 04/25/25 pharmacy recommendations being implement for Resident #15 after they were approved by the facility physician.
Interview on 05/29/25 at 11:33 A.M. with Hospice Registered Nurse (RN) #123 revealed, Hospice was never contacted when the facility's physician approved the pharmacy's recommendations for Xarelto to be changed to Eliquis or Lidocaine patch order to be changed from PRN to daily. RN #123 stated the DON contacted her today to discuss the concern with her and if Hospice had known, they would have contacted the hospice physician and the approval department.
CONCERN
(D)
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 and staff interviews, the facility failed to administer medications per physician orders. This af...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to administer medications per physician orders. This affected one (#15) of the seven residents investigated for medication administration. The facility census was 59.
Findings include:
Review of the medical record for Resident #15 revealed an admission date of 04/22/25 with diagnoses of chronic obstructive pulmonary disease (COPD), cerebral infarction (stroke) and dementia.
Review of the five day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 had moderate cognitive impairment.
Review of the May 2025 Medication Administration Record (MAR) revealed the following:
a) On 05/15/25 at 11:00 A.M., Rivaroxaban 20 mg for Deep Vein Thrombosis (DVT) was not administered due to being out of stock.
b) On 05/23/25 at 10:19 A.M., Rivaroxaban 20 mg was not administered due to being out of stock and the pharmacy was notified.
c) On 05/24/25 at 8:55 A.M., Rivaroxaban 20 mg was not administered due to medication being unavailable and a reorder was sent to the pharmacy.
d) On 05/27/25 at 10:46 A.M., Rivaroxaban 20 mg was not administered due to medication being on order and the pharmacy was notified.
Interview on 05/28/25 at 3:34 P.M. with the Director of Nursing (DON), verified there was no documented evidence Resident #15 received Rivaroxaban on 05/15/25, 05/23/25, 05/24/25, and 05/27/25 and the MAR indicated the medication was not available.
Review of the undated facility policy titled Medication Administration, revealed medications are administered as ordered by the physician and in accordance with standards of practice.
CONCERN
(D)
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, staff interview, record review and policy review, the facility failed to ensure medications were stored pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and policy review, the facility failed to ensure medications were stored properly. This affected one (#30) of the 12 residents who resided on the 400-hall and received medications. The facility census was 59.
Findings include:
Review of medical record for Resident #30 revealed the resident was admitted on [DATE]. Diagnoses included open angle glaucoma, hypertension, Parkinson's Disease, and chronic kidney disease
Review of the May 2025 active physician orders for Resident #30, revealed the resident was ordered Rhopressa Ophthalmic solution (for open angle glaucoma) 0.02 percent (%) one drop instilled in both eyes daily.
Observation of the 400-hall medication cart on 05/29/25 at 08:01 A.M., with Licensed Practical Nurse (LPN) #39, revealed an open container of Rhopressa 0.02 % Ophthalmic Solution for Resident #30 with no open date. Interview with LPN #39 at the same time, verified the container of Rhopressa was opened and undated. Interview with Licensed Practical Nurse (LPN) #39 at the time of the observation, verified the bottle was opened, not dated and should have been dated when it was opened.
Review of online resources from Medsccape.com (https://reference.medscape.com/drug/rhopressa-netarsudil-1000159#11), revealed the an open bottle of Rhopressa could be stored up to six weeks.
Review of facility's policy titled Medication Storage revealed all medications will be stored in the pharmacy and/or medication rooms according to the manufacturer recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of the undated facility form titled Legionella Environmental Assessment Form with Maintenance Supervisor (MS) #58, rev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of the undated facility form titled Legionella Environmental Assessment Form with Maintenance Supervisor (MS) #58, revealed the facility's WMP included monthly chlorine testing and visual inspections for biofilm. The Legionella Assessment form did not include a description or diagram of the facility's water system.
Interview on 06/02/25 at 2:29 P.M. with MS #58, verified there was no description or diagram of the facility's water system. MS #59 stated he had no documentation related to biofilm inspections or chlorine testing because they had not been completed.
Review of the facility's undated Water Management Program revealed the facility would establish a WMP for reducing risk of pathogens in the facility's water systems. The policy indicated a variety of control measures may be used, such as visual inspections and disinfectant level control. The policy also stated testing protocols and control limits would be established, and individuals responsible for testing or conducting visual inspections would record the information.
Review of online resources from CDC, (https://www.cdc.gov/control-legionella/php/healthcare/index.html) dated 03/15/24, revealed healthcare facilities should develop and implement comprehensive WMP to reduce the risk of Legionella growth and transmission. Developing and maintaining a WMP is a multi-step process that requires continuous review. The seven steps to building an effective Legionella water management program are briefly described as the following:
1.
Establish a WMP team
2.
Describe the building water systems
3.
Identify areas where Legionella could grow and spread
4.
Decide where to apply and how to monitor control measures
5.
Establish interventions when control limits aren't met
6.
Make sure the program runs as designed and is effective
7.
Document and communicate all the activities
Based on staff interview, record review, observation and review of the Centers for Medicare and Medicaid Services (CMS) guidance for Enhanced Barrier Precautions (EBPs) in nursing homes, review of online resources from the Centers for Disease Control and Prevention (CDC), and review of the facility's Water Management Plan (WMP), the facility failed to ensure EBPs were utilized during a resident's chronic pressure ulcer dressing change. The facility also failed to ensure the appropriate infection control techniques were performed during a resident's pressure ulcer dressing change. This affected one (#24) of the two residents observed for dressing changes of pressure ulcers. The facility also failed to develop and implement a Water Management Program (WMP) to reduce the risk of Legionella (a type of bacteria which causes Legionnaires' disease and poses a significant risk in nursing homes due to their complex water systems and vulnerable resident populations). This had the potential to affect all residents in the facility. The facility census was 59.
Findings include:
1) Review of the medical record for Resident #24 revealed the resident was admitted on [DATE] with diagnosis including pressure ulcer on sacrum and buttocks, Type II Diabetes Mellitus (DM II), hypertension, heart failure, and anemia.
Review of the May 2025 active physician orders for Resident #24, revealed there were no orders for the resident to be in EBP. The physician orders revealed for the resident to have his pressure ulcer on sacrum and buttocks cleansed twice daily and as needed (PRN) with normal saline, iodine applied, peri-guard barrier applied and covered with an abdominal (ABD) dressing pad.
Interview with Resident #24 on 05/27/25 at 10:37 A.M., revealed he was receiving treatment twice a day and as needed for a pressure ulcer that he was admitted with.
Observation of Resident #24's dressing change on 05/28/25 at 1:26 P.M. with Licensed Practical Nurse (LPN) #54 and LPN #42, revealed no EBP signage or personal protective equipment (PPE) cart outside the resident's room. LPN #54 and LPN #42 announced they were there to conduct a dressing change and entered the resident's room. The dressing change supplies were placed on a rolling bedside table and both nurses washed hands and applied gloves. Resident #24 independently rolled to the left side and LPN #42 removed the resident's pants, incontinent brief, the old dressing, and disposed of the incontinence brief and the old dressing. LPN #42 washed hands and applied new gloves. LPN #54 poured normal saline (NS) into small cup, submerged a cotton wipe and washed from the outside of the wound towards the center of the wound. LPN #42 submerged a second cotton wipe in the NS, and the wound was again cleansed from the outside of the wound towards the center of the wound. LPN#54 then applied iodine to the wound using two gauze four by fours (4x4s). LPN #54 washed hands and applied new gloves, opened an ABD pad and applied peri-guard barrier cream using a tongue depressor. LPN #54 applied the ABD pad to the wound and was assisted by LPN#42 with pulling up Resident#24's incontinent brief and pants. Both LPNs removed and disposed of gloves and washed hands.
Interview with LPN #54 on 05/28/25 at 1:45 P.M., verified Resident #24 had a pressure ulcer to his sacrum and buttocks and the resident should have been in EBP. LPN #54 verified she and LPN #42 didn't follow the EBP guidelines by wearing gowns during the resident's dressing change procedure. LPN #54 also verified she cleansed the pressure ulcer from the outside towards the center instead of from the center towards the outside of the pressure ulcer.
Review of online resources from CDC (https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html) dated 06/28/24, revealed EBPs are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBPs involves at minimum gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical device. EBP expands the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on the use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. EBPs are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Standard Precautions still apply while using EBPs. For example, if splashes and sprays are anticipated during the high-contact care activity, face protection should be used in addition to the gown and gloves. Indwelling medical devices and wounds are risk factors for colonization with a MDRO. Once colonized, these residents can serve as sources of transmission within the facility. The expansion of EBPs for all residents with wounds or indwelling medical devices is intended to protect these high-risk individuals both from acquisition and from serving as a source of transmission if they have already become colonized. Preventing infection by cleaning a wound from the center to the outer edges helps to remove bacteria and debris from the wound and minimize the chance of introducing microorganisms from the surrounding skin back into the wound bed. A moistened gauze pad can be used or other suitable cleaning material, starting at the center of the wound and wiping or dabbing outwards in concentric circles. Discard the used gauze pad or cloth and use a fresh one for each subsequent wipe as you work your way outwards
Review of CMS QSO Memorandum [QSO-24-08-NH] dated 03/20/24, revealed new guidance for Long Term Care (LTC) facilities on the use of EBPs to align with nationally accepted standards. EBP refers to an infection control intervention designed to reduce transmission of MDRO that employs targeted gown and glove use during high contact resident care activities. EBP recommendations now include the use of EBPs for residents with chronic wounds (e.g., pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers) or indwelling medical devices during high-contact resident care activities regardless of their MDRO status.
Dec 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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on medical record review, hospital documentation review, staff interview, and review of a facility policy, the facility failed ensure medications were available to administer as ordered. This af...
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Based on medical record review, hospital documentation review, staff interview, and review of a facility policy, the facility failed ensure medications were available to administer as ordered. This affected one (#13) of three residents received for medication administration. The census was 54.
Findings Included:
Review of Resident #13's medical record revealed an admission date of 12/15/24. Diagnoses included chronic obstructive pulmonary disease, asthma, diabetes mellitus type II, atrial fibrillation, and bipolar disorder.
Review of a hospital discharge document dated 12/15/24 revealed Resident #13 had a medication order for the decongestant guaifenesin 600 mg one tablet every 12 hours.
Review of a physician order dated 12/17/24 revealed Resident #13 was ordered guaifenesin extended release 600 mg one tablet twice daily for cough for seven days.
Review of a nursing progress note dated 12/17/24 by Registered Nurse (RN) #219 revealed Resident #13's guaifenesin 600 mg extended release tablet twice a day for seven days for cough was on order.
Review of Resident #13's December 2024 medication administration record (MAR) revealed the resident received the first dose of guaifenesin on 12/18/24 at 9:00 A.M.
Interview on 12/30/24 at 4:00 P.M. with Assistant Director of Nursing (ADON) #262 verified Resident #13 missed doses of the ordered guaifenesin 600 extended release tablets and did not received the first dose until 12/17/24.
Review of a facility policy titled, Medication Administration, dated 2024, revealed medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.
This deficiency represents non-compliance investigated under Master Complaint Number OH00161089 and Complaint Number OH00160325.
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
Based on medical record review, hospital documentation review, resident and staff interview, review of a photograph of a medication package, review of a contingent medication inventory list, and revie...
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Based on medical record review, hospital documentation review, resident and staff interview, review of a photograph of a medication package, review of a contingent medication inventory list, and review of a facility policy, the facility failed to ensure medications were administered as ordered to prevent significant medication errors. This affected one (#13) of three residents reviewed for medication administration. The facility census was 54.
Findings Included:
Review of Resident #13's medical record revealed an admission date of 12/15/24. Diagnoses included chronic obstructive pulmonary disease, asthma, diabetes mellitus type II, atrial fibrillation, and bipolar disorder.
Review of a hospital discharge document dated 12/15/24 revealed Resident #13 had medication orders for the diuretic furosemide 20 milligrams (mg) by mouth once a day and the steroid Medrol dose package (pack) four (4) mg with instructions to follow the dose pack.
Review of physician orders dated 12/16/24 revealed Resident #13 was ordered Medrol 4 mg two (2) tablets in the morning scheduled for 9:00 A.M., 2 tablets by mouth at 2:00 P.M., 2 tablets by mouth at 6:00 P.M., 2 tablets by mouth at 8:00 P.M., and 2 tablets by mouth at 9:00 P.M. Review of a physician order dated 12/28/24 revealed Resident #13 was ordered Medrol 4 mg once daily until 12/30/24. Review of physician orders dated 12/30/24 revealed Resident #13 was ordered Medrol 4 mg once daily at 3:00 P.M. and 6:00 P.M.
Review of a physician order dated 12/17/24 revealed Resident #13 was ordered furosemide 20 mg daily.
Review of Resident #13's December 2024 medication administration record (MAR) revealed Resident #13's Medrol 4 mg was administered on 12/16/24 at 2:00 P.M., 6:00 P.M., 8:00 P.M., and 9:00 P.M.; on 12/28/24 at 6:00 A.M.; on 12/29/24 at 6:00 A.M.; and on 12/30/24 at 6:00 A.M. and 3:00 P.M. Further review of the December 2024 MAR revealed Resident #13 received furosemide 20 mg on 12/18/24 at 9:00 A.M.
Interview on 12/30/24 at 2:36 P.M. with Resident #13 stated she did not receive her medications for several days after she was admitted to the facility.
Interview on 12/30/24 at 4:00 P.M. with Assistant Director of Nursing (ADON) #262 verified Resident #13 missed doses of furosemide 20 mg and was not administered Medrol 4 mg correctly per physician order. ADON #262 verified furosemide 20 mg was in stock in the facility contingency medication supply and should have been pulled by the nurse.
Review of photograph of a Medrol 4 mg medication pack, supplied by the facility on 12/31/24, revealed on the first day to take 2 tablets before breakfast, one tablet after lunch, and one tablet after supper, and two tablets at bedtime. The pack instructions continued on the second day take one tablet before breakfast, one tablet after lunch, one tablet after supper, and two tablets at bedtime. On the third day, take one tablet before breakfast, one tablet after lunch, one tablet after supper, and one tablet at bedtime. On the fourth day, take one tablet before breakfast, one tablet after lunch, and one tablet at bedtime. On the fifth day, take one tablet before breakfast, and one tablet at bedtime. On the sixth day, take one tablet before breakfast. Further review revealed eight Medrol 4 mg tablets were removed from the pack and 13 tablets remained not administered.
Interview on 12/31/24 at 3:13 P.M. with Administrator confirmed the photograph of the Medrol 4 mg pack was Resident #13's medication that was left and not administered.
Review of facility document titled, Inventory on Hand, dated 12/30/24, revealed 16 furosemide 20 mg tablets were on hand at the facility stock.
Review of the facility policy titled, Medication Administration, dated 2024, revealed medication are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Medications are to be administered as ordered in accordance with manufacturer specifications.
This deficiency represents non-compliance investigated under Master Complaint Number OH00161089 and Complaint Number OH00160325.
Nov 2024
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
Deficiency F0558
(Tag F0558)
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 and resident interview, and policy review, the facility failed to ensure the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff and resident interview, and policy review, the facility failed to ensure the appropriate size brief was provided to the residents who require and prefer a specific size brief. This affected two (#8 and #16) of two residents reviewed for briefs. The facility census was 60.
Findings include:
1. Medical record review for Resident #7 revealed an admission date of 03/20/17. Diagnoses included cerebrovascular attack, coronary artery disease, and morbid obesity.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact. Resident #7 was dependent on staff for toileting and was incontinent for bowel and bladder.
Interview with Resident #7 on 11/21/24 at 3:21 P.M. revealed the nursing aides do not provide her with a brief that fits. She has asked many times for a three x-large (XML) brief and the facility doesn't have them.
Observation of Resident #7 on 11/21/24 at 3:30 P.M. with Certified Nursing Aide (CNA) #169 revealed CNA #169 stated Resident #7 had on a two XL brief and the right side was fastened ok, but the left side you could see her skin exposed through the fasteners.
Interview with CNA #169 on 11/21/24 at 3:35 P.M. verified Resident #7 had on a two XL brief, and Resident #7 required a three XL brief. CNA #169 stated the facility doesn't have any three XL briefs in the facility so she wasn't able to put one on the resident.
During an observation of incontinence care for Resident #7 and staff interviews on 11/24/24 at 6:40 A.M. with CNA #186 and CNA #188 both said the brief that was on the resident was a two XL and the agency worked yesterday and didn't put on a three XL on the resident. CNA #186 stated she searched the closet and there wasn't any three XL briefs, so a two XL was placed on Resident #7. Again the right side of the brief fit the resident, but the left side of the brief, one could see her skin through the fasteners.
Observation of the three supply rooms in the facility on 11/25/24 at 1:45 P.M. with the Dietary Manager (DM) #116 revealed there wasn't any three XL briefs found. DM #116 verified there were no three XL briefs found in the three supply rooms.
2. Medical record review for Resident #16 revealed an admission date of 02/01/22. Diagnoses included peripheral vascular disease, respiratory failure, and renal insufficiency.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was cognitively intact. She was frequently incontinent for bowel and bladder.
Interview with Resident #16 on 11/24/24 at 2:40 P.M. revealed she wore a size three x-large (XL) brief and she wasn't able to get them because the facility runs out of them, and it happens all the time. She said when a two XL brief was placed on her and it makes her raw.
Observation of the three supply rooms in the facility on 11/25/24 at 1:45 P.M. with the Dietary Manager (DM) #116 revealed there wasn't any three XL briefs found. DM #116 verified there were no three XL briefs found in the three supply rooms.
Review of the policy titled Resident Rights dated 2024 revealed the resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents.
This deficiency represents non-compliance investigated under Complaint Number OH00158992.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review the facility failed to ensure a change of condition was repor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review the facility failed to ensure a change of condition was reported to the physician. This affected one (#64) of three residents reviewed for change of condition. The facility census was 60.
Findings include:
Medical record review for Resident #64 revealed an admission date of 08/06/24. Diagnoses included aftercare for a displaced supracondylar fracture with intercondylar extension of lower end of right femur, diabetes mellitus, arthritis, and cerebrovascular accident.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact.
Review of the Physical Therapy (PT) notes dated 08/12/24, 08/16/24, 08/20/24, 08/21/24, and 08/22/24 revealed Resident #64 was bleeding from her surgical incision site to her right lower extremity. These notes were absent for notifying the physician of the bleeding.
Review of the Occupational Therapy (OT) notes dated 08/12/24, 08/22/24, and 08/30/24 revealed Resident #64 was bleeding from her surgical incision site to her right lower extremity. These notes were absent for notifying the physician of the bleeding.
Review of the progress notes from 08/12/24 through 08/30/24 revealed the notes were absent for notifying the physician about the bleeding from her surgical incision site to Resident #64's right lower extremity.
Review of the Wound Nurse Practitioner (NP) #189 notes on 08/21/24 revealed there was no mention of Resident #64's incision site was bleeding.
Interview with NP #189 on 11/26/24 at 9:55 A.M. verified the staff did not notify her there was bleeding from Resident #64's incision site. NP #189 stated she would have notified the surgeon if she knew about the bleeding.
Review of the undated policy titled Notification of Changes revealed the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.
This deficiency represents non-compliance investigated under Complaint Number OH00159578.
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
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure incontinence care...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure incontinence care was provided appropriately and thoroughly. This affected one (Resident #7) of three residents reviewed for incontinence. The facility census was 60.
Findings include:
Medical record review for Resident #7 revealed an admission date of 03/20/17. Diagnoses included cerebrovascular attack, coronary artery disease, and morbid obesity.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact. Resident #7 was dependent on staff for toileting and was incontinent for bowel and bladder.
Interview with Resident #7 on 11/21/24 at 3:21 P.M. revealed the aides do not clean her very good when they provide her with incontinence care.
Observation of incontinence care for Resident #7 on 11/24/24 at 6:40 A.M. with Certified Nursing Aide (CAN) #186 and CNA #188 revealed CNA #186 took a end of the bath towel and wet it and placed soap in the cloth and washed the front of the resident with it and turned the resident over on her side towards CNA #188 and washed the backside of the resident with the bath towel without tuning it over to wash her. While the CNAs were cleaning the resident, she had urinated down the front of her legs and down in between them too. CNA #188 said it was urine running down the resident's legs. STNA #188 took a clean cloth and washed down the front of the resident and didn't wipe her legs.
Interview with CNA #186 on 11/24/24 at 6:50 A.M. verified she had to use the same towel, because she didn't have anything else to wipe the back side of Resident #7 with.
Interview with CNA #188 on 11/24/24 at 6:55 A.M. verified she saw urine running down Resident #7's legs and verified she did not wash Resident #7's legs afterwards.
Review of the undated policy titled Perineal Care revealed it is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown.
Females:
a. Assist resident in bending her knees slightly and spreading her legs.
b. Wet washcloth and apply perineal cleanser. If using prepackaged product, open package and obtain
the wet cloth.
c. Separate the resident's labia with one hand, and cleanse perineum with the other hand by wiping
in direction from front to back (from pubic area toward anus).
d. Repeat on opposite side using separate section of washcloth or new disposable wipe.
e. Clean urethral meatus and vaginal orifice using clean portion of washcloth or new disposable
wipe with each stroke.
f. Pat dry with towel.
This deficiency represents non-compliance investigated under Complaint Number OH00158992.
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 F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, and policy review, the facility failed to ensure residents were ad...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, and policy review, the facility failed to ensure residents were administered the COVID-19 vaccine when requested. This affected one (#7) of three residents reviewed for vaccines. The facility census was 60.
Findings included:
Medical record review for Resident #7 revealed an admission date of 03/20/17. Diagnoses included cerebrovascular attack, coronary artery disease, and morbid obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact.
Review of the vaccine consent form dated 11/05/24 revealed Resident #7 had read the above information concerning risks for vaccines and had an opportunity to ask questions. The form was checked mark the resident requested to have two COVID-19 vaccines administered.
Review of the progress notes and the Medication Administration Record (MAR) from 11/05/24 through 11/25/24 revealed no evidence the COVID-19 vaccines were administered to Resident #7.
Interview with Resident #7 on 11/21/24 at 3:21 P.M. stated she had been asking for the COVID-19 vaccines since September 2024 and has not received them yet.
Interview with Assistant Director of Nursing (ADON) #141 on 11/25/24 at 2:00 P.M. confirmed Resident #7 did not receive her COVID-19 vaccines.
Review of the policy titled COVID-19 Vaccination dated 2024 revealed it is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complication from COVID-19 (SAR'S-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine.
This deficiency represents non-compliance investigated under Complaint Number OH00158992.
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
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 and resident and staff interviews, the facility failed to ensure residents were assisted with arr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and resident and staff interviews, the facility failed to ensure residents were assisted with arranging transportation to physician appointments. This affected one (#52) of three residents reviewed for appointments. The censes was 57.
Findings include:
Review of Resident #52's medical record revealed an admission dated of 12/27/23. Diagnoses listed include type two diabetes mellitus, chronic obstructive pulmonary disease, chronic viral hepatitis, hypertension, and osteoarthritis of the hip.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of a possible 15.
Review of physician orders revealed an order dated 12/28/23 for schedule an appointment with ortho (orthopedic physician). An order dated 01/19/24 was for schedule a follow-up with cardiologist (heart physician).
Review of progress notes and transportation information revealed Resident #52 had yet to be seen by an orthopedic physician or cardiologist.
A orthopedic appointment was first scheduled for on 02/24/24 for 02/28/24. Further record review revealed there was no documented reason for Resident #52 missing the appointment on 02/28/24. Resident #52 then missed orthopedic appointments on 03/11/24, 03/14/24, and 04/01/24 due to transportation related issues. An appointment for a cardiologist was first scheduled on 04/10/24 for 04/16/24. Record review revealed there was no documented reason for Resident #52 missing the appointment on 04/16/24.
Interview with Resident #52 on 04/24/24 at 10:18 A.M. revealed he had yet to go to an orthopedic physician or cardiologist appointment while at the facility.
Interview with the Director of Nursing (DON) on 04/24/24 at 8:30 A.M. confirmed there was delay in scheduling Resident #52's orthopedic and cardiologist appointments. The DON stated that Resident #52 was not able to to transported to the 04/01/24 orthopedic and 04/16/24 cardiologist appointments due to a change in payor source that was not caught before the scheduled appointment dates. The DON that facility staff were responsible for contacting transportation companies and providing correct payor source information.
This deficiency represents non-compliance investigated under Complaint Number OH00152779.
Nov 2023
3 deficiencies
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
Deficiency F0687
(Tag F0687)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff, resident, and Certified Nurse Practitioner (CNP) #19 interviews and policy review, the fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff, resident, and Certified Nurse Practitioner (CNP) #19 interviews and policy review, the facility failed to appropriately assessment and implement a physician ordered treatment for a residents newly identified skin breakdown on the residents toes on the left foot. This resulted in Actual Harm when Resident #22's newly identified open areas on the resident's left toes were not assessed, and a physician ordered treatment was not implemented subsequently resulting in worsening of the area and hospitalization. This affected one (#22) of three residents reviewed for skin breakdown. Facility census was 53.
Findings include:
Review of medical record for Resident #22 revealed an admission date of 05/21/23 and was recently readmitted on [DATE]. Diagnoses include prostate cancer, dementia, peripheral vascular disease, depression, anxiety, contact and expected exposure to other hazardous substances (agent orange), lower extremity venous insufficiency with recurrent ulceration, and non-pressure chronic ulcer of right lower leg and left lower leg.
Review of Resident #22's care plan dated 06/08/23 revealed the resident at risk for alterations in skin integrity related to requiring assistance with personal care, peripheral vascular disease, dementia, Alzheimer's disease, incontinence, morbid obesity, osteoarthritis and prostate cancer. The care plan instructed staff to provide skin care as needed.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had a Brief Interview Mental Status (BIMS) score of 11 out of 15 indicating impaired cognition. Resident #22 required set up for eating, maximum assistance for toileting, lying to sitting and dependent for transfers.
Review of Resident #22's progress notes revealed a late entry for 10/04/23 which was created on 10/10/23 at 7:53 A.M. by the Director of Nursing (DON) documented Resident #22's toes on his left foot were open and bleeding. The physician was notified and a treatment order to cleanse with normal saline, pat dry, apply collagen sheet and cover with bordered super absorbent dressing was obtained. The note did not identify which toes were affected on Resident #22's left foot and no further assessment/measurements were documented.
Review of Resident #22's physician orders to cleanse the second and third toes on left foot with normal saline, pat dry and apply collagen sheet, and cover with super absorbent dressing was ordered on 10/05/23 and was created and discontinued on 10/10/23. Further review of the October 2023 Treatment Administration Record (TAR) revealed there was no order to cleanse the second and third toes on left foot with normal saline, pat dry and apply collagen sheet, and cover with super absorbent dressing.
Review of the Wound Clinic Notes dated 10/09/23 revealed Resident #22 presented to his appointment for chronic bilateral foot wounds, the clinic documented there were new wounds to the second and third toes with exposed bone.
Review of the hospital notes for Resident #22 revealed he was referred from the wound clinic with new left foot wounds to the second and third digit with exposed bone and a concern for osteomyelitis.
Review of Resident #22's hospital note dated 10/11/23 revealed an Magnetic Resonance Imaging (MRI) was completed and the the findings were suggestive of osteomyelitis involving the second proximal and middle phalanges as well as the third middle and distal phalanges. No definite abscess.
Review of Resident #22's a surgical note dated 10/12/23 documented surgical amputation of the left foot second and third digit. Resident #22 was readmitted to the facility following the hospitalization on 10/20/23.
Interview on 11/14/22 at 10:53 A.M. with Resident #22 revealed he had seen an outside physician for the care of his foot wounds due to poor circulation of the lower extremities. Resident #22 was unable to recall how long he had the wounds to his lower extremities and left foot, but did share he had two toes on the left foot removed the month prior.
Observation on 11/14/23 at 4:05 P.M. of Resident #22's dressing change by Registered Nurse (RN) #12 revealed the dressing dated 11/14/23 was removed from Resident #22's left foot. Further observations revealed Resident #22 had amputations on the left second and third digits and there were no signs of infection noted.
Interview on 11/15/23 at 2:53 P.M. with the DON revealed Resident #22 had been admitted to the facility with chronic bilateral ulcers for which he received treatment from a wound clinic. The DON verified Resident #22 had new wounds observed on 10/04/23 and the physician was notified of the new areas; however, the treatment order was not implemented. The DON confirmed there were no measurements or further assessment documented of Resident #22's left toes on 10/04/23 through 10/09/23. The DON confirmed Resident #22 went to the wound clinic on 10/09/23 and was subsequently hospitalized due to worsening of the left toe areas.
Interview on 11/15/23 at 3:42 P.M. with CNP #19 revealed she did assess Resident #22 at the facility on 10/05/23 and denied anyone from the facility informing her on the day of visit a concern with the resident toes to the left foot. CNP #19 further stated Resident #22 was seen by an outside physician for wound care related to ongoing issues with wounds to the lower extremities, and she generally only checked to ensure the dressing appeared dry and intact.
Review of an undated facility policy revealed the effectiveness of treatments will be monitored through ongoing assessment of the wound.
This deficiency represents non-compliance investigated under Complaint Number OH00147600.
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
Report Alleged Abuse
(Tag F0609)
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 self-reported incidents (SRI's), staff interviews and policy review, the facility fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility self-reported incidents (SRI's), staff interviews and policy review, the facility failed to timely report an allegation involving misappropriation of resident's medications to the Ohio Department of Health as required. This affected one (#18) out of three residents reviewed for misappropriation. Facility census was 53.
Findings include:
Review of medical record for Resident #18 revealed admission date of 09/13/23. Diagnoses include wedge compression fracture, hypertension and depression.
The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 had impaired cognition. He required partial assistance for eating and substantial assistance for bed mobility, transfers and toileting.
Review of Resident #18's physician orders revealed an order for Oxycodone (narcotic for pain) five milligram (mg) capsule every six hours as needed for pain with a start date of 09/13/23. Further review of the controlled substance record sign out sheet from 09/27/23 through 10/16/23 revealed Licensed Practical Nurse (LPN) #16 signed for Resident #18's Oxycodone a total of 34 times and wasted the medication with another nurse 11 times.
Review of facility SRI's revealed there was no SRI regarding an allegation involving potential misappropriation of medications involving Resident #18 or LPN #16.
Interviews on 11/16/23 with the Director of Nursing (DON) revealed it had been brought to her attention by Registered Nurse (RN) #12 and LPN #18 that they felt LPN #16 was wasting a lot of narcotic medications specifically for Resident #18 and there was the possibility of misappropriation of narcotics. The DON stated she reviewed the narcotic sheets on LPN #16's assignment for items of suspicion and noted there were several incidents of medications being wasted by LPN #16, but the second nurse present during the medication wasting varied. The DON shared she contacted the Corporate DON and the facility pharmacy to review the narcotic log documentation. The DON stated LPN #16 was interviewed and denied misappropriation of medication. LPN #16 was given a urine drug screen at the facility on 10/18/23 which was negative. The DON verified a SRI for potential misappropriation of medication was not done.
Review of a facility's undated Abuse Policy revealed misappropriation of resident property, means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facility process for reporting/response to allegations of abuse includes, but not limited to: immediately reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframe's.
This deficiency is based on incidental findings discovered during the course of this complaint investigation.
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 medical record review, observations and resident and staff interviews, the facility failed to ensure residents received...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and resident and staff interviews, the facility failed to ensure residents received timely incontinence care. This affected one (#22) of three residents reviewed for incontinence care. Facility census was 53.
Findings include:
Review of medical record for Resident #22 revealed admission date of 05/21/23. Diagnoses include prostate cancer, dementia, peripheral vascular disease, depression, anxiety, contact and expected exposure to other hazardous substances (agent orange), non-pressure chronic ulcer of right lower leg and left lower leg. The resident remains in the facility.
The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #22 had a Brief Interview Mental Status (BIMS) score of 11 out of 15 indicating impaired cognition. He required set up for eating, maximum assistance for toileting, lying to sitting and dependent for transfers.
Review of Resident #22's care plan for alteration in elimination was last revised on 07/26/23 with an intervention to provide incontinence care as needed.
Observation of incontinence care on 11/13/23 at 11:30 A.M. by State Tested Nursing Assistant (STNA) #11 for Resident #22 revealed the resident was incontinent of both urine and stool. Resident #22 was cleansed with wet soapy towel, and patted dry. Bilateral buttocks and peri were noted to be bright red with an approximate 2.0 centimeter (cm) by (x) 0.65 (cm) apparent open area to the right thigh fold. This was verified with STNA #11. Barrier cream was applied and a new incontinence product was secured. Interview on 11/13/23 with Resident #22 following incontinence care revealed he had not been checked and changed since 6:15 A.M. that morning and this was verified with STNA #22 who shared she usually did rounds prior to breakfast but was unable to that morning.
This deficiency represents non-compliance investigated under Complaint Number OH00147600.
Dec 2022
14 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #15's medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #15's medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including but not limited to chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, nontraumatic subarachnoid hemorrhage from unspecified intracranial artery, and atherosclerotic heart disease of native coronary artery without angina pectoris.
Review of Resident #15's significant change MDS assessment, dated 10/05/22, revealed Resident #15 was cognitively intact.
Review of Resident #15's code status care plan, dated 10/31/22, revealed Resident #15 was a Do Not Resuscitate Comfort Care Arrest (DNRCCA). Interventions included code status orders reviewed as needed, offer religious services per advanced care planning preferences, and review advanced care planning wishes upon admission, quarterly and as needed.
Review of Resident #15's code status in the paper chart on 12/18/22, revealed Resident #15 was a DNRCC. Further review of the code status form revealed Resident #15's code status form was faxed to the facility from the physician's office on 10/13/22.
Review of Resident #15's electronic orders on 12/18/22 revealed Resident #15 had an order to be a DNRCCA from 10/18/22 to 12/18/22 in the electronic record.
Interview with Corporate Registered Nurse (CRN) #81 on 12/21/22 at 8:43 A.M. verified Resident #15's DNRCCA code status was not accurate in the electronic chart from 10/18/22 to 12/18/22.
Based on medical record review and staff interview, the facility failed to ensure resident advanced directives were accurate. This affected two (#4 and #15) out of 24 residents reviewed for advanced directives. The facility census was 58.
Findings include:
1. Review of the medical record for Resident #4 revealed an admission date of 10/19/22 with a diagnoses including but not limited to fracture of shaft of left femur, fracture of shaft of right femur, major depressive disorder, and chronic embolism and thrombosis of unspecified deep veins of right proximal lower extremity.
Review of Resident #4's Minimal Data Set (MDS) assessment, dated 10/23/22, revealed Resident #4 had intact cognition.
Review of Resident #4's care plan, dated 10/27/22, revealed there was a plan in place for advanced care planning needs for resident code status of full code. The interventions included code status and orders reviewed as needed, review advanced care planning wishes upon admission, quarterly and as needed, review and coordinate advanced care planning choices with Resident #4 and/or responsible party.
Review of Resident #4's medical record on 12/18/22 revealed Resident #4's code status in the paper chart was Do Not Resuscitate Comfort Care (DNRCC). Resident #4's electronic medical record indicated Resident #4's code status was full code.
Interview with the Unit Manager #47 on 12/29/22 at 9:04 A.M. confirmed Resident #4's code status in the paper chart and electronic medical record did not match on 12/18/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure residents and/or resident repr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure residents and/or resident representatives were provided Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) when required. This affected two (#33 and #46) out of three residents reviewed for beneficiary notices. The facility census was 58.
Findings include:
1. Review of Resident #33's medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including but not limited to type two diabetes mellitus without complications, unspecified dementia unspecified severity without behavioral disturbance, contracture of muscle of the left lower leg, and contracture of muscle right lower leg.
Review of Resident #33's quarterly Minimum Data Set (MDS) assessment, dated 11/09/22, revealed Resident #33 was severely cognitively impaired.
Review of Resident #33's payer source documentation revealed Resident #33 was on Medicare Part A with a last covered day of 11/09/22. Resident #33's payer source was changed to private pay on 11/10/22.
Review of Resident #33's Notice of Medicare Non Coverage (NOMNC), dated 11/09/22, revealed Resident #33's last covered day of skilled services was on 11/09/22. Resident #33's responsible party was made aware of the NOMNC by phone on 11/07/22 at 1:00 P.M. but the NOMNC was not signed.
Review of Resident #33's chart revealed Resident #33 did not have a SNFABN to inform the resident of the potential liability for a non-covered stay for Resident #33's payer change on 11/10/22.
Interview with Licensed Practical Nurse (LPN) #82 on 12/19/22 at 4:41 P.M. verified Resident #33 and/or Resident #33's responsibly party were not provided a SNF ABN as a result of Resident #33 changing payer sources from Medicare Part A to private pay on 11/10/22, having skilled days remaining, and remaining in the facility.
2. Review of the Resident #46's medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including but not limited to fracture of unspecified part of neck of left femur subsequent encounter for closed fracture with routine healing, Parkinson's disease, and unspecified fracture of head of right femur subsequent encounter for closed fracture with routine healing.
Review of Resident #46's quarterly MDS assessment, dated 11/11/22, revealed Resident #46 was moderately cognitively impaired.
Review of Resident #46's payer source documentation revealed Resident #46 was on Medicare Part A with a last covered day of 10/04/22. Resident #46's payer source was changed to private pay on 10/05/22.
Review of Resident #46's NOMNC, dated 10/04/22, revealed Resident #46's last covered day of skilled services was on 10/04/22. Resident #46's responsible party signed the NOMNC on 09/30/22.
Review of Resident #46's medical record revealed Resident #46 did not have a SNFABN to inform the resident of the potential liability for a non-covered stay for Resident #46's payer change on 10/05/22.
Interview with LPN #82 on 12/19/22 at 4:41 P.M. verified Resident #46 and/or Resident #46's responsibly party were not provided a SNF ABN as a result of Resident #46 changing payer sources from Medicare Part A to private pay on 10/05/22, having skilled days remaining, and remaining in the facility.
Review of the facility's undated Advanced Beneficiary Notices policy revealed the facility shall use a SNF ABN form for part A items and services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, and policy review, the facility failed to provide residents and/or resident rep...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, and policy review, the facility failed to provide residents and/or resident representatives with bed hold notices upon transfer to the hospital. This affected two (#15 and #43) out of six residents reviewed for hospitalizations. The facility census was 58.
Findings include:
1. Review of Resident #15's medical record revealed Resident #15 admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, nontraumatic subarachnoid hemorrhage from unspecified intracranial artery, hypertension, displaced fracture of shaft of right clavicle, atherosclerotic heart disease of native coronary artery without angina pectoris.
Review of Resident #15's significant change Minimum Data Set (MDS) assessment, dated 10/05/22, revealed Resident #15 was cognitively intact.
Review of Resident #15's progress note, dated 09/26/22, revealed Resident #15 was sitting in the front lobby at 10:15 A.M. and was unable to hold her head up and was slow to arouse. Resident #15's blood pressure was 82 over 37. The nurse practitioner was notified, and an order was obtained to send Resident #15 to the emergency room. Resident #15's daughter was notified.
Review of Resident #15's progress note, dated 10/04/22, revealed Resident #15 arrived back at the facility from the hospital.
Review of Resident #15's progress note, dated 10/07/22, revealed Resident #15 was noted with increased lethargy, increased weakness and was unable to stay awake. A new order was obtained to send Resident #15 to the hospital. Resident #15's daughter was notified.
Review of Resident #15's progress note, dated 10/12/22, revealed Resident #15 was readmitted to the facility.
Review of Resident #15's progress note, dated 11/07/22, revealed Resident #15 was sent to the hospital. Resident #15 had a previous fall on 11/06/22 and x-rays showed an acute mildly displaced right distal clavicular fracture. Resident #15 also had a big bruise to the right side of her forehead up to the top of her head. Resident #15 was complaining of right hip pain. Resident #15's daughter was notified, and Resident #15's daughter stated to send Resident #15 to the hospital for treatment.
Review of Resident #15's progress note, dated 11/11/22, revealed Resident #15 was readmitted to the facility.
Review of Resident #15's medical record revealed no evidence a bed hold notice was provided to Resident #15 when Resident #15 was discharged to the hospital on [DATE], 10/07/22, and 11/07/22.
Interview on 12/21/22 at 8:39 A.M. with Corporate Registered Nurse (CRN) #81 verified Resident #15 did not receive a bed hold notice for her admissions to the hospital on [DATE], 10/07/22, and 11/07/22.
2. Review of the Resident #43's medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including heart failure, diverticulosis of large intestine without perforation or abscess without bleeding, type two diabetes mellitus with diabetic polyneuropathy, other specified abdominal hernia with obstruction, peptic ulcer, and hypertension.
Review of Resident #43's quarterly MDS assessment, dated 10/11/22, revealed Resident #43 was cognitively intact.
Review of Resident #43's progress note, dated 10/16/22, revealed Resident #43 was sent to the hospital at 12:10 P.M. due to profuse emesis events consisting of dark vomit.
Review of Resident #43's progress note, dated 10/25/22, revealed Resident #43 was transported back to the facility by ambulance.
Review of Resident #43's progress note, dated 11/01/22, revealed Resident #43 was admitted to the hospital for nausea and vomiting. Resident #43 was still in the emergency department awaiting an open bed.
Review of Resident #43's progress note, dated 11/03/22, revealed Resident #43 was transported to the facility.
Review of Resident #43's medical record revealed no evidence a bed hold notice was provided to Resident #43 when Resident #43 was discharged to the hospital on [DATE] and 11/01/22.
Interview with CRN #81 on 12/19/22 at 12:01 P.M. verified Resident #43 did not receive a bed hold notice for the discharges to the hospital on [DATE] and 11/01/22.
Review of the facility's undated Bed Hold Prior to Transfer policy revealed the facility will provide written information to the resident or representative regarding bed hold policies prior to transferring a resident to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, the facility failed to ensure medications were administered according to physician order. This affected one (#26) out of five residents reviewed for...
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Based on medical record review and staff interview, the facility failed to ensure medications were administered according to physician order. This affected one (#26) out of five residents reviewed for unnecessary medications. The census was 58.
Findings include:
Medical record review for Resident #26 revealed an admission date of 09/30/20. Resident #26's medical diagnoses included respiratory failure, heart failure, hypertension, orthostatic hypotension, and peripheral vascular disease.
Review of Resident #26's physician orders, dated 11/27/22, revealed an order for Midodrine HCl (medication used to treat orthostatic hypotension) oral tablet, give 10 milligram (mg) by mouth every eight hours related to hypotension. Hold if systolic (the first number in a blood pressure reading) blood pressure was above 110.
Review of Resident #26's Medication Administration Record (MAR) from 12/01/22 through 12/21/22 revealed for the 6:00 A.M. dose of Midodrine, Resident #26's blood pressure (BP) on 12/07/22 was 125/75, on 12/08/22 was 119/70, on 12/12/22 was 121/80, on 12/14/22 was 128/45, on 12/15/22 was 115/64, on 12/16/22 was 120/78, and on 12/17/22 was 130/84. The Midodrine HCl was marked as given to Resident #26 on all of these instances.
Review of Resident #26's MAR from 12/01/22 through 12/21/22 revealed for the 2:00 P.M. dose of Midodrine, Resident #26's BP on 12/03/22 was 128/99, on 12/07/22 was 119/70, on 12/08/22 was 114/83, on 12/09/22 was 127/92, on 12/12/22 was 122/82, on 12/13/22 was 123/83, on 12/16/22 was 131/94, and on 12/17/22 was 129/75. The Midodrine HCl was marked as given to Resident #26 on all of these instances.
Review of Resident #26's MAR from 12/01/22 through 12/21/22 revealed for the 10:00 P.M. dose of Midodrine, Resident #26's BP on 12/06/22 was 125/75, on 12/07/22 was 119/70, on 12/11/22 was 121/80, on 12/13/22 was 128/85, on 12/14/22 was 115/64, on 12/15/22 was 120/78, and on 12/16/22 was 130/84. The Midodrine HCl was marked as given to Resident #26 on all of these instances.
Interview with Licensed Practical Nurse (LPN) #55 on 12/21/22 at 12:41 P.M. confirmed she gave Midodrine to Resident #26 on multiple occasions when Resident #26's systolic BP was above 110, because she didn't know the order had changed and had parameters. LPN #55 indicated no one had told her the order changed.
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
Based on medical record review and staff interview, the facility failed to ensure a monthly medication reviews were completed monthly by a licensed pharmacist. This affected two (#26 and #39) of five ...
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Based on medical record review and staff interview, the facility failed to ensure a monthly medication reviews were completed monthly by a licensed pharmacist. This affected two (#26 and #39) of five residents reviewed for unnecessary medications. The census was 58.
Findings include:
1. Medical record review for Resident #26 revealed an admission date of 09/30/20. Medical diagnoses included respiratory failure, heart failure, hypertension, orthostatic hypotension, and peripheral vascular disease.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/21/22, revealed Resident #26 was cognitively intact. Resident #26's required extensive assistance for bed mobility, transfers, toilet use, and supervision for eating.
Review of the monthly pharmacy reviews since 01/01/22 revealed there was no evidence of a monthly pharmacy review having been completed by a licensed pharmacist since June 2022.
Interview with the Minimum Data Set Licensed Practical Nurse (MDSLPN) #82 on 12/21/22 at 1:20 P.M. confirmed Resident #26 did not have a monthly pharmacy review since June 2022.
2. Medical record review for Resident #39 revealed an admission date of 12/26/21. Diagnoses included non-Hodgkin lymphoma, cancer, anemia, heart failure, hypertension, and peripheral vascular disease.
Review of Resident #39's annual MDS assessment, dated 11/19/22, revealed Resident #39 was cognitively intact. Resident #39 required supervision for bed mobility, transfers, eating, and toilet use.
Review of Resident #39's monthly pharmacy reviews since 01/01/22 revealed there was no evidence of a review having been completed by a licensed pharmacist in May 2022, June 2022, and October 2022.
Interview with the MDSLPN #82 on 12/21/22 at 1:20 P.M. confirmed Resident #39 did not have a pharmacy medication review completed in May 2022, June 2022, and October 2022.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident and staff interview, and policy review, the facility failed to ensure a re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident and staff interview, and policy review, the facility failed to ensure a resident with dental issues received routine dental care. This affected one (#43) out of two residents reviewed for dental services. The facility census was 58.
Findings include:
Review of Resident #43's medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including heart failure, diverticulosis of large intestine without perforation or abscess without bleeding, type two diabetes mellitus with diabetic polyneuropathy, unspecified osteoarthritis, cervicalgia, rectal abscess, other specified abdominal hernia with obstruction, peptic ulcer, major depressive disorder, and hypertension.
Review of Resident #43's quarterly Minimum Data Set (MDS) assessment, dated 10/11/22, revealed Resident #43 was cognitively intact. Resident #43 had a broken or loosely fitting full or partial denture that was chipped, cracked, uncleanable, or loose.
Review of Resident #43's dental care plan, dated 09/24/21, revealed Resident #43 had a potential for dental problems due to some missing or broken teeth. Interventions included refer Resident #43 to the dentist as needed and dental consultation or follow up as ordered and as needed.
Review of Resident #43's dental visits from 03/26/21 to 12/19/22 revealed Resident #43 had no dental visits between 03/26/21 and 12/19/22 while at the facility.
Interview with Resident #43 on 12/18/22 at 9:10 A.M. revealed Resident #43 had not seen the dentist at the facility and had multiple missing teeth as well as teeth that needed to be pulled. Resident #43 stated he wanted to pursue getting dentures.
Observation of Resident #43 on 12/18/22 at 9:10 A.M. revealed Resident #43 had multiple missing teeth and teeth that appeared to be broken and brown in color in his mouth.
Interview with Corporate Registered Nurse (CRN) #81 on 12/19/22 at 2:43 P.M. verified Resident #43 had not been seen by the dentist, but a new order was written on 12/19/22 to have Resident #43 seen at the next mobile dental visit.
Review of the facility's Routine Dental Services policy revealed the facility will assist residents in obtaining routine dental care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #15's medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #15's medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including but not limited to chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, nontraumatic subarachnoid hemorrhage from unspecified intracranial artery, and atherosclerotic heart disease of native coronary artery without angina pectoris.
Review of Resident #15's significant change MDS assessment, dated 10/05/22, revealed Resident #15 was cognitively intact.
Review of Resident #15's code status care plan, dated 10/31/22, revealed Resident #15 was a Do Not Resuscitate Comfort Care Arrest (DNRCCA). Interventions included code status orders reviewed as needed, offer religious services per advanced care planning preferences, and review advanced care planning wishes upon admission, quarterly and as needed.
Review of Resident #15's code status in the paper chart on 12/18/22, revealed Resident #15 was a DNRCC. Further review of the code status form revealed Resident #15's code status form was faxed to the facility from the physician's office on 10/13/22.
Review of Resident #15's electronic orders on 12/18/22 revealed Resident #15 had an order to be a DNRCCA from 10/18/22 to 12/18/22 in the electronic record.
Interview with Corporate Registered Nurse (CRN) #81 on 12/21/22 at 3:15 P.M. verified Resident #15's DNRCCA code status was not accurate in Resident #15's care plan.
3. Medical record review for Resident #10 revealed an admission date of 08/03/17. Resident #10's diagnoses included stroke, coronary artery disease, heart failure, diabetes, depression and schizophrenia.
Review of Resident #10's annual MDS assessment, dated 12/05/22, revealed Resident #10 was cognitively intact.
Review of Resident #10's care conferences since 01/01/22 revealed Resident #10 had a care conference on 04/07/22 and 07/14/22. There was no evidence Resident #10 had a care conference since 07/14/22.
Interview with Resident #10 on 12/18/22 at 11:59 A.M. revealed it had been awhile since she had a care conference.
Interview with Social Service Designee (SSD) #49 on 12/19/22 at 10:51 A.M. revealed she started in March 2022 and went out on medical leave in August 2022 and came back in September 2022. SSD #49 stated she left a list of care conferences that needed to be completed. SSD #49 confirmed Resident #10 only had two care conferences completed for 2022 and stated Resident #10 was supposed to have care conferences completed quarterly.
4. Medical record review for Resident #39 revealed an admission date of 12/26/21. Resident #39's medical diagnoses included non-Hodgkin lymphoma, diabetes, and peripheral vascular disease.
Review of Resident #39's annual MDS assessment, dated 11/19/22, revealed Resident #39 was cognitively intact.
Review of Resident #39's care conferences since 01/01/22 revealed Resident #39 had a care conference held on 04/05/22. There was no evidence Resident #39 had a care conference since 04/05/22.
Interview with Resident #39 on 12/18/22 at 11:18 A.M. revealed he doesn't get invited to care conferences.
Interview with SSD #49 on 12/19/22 at 2:00 P.M. verified there was no evidence Resident #39 had a care conference completed since 04/05/22.
Review of policy titled Care-Planning-Resident Participation, undated, revealed the facility supported the resident's right to be informed of and participate in his or her care planning. The facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences and allow them to see the care plan, initially, at routine intervals, and after significant changes. The facility will make an effort to schedule the conference at the best time of the day for the resident or representative.
Based on medical record review, staff and resident interview, and policy review, the facility failed to care plans were revised to reflect accurate advanced directives. This affected two (#4 and #15) out of five residents reviewed for care plan revisions. Additionally, the facility failed to ensure care conference were completed. This affected two (#10 and #39) out of two residents reviewed for care conferences. The facility census was 58.
Findings include:
1. Review of the medical record for Resident #4 revealed an admission date of 10/19/22 with a diagnoses including but not limited to fracture of shaft of left femur, fracture of shaft of right femur, major depressive disorder, and chronic embolism and thrombosis of unspecified deep veins of right proximal lower extremity.
Review of Resident #4's Minimal Data Set (MDS) assessment, dated 10/23/22, revealed Resident #4 had intact cognition.
Review of Resident #4's care plan, dated 10/27/22, revealed there was a plan in place for advanced care planning needs for resident code status of full code. The interventions included code status and orders reviewed as needed, review advanced care planning wishes upon admission, quarterly and as needed, review and coordinate advanced care planning choices with Resident #4 and/or responsible party.
Review of Resident #4's medical record on 12/18/22 revealed Resident #4's code status in the paper chart was Do Not Resuscitate Comfort Care (DNRCC). Resident #4's electronic medical record indicated Resident #4's code status was full code.
Interview with Unit Manager #47 on 12/29/22 at 9:04 A.M. confirmed Resident #4's code status in her care plan was inaccurate and had not been revised.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on review of menu spreadsheets, observation, staff interview, and policy review, the facility failed to ensure residents received meals according to the menu spreadsheet. This affected all 52 re...
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Based on review of menu spreadsheets, observation, staff interview, and policy review, the facility failed to ensure residents received meals according to the menu spreadsheet. This affected all 52 residents residing in the facility who received a regular or mechanical soft diet. The facility identified six residents (#3, #14, #16, #19, #20, and #104) who did not receive a regular or mechanical soft diet. The facility census was 58.
Findings include:
Review of the undated menu spreadsheet revealed regular diets and mechanical soft diets were to receive four ounces (oz) of ham and cheese strata, a slice of toast, and six oz of cold cereal or oatmeal.
Observation of tray line on 12/19/22 at 7:52 A.M. revealed [NAME] #09 was serving regular diets and mechanical soft diets three oz of ham and cheese strata, a slice of toast, and six oz of cold cereal or oatmeal.
Interview with Dietary Manager #05 and [NAME] #09 on 12/19/22 at 8:13 A.M. verified the residents on regular diets and mechanical soft diets were served three oz of ham and cheese strata instead of the four oz of ham and cheese strata that was listed on the menu spreadsheet.
Review of the undated Therapeutic Diet Spreadsheet policy revealed the therapeutic diet spreadsheet shall be available and followed at all meals.
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
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on review of staffing schedule and staff interview, the facility failed to ensure Registered Nurse (RN) services were used for at least eight consecutive hours a day seven days a week. This had ...
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Based on review of staffing schedule and staff interview, the facility failed to ensure Registered Nurse (RN) services were used for at least eight consecutive hours a day seven days a week. This had the potential to affect all 58 residents in the facility. The facility census was 58.
Findings include:
Review of the staffing schedule, dated 12/10/22, revealed no Registered Nurse (RN) was present in the facility on 12/10/22.
Interview with Corporate Registered Nurse (CRN) #81 on 12/20/22 at 10:03 A.M. verified the facility did not have an RN present in the facility for eight consecutive hours on 12/10/22.
This deficiency represents non-compliance investigated under Complaint Number OH00138026.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
Based on review of personnel files and staff interview, the facility failed to complete nurse aide performance reviews at least every 12 months for two State Tested Nurse Aides. This had the potential...
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Based on review of personnel files and staff interview, the facility failed to complete nurse aide performance reviews at least every 12 months for two State Tested Nurse Aides. This had the potential to affect all 58 residents in the facility. The facility census was 58.
Findings include:
Review of State Tested Nurse Aide (STNA) #02's personnel file revealed STNA #02 was hired at the facility on 10/01/19. Further review of STNA #02's personnel file revealed STNA #02 did not have any performance reviews completed from 10/01/21 to 12/21/22.
Review of STNA #14's personnel file revealed STNA #14 was hired at the facility on 05/24/16. Further review of STNA #14's personnel file revealed STNA #14 did not have any performance reviews completed from 05/24/21 to 12/21/22.
Interview on 12/21/22 at 10:50 A.M. with Human Resources (HR) #32 verified STNA #02 and STNA #14 did not have performance reviews completed at least once every 12 months.
Review of the facility's undated Evaluation policy revealed the facility will complete formal written work performance evaluations of employees annually.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, staff interview, and policy review, the facility failed to ensure hair nets were worn appropriately, proper hand hygiene was followed, and food items were maintained in a sanitar...
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Based on observation, staff interview, and policy review, the facility failed to ensure hair nets were worn appropriately, proper hand hygiene was followed, and food items were maintained in a sanitary manner in the kitchen. This had the potential to affect all 58 residents who received meals from the kitchen. The facility census was 58.
Findings include:
1. Observation of the kitchen on 12/18/22 at 8:33 A.M. revealed a gallon zip lock bag of raw chicken which was open to air and dated 12/22/22 sitting on a pan in the walk in refrigerator. The observation further revealed an open undated bag of shredded cheese, an open undated package of American singles, an open undated and unlabeled bag of white substance, and an open undated package of bologna sitting on the shelf in the walk in refrigerator. Further observation of the kitchen revealed an opened undated box of hamburger patties which was open to air and an opened and undated box of tilapia filets in the walk in freezer.
Interview with [NAME] #09 on 12/18/22 at 8:33 A.M. verified there was a gallon zip lock bag of raw chicken which was open to air and dated 12/22/22 sitting on a pan in the walk in refrigerator. [NAME] #09 also verified there was also an open undated bag of shredded cheese, an open undated package of American singles, an open undated and unlabeled bag of white substance which he identified as mashed potatoes, and an open undated package of bologna sitting on the shelf in the walk in refrigerator. The interview further verified an opened undated box of hamburger patties which was open to air and an opened and undated box of tilapa filets in the walk in freezer.
Review of the undated Date Marking for Food Safety policy revealed food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.
Review of the facility's Storage of Potentially Hazardous Foods policy revealed potentially hazardous foods shall be stored in a manner that prevents cross contamination and foodborne illnesses. Food shall be dated and labeled and properly covered or wrapped tightly.
2. Observation of the kitchen on 12/19/22 at 7:45 A.M. revealed Administrative Assistant #34 walked into the kitchen without wearing a hair net. Administrative Assistant #34 did not wash her hands upon entering the kitchen and proceeded to walk across the kitchen while holding onto and touching the preparation table in front of the stove while she was walking towards the ice machine with a personal cup in the other hand.
Interview with Dietary Manager #5 on 12/19/22 at 7:45 A.M. verified Administrative Assistant #34 did not wash her hand and did not have a hair net on, and was in the kitchen holding onto the preparation table in front of the stove.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on review of personnel files, staff interview, and policy review, the facility failed to ensure the facility was administered in a manner to prevent the falsification of documentation. This had ...
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Based on review of personnel files, staff interview, and policy review, the facility failed to ensure the facility was administered in a manner to prevent the falsification of documentation. This had the potential to affect all 58 residents who resided at the facility. The facility census was 58.
Findings include:
Review of the Administrator's personnel file revealed the Administrator was hired at the facility on 08/22/22. Further review of the Administrator's personnel file revealed the Administrator had a physical date of 08/20/22 that had all original ink except for the signature of Nurse Practitioner #83 which was a copied signature and appeared to be a part of the original form.
Review of State Tested Nurse Aide (STNA) #22's personnel file revealed STNA #22 was hired at the facility on 06/01/22. Further review of STNA #22's personnel file revealed STNA #22 had a physical date of 06/02/22 that had all original ink except for the signature of Nurse Practitioner #83 which was a copied signature and appeared to be a part of the original form.
Review of STNA #67's personnel file revealed STNA #67 was hired at the facility on 11/28/22. Further review of STNA #67's personnel file revealed STNA #67 had a physical date of 12/28/22 that had all original ink except for the signature of Nurse Practitioner #83 which was a copied signature and appeared to be a part of the original form. The date on the form had not occurred at the time of the review and was in the future.
Review of Registered Nurse (RN) #25's personnel file revealed RN #25 was hired at the facility on 10/11/22. Further review of RN #25's personnel file revealed RN #25 had a physical date of 10/06/22 that had all original ink except for the signature of Nurse Practitioner #83 which was a copied signature and appeared to be a part of the original form.
Review of the Director of Nursing (DON)'s personnel file revealed the DON was hired at the facility on 07/18/22. Further review of the DON's personnel file revealed the DON had a physical date of 07/14/22 that had all original ink except for the signature of Nurse Practitioner #83 which was a copied signature and appeared to be a part of the original form.
Review of Licensed Social Worker (LSW) #49's personnel file revealed LSW #49 was hired at the facility on 03/24/22. Further review of LSW #49's personnel file revealed LSW #49 had a physical date on 03/24/22 that had all original ink except for the signature of Nurse Practitioner #83 which was a copied signature and appeared to be a part of the original form.
Interview on 12/21/22 at 10:50 A.M. with Human Resources (HR) #32 and the Administrator verified the Administrator, STNA #22, STNA #67, RN #25, the DON, and LSW #49 had physical forms with Nurse Practitioner #83's signature photo copied on the form while the rest of the form was filled out in original ink.
Telephone interview with Nurse Practitioner #83 on 12/21/22 at 12:07 P.M. verified Nurse Practitioner #83 did not conduct physicals on the Administrator, the DON and LSW #49. Nurse Practitioner #83 stated she could not remember staff names but did not think she completed physicals on STNA #22, STNA #67, or RN #25 because she had not completed physicals at the facility in a long time. Nurse Practitioner #83 was not aware her signature was photocopied on a physical form at the facility.
Interview with the DON on 12/21/22 at 12:31 P.M. verified she did not receive a physical upon hire at the facility, but stated she sees her personal physician regularly.
Review of the undated Falsification of Documentation policy revealed the facility will ensure all documentation is timely, accurate, and truthful.
MINOR
(C)
Minor Issue - procedural, no safety impact
Abuse Prevention Policies
(Tag F0607)
Minor procedural issue · This affected most or all residents
Based on review of personnel files, staff interview, and policy review, the facility failed to implement their abuse policy. This had the potential to affect all 58 residents in the facility. The faci...
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Based on review of personnel files, staff interview, and policy review, the facility failed to implement their abuse policy. This had the potential to affect all 58 residents in the facility. The facility census was 58.
Findings include:
Review of State Tested Nurse Aide (STNA) #67's personnel file revealed STNA #67 was hired at the facility on 11/28/22. Further review of STNA #67's personnel file revealed STNA #67 did not have any reference checks completed upon hire.
Review of Registered Nurse (RN) #25's personnel file revealed RN #25 was hired at the facility on 10/11/22. Further review of RN #25's personnel file revealed RN #25 did not have any reference checks completed upon hire.
Review of the Administrator's personnel file revealed the Administrator was hired at the facility on 08/22/22. Further review of the Administrator's personnel file revealed the Administrator did not have any reference checks completed upon hire.
Interview on 12/21/22 at 10:50 A.M. with Human Resources #32 verified STNA #67, RN #25, and the Administrator did not have reference checks completed upon hire as required by the facility's abuse policy.
Review of the facility's undated Abuse policy revealed screening of potential employees will consist of reference checks from previous and current employers.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation and staff interview, the facility failed to ensure the daily nurse staffing information was posted every day. This had the potential to affect all 58 residents in the facility. Th...
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Based on observation and staff interview, the facility failed to ensure the daily nurse staffing information was posted every day. This had the potential to affect all 58 residents in the facility. The facility census was 58.
Findings include:
Observation of the daily nurse staffing information on the receptionist desk on 12/20/22 at 11:27 A.M. revealed the posted daily nurse staffing data was from 12/18/22.
Interview with Administrative Assistant #34 on 12/20/22 at 11:27 A.M. verified the daily nurse staffing data that was posted on 12/20/22 was from 12/18/22.
Nov 2019
7 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interview, the facility failed to provide adequate pain control for a resident aft...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interview, the facility failed to provide adequate pain control for a resident after her admission to the facility. This resulted in actual harm when nursing staff failed to ensure Resident #110 received an as needed (PRN) pain medication when she rated her pain a 10 out of 10 (a scale indicating zero for no pain and ten being the worse pain ever) and when interviewed described it as excruciating pain resulting in crying. This affected one (#110) of six residents reviewed for pain during the annual survey. The facility identified 24 residents on a pain management program. The facility census was 60.
Findings include:
Record review for Resident #110 revealed the resident was admitted to the facility on [DATE]. Diagnoses included non-displaced intertrochanteric fracture of the left femur, chronic kidney disease, muscle weakness and age-related osteoporosis.
Review of the plan of care, dated 11/18/19, revealed the resident was at risk for acute and chronic pain related to her left hip fracture, chronic kidney disease, arthritis, chronic back pain, osteoporosis, and generalized pain. Interventions included to administer medications as ordered, anticipate the resident's needs for pain relief and respond immediately to any compliant of pain and to monitor for potential side effects of medications.
Review of the physician orders, dated 11/18/19, revealed orders for Oxycodone (narcotic pain medication) five milligrams (mg.) every six hours as needed for pain and Oxycodone five mg. every six hours scheduled for seven days.
Review of the progress notes, dated 11/18/19, revealed Resident #110 was admitted to the facility at 2:43 P.M. on 11/18/19.
Review of the Pain admission Assessment, dated 11/18/19 at 2:46 P.M., revealed Resident #110 rated her pain a 10 out of 10 (a scale indicating zero for no pain and ten being worse pain ever).
Review of the Medication Administration Record (MAR), dated 11/2019, revealed Resident #110 received pain medication at 10:10 P.M. on 11/18/19. This was over seven hours after reporting a pain level of 10 to the nurse.
Interview with Resident #110 on 11/26/19 at 2:00 P.M. revealed she doesn't remember much about the evening she arrived at the facility. She revealed she was in excruciating pain and was crying. She stated she had requested pain medication and reported she did not receive any medication that evening.
Interview on 11/26/19 at 1:15 P.M. with Licensed Practical Nurse (LPN) #100 stated it was her understanding that the new admission orders were to be faxed over to the physician and pharmacy so they could be reviewed. LPN #100 stated the physician was normally in the facility and if the physician was not in the facility then it would be faxed both to the physician and the pharmacy to be reviewed. LPN #100 stated the day shift nurse (LPN #99) had not completed the three admissions from her shift and had stated that she would remain in the nursing station before she left. LPN #100 stated she had been walking down the hallway at an unknown time and went past the closed door of the resident and had heard a noise, which was described as crying out. LPN #100 stated that the resident informed her that she had been in the facility since 1:00 P.M. and had not had any pain medication. LPN #100 stated when she returned to the nurse ' s station, LPN #99 had left, and not completed any of the new admission checklists for any of three new admissions and she had no way to know what was done and what was not done. LPN #100 stated prior to LPN #99 leaving, the LPN had informed her that she had three new admissions and she had not had a chance to get them all done. LPN #100 stated she had to sort through all three admissions to figure out what was needed done. LPN #100 stated before she could go through any of the admission paperwork, she did her medication pass on the 200 hallway and then came to sort through the admission paperwork and then went to do the medications on the 100 hallway. The LPN verified she administered the Oxycodone to Resident #110 at 10:10 P.M.
Interview with the Director of Nursing (DON) on 11/26/19 at 2:20 P.M. confirmed LPN #99 did not fax over the prescription for the Oxycodone to the pharmacy. She also revealed the facility cannot pull out of their E-Box (emergency drug box) until a prescription had been faxed to the pharmacy. The DON confirmed that LPN #99 should have faxed all medications and prescriptions over to the pharmacy before leaving for the day and the Oxycodone should have been administered sooner to Resident #110. The DON also confirmed the resident received Oxycodone at 10:10 P.M., more than seven hours after the resident expressed a pain level of 10 to the nurse. The DON stated LPN #99 no longer worked at this facility.
This deficiency substantiated Complaint Number OH00108453.
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 and staff interview, the facility failed to have an accurate advance directive status for one (#40) of 24 residents reviewed in the initial pool during the annual survey...
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Based on medical record review and staff interview, the facility failed to have an accurate advance directive status for one (#40) of 24 residents reviewed in the initial pool during the annual survey. The facility census was 60.
Findings include:
Medical record review for Resident #40 revealed an admission date of 06/20/19. Diagnoses included peripheral vascular disease, osteomyelitis of vertebra lumbar region, hypertensive heart and chronic kidney disease with heart failure and stage one through four chronic kidney disease, Methicillin resistant staphylococcus aureus infection, acute kidney failure and Charcot's joint. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/28/19, revealed the resident's cognition was slightly impaired.
Review of the resident's electronic physician orders, dated 06/20/19, revealed an order for the advanced directive status of full code.
Review of the resident's hard chart revealed a signed Do Not Resuscitate Comfort Care Arrest (DNRCCA) form dated 04/18/19.
Interview on 11/25/19 at 11:24 A.M. with Licensed Practical Nurse (LPN) # 701 who stated if a resident coded / arrested he would look in the hard chart first to verify their advance directive status.
Interview on 11/24/19 at 5:56 P.M. with the Director of Nursing confirmed the resident's advance directives did no match from the hard chart to the electronic medial record. She verified the electronic record stated a full code status and the hard chart was a code status of DNRCCA
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and facility staff interview, the facility failed to accurately assess residents on their Minimum Data Se...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and facility staff interview, the facility failed to accurately assess residents on their Minimum Data Set assessments. This affected two (#11 and #48) of 20 resident records reviewed. The total facility census was 60.
Findings include:
1. Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE].
Review of the physician orders, dated 10/17/19, revealed Resident #48 had a new order for Seroquel (antipsychotic) 25 milligrams (mg.) by mouth daily at 2:00 P.M. for dementia with psychosis.
Review of the most recent Minimum Data Set (MDS) assessment, dated 11/09/19, revealed the resident was not coded to have the recently new diagnosis of dementia with psychosis.
During an interview with Registered Nurse #703 on 11/26/19 at 11:09 A.M., it was verified the resident did not have dementia with psychosis coded on the MDS assessment dated [DATE] when the resident had the diagnosis added as indication for use with the antipsychotic medication Seroquel on 10/17/19.
2. Record review for Resident #11 revealed the resident was admitted to the facility on [DATE]. Diagnoses included atresia of esophagus with trachea-esophageal fistula, malignant neoplasm of larynx, chronic obstructive pulmonary disease and protein-calorie malnutrition.
Review of the physician orders, dated 08/30/19, revealed Resident #11 was to have enteral feeding and was not to receive any food by mouth.
Review of the MDS assessment, dated 11/05/19, revealed Resident #11 was coded as having a percutaneous endoscopic gastrostomy (PEG) for enteral feeding. Section K of the MDS listed Resident #11 as not having enteral feeding.
Interview with the Director of Nursing (DON) on 11/25/19 at 2:00 P.M. confirmed the MDS assessment section K was wrong and should include Resident #11 as having enteral feeding.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review, the facility failed to store medications, inhalation medications and nu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review, the facility failed to store medications, inhalation medications and nutritional supplements according to their expiration dates. This had the potential to affect six residents (#11, #15, #26, #31, #44 and #110) who were identified as having used inhalation medications and seven residents (#20, #27, #33, #38, #43, #45 and #111) as having used nutritional supplements by the facility. The facility census was 60.
Findings include:
Observation on [DATE] at 11:42 A.M. with Licensed Practical Nurse (LPN) #701 revealed a medication storage room on the 300 and 400 hall. Inside the medication storage room, there were 20 containers of Boost Plus Creamy Strawberry nutritional supplements dated [DATE] and four containers of Med Pass 2.0 Butter Pecan Flavor Nectar Consistency Nutritional Supplement dated [DATE].
Further observation with LPN #701 revealed inside the refrigerator of the 300 and 400 hall medication storage room, there was one box of 10 each 25 milligrams (mg.) Promethazine (anti-nausea) suppositories for Resident #26 with an expiration date of [DATE].
Interview on [DATE] at 11:45 A.M. with LPN #701 who verified the nutritional supplements and the anti-nausea suppositories were expired.
Observation on [DATE] at 12:03 P.M. of the medication cart on the 200 hall revealed two boxes of Ipratropium-Albuterol 0.5-3 mg. per three milliliter (ml.) sterile unit dose vials (one pouch of 30 - three ml. vials in each box with an expiration date on the box of [DATE]). The box was labeled for Resident #15.
Interview on [DATE] at 12:03 P.M. with LPN # 975 who verified the two boxes of inhalation supplies were expired.
The facility identified Resident #11, #15, #26, #31, #44 and #110) used inhalation medications and Resident #20, #27, #33, #38, #43, #45 and #111 were on nutritional supplements.
Review of the facility's policy titled Medication Storage in the facility, dated 11/2018, revealed outdated medications are immediately removed from inventory, disposed of according to procedures for medication disposal and reordered from the pharmacy.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and staff interview, the facility failed to ensure the kitchen was maintained in a sanitary manner, food was stored off the floor, and food was dated and labeled. This affected 59...
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Based on observation and staff interview, the facility failed to ensure the kitchen was maintained in a sanitary manner, food was stored off the floor, and food was dated and labeled. This affected 59 of 60 residents who receive food from the kitchen (Residents #11 received nothing by mouth).
Findings include:
Observations of the kitchen on 11/24/19 from 8:15 A.M. through 8:47 A.M. revealed there was a black, hairy, removable substance on the wall above the sink area. There was also a black, hairy, removable substance inside the ice machine. The refrigerator had a package of uncooked meat that was not dated. Observation of the dry storage area revealed the following items were stored on the floor: one case of peanut butter snack crackers on floor, one case of saltine crackers, one case of dry noodles, one case of individual mustards, one case individual pudding in cups and one case of canned tomato juice. Observation of the facility freezer revealed the following items were stored on the freezer floor: two cases of turkeys, packed four to a case, one case of frozen vegetables, one case of individual ice cream and one case of uncooked beef.
Interview with Food Service Manager (FSM) #31 on 11/24/19 from 9:30 A.M. through 9:45 A.M. verified the black hairy removable substance on the walls above the sink area and inside the ice machine. The FSM verified the package of uncooked meat in the refrigerator was not dated. The FSM verified the six items stored on the floor inside the dry storage area. The FSM verified the five cases of food stored on the freezer floor.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's water management program, dated 2017, revealed monthly testing of one area per water heater source, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's water management program, dated 2017, revealed monthly testing of one area per water heater source, testing of chlorine level at each source for acceptable normal range of 0.5 to one milligram per liter, and testing of the temperature at each source for minimum of 122 degrees Fahrenheit would be completed as part of their Legionella prevention program.
Review of the facility's undated Legionella Environmental Assessment Form revealed there was no evidence the facility completed the routine testing specified in their water management program.
Interview with Maintenance Director #604 on 11/26/19 at 2:15 P.M. verified there was no evidence the facility completed the routine monitoring specified in their water management program.
This deficiency substantiates Complaint Number OH00108401.
Based on observation, record review, resident and staff interview, review of Centers for Disease and Control Prevention (CDC) guidelines and policy review, the facility failed to ensure standard infection control practices were followed for the residents. This affected one (#4) of three residents reviewed for infections. The facility additionally failed to provide monitoring of their water management plan to assist in the prevention of Legionella. This had the potential to affect all 60 residents residing in the facility.
Findings Include:
1. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cellulitis of upper and multiple myeloma. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/19/19, revealed the resident was cognitively intact and had no delusions, hallucinations or behaviors.
Review of the physician orders, dated 11/22/19, revealed the resident had the following orders for
caladryl lotion 1-8% apply to rash on the left breast and valacyclovir (anti-viral) hcl 500 mg. one time a day for suspected herpes zoster (also known as shingles) for 10 days.
Observation of Resident #4's room on 11/24/19 at 10:40 A.M. revealed there was no isolation cart or sign on the door indicating the resident was on isolation precautions. There was no isolation cart outside the door or no alert to see a staff member prior to entering the room.
Interview with Licensed Practical Nurse (LPN) #910 on 11/24/19 at 11:47 A.M. verified the physician orders for Resident #4. The LPN verified she was receiving valcyclovir (anti-Viral) for suspected herpes zoster infection. The LPN confirmed the resident was not on any isolation precautions. The LPN said if a resident required isolation precautions, the orders for the isolation comes from the doctor. LPN #910 verified there were no orders for isolation precautions for Resident #4.
Interview and observation with Resident #4's skin on 11/24/19 at 10:48 A.M. revealed State Tested Nursing Assistant (STNA) #920 donned gloves and showed the skin alterations to the resident's left upper chest and left lower abdomen. The resident had a single fluid filled alteration on the lower abdomen and the upper left chest area had three areas which were noted with the appearance of prior fluid filled alterations, where the fluid was no longer present and a small crater was left, the areas were white with ointment on them, and no drainage was noted. The resident stated the areas on her chest had been there about a month and they itch and the area to her lower abdomen was new. The STNA was not aware of the area to her lower abdomen.
Subsequent review of the physician orders, dated 11/24/19 at 12:19 P.M., revealed Resident #4 had a new order for airborne and contact precautions until the lesions were dry and crusted over.
Review of the facility's undated policy titled Transmission-Based Precautions revealed it is the policy of the facility that in addition to Standard Precautions, Transmission-based precautions will be implemented when a resident is suspected of or known to be colonized or infected with an epidemiologically important organism or highly infectious microorganism. The process stated in addition to Standard Precautions, the following may be implemented dependent on the potential infectious agent: Contact, Droplet and/or Airborne. This facility is not equipped for Airborne Precautions. Place a mask on the resident with suspected airborne infection and set up transport to the hospital with required negative pressure room and equipment.
During an interview with the Director of Nursing (DON) on 11/25/19 at 4:07 P.M. it was verified the isolation precautions should have been initiated for Resident #4 when the skin areas were identified and shingles were suspected on 11/22/19. The DON also verified the facility cannot perform airborne isolation and Resident #4 isolation precautions should be for contact precautions and not airborne precautions.
Review of the Centers for Disease and Control Prevention (CDC) guidelines, dated 08/14/19, revealed isolation precautions are recommended for residents with shingles until the areas are dry and crusted.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0730
(Tag F0730)
Minor procedural issue · This affected most or all residents
Based on record review and staff interview, the facility failed to ensure annual performance reviews were completed for state tested nurse aides (STNA). This affected two of two personnel records revi...
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Based on record review and staff interview, the facility failed to ensure annual performance reviews were completed for state tested nurse aides (STNA). This affected two of two personnel records reviewed for annual performance reviews. This had the potential to affect all 60 residents residing in the facility.
Findings Include:
1. Review of the personnel record for STNA #702 revealed a hire date of 06/04/18. The personnel record for STNA #702 lacked any evidence that an annual performance review was completed.
2. Review of the personnel record for STNA #704 revealed a hire date of 08/10/18. The personnel record for STNA #704 lacked any evidence that an annual performance review was completed.
Interview with Staff Scheduler #600 on 11/26/19 at 2:45 P.M. verified there was no evidence of annual performance reviews completed for STNA #702 and STNA #704.
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
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Ohio facilities.
Concerns
- • 40 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • Grade D (40/100). Below average facility with significant concerns.
- • 79% turnover. Very high, 31 points above average. Constant new faces learning your loved one's needs.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Sanctuary At Wilmington Place's CMS Rating?
CMS assigns SANCTUARY AT WILMINGTON PLACE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Ohio, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Sanctuary At Wilmington Place Staffed?
CMS rates SANCTUARY AT WILMINGTON PLACE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 79%, which is 33 percentage points above the Ohio average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 71%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Sanctuary At Wilmington Place?
State health inspectors documented 40 deficiencies at SANCTUARY AT WILMINGTON PLACE during 2019 to 2025. These included: 2 that caused actual resident harm, 35 with potential for harm, and 3 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Sanctuary At Wilmington Place?
SANCTUARY AT WILMINGTON PLACE is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by AMERICAN HEALTH FOUNDATION, a chain that manages multiple nursing homes. With 63 certified beds and approximately 55 residents (about 87% occupancy), it is a smaller facility located in DAYTON, Ohio.
How Does Sanctuary At Wilmington Place Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, SANCTUARY AT WILMINGTON PLACE's overall rating (3 stars) is below the state average of 3.2, staff turnover (79%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Sanctuary At Wilmington Place?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "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 high staff turnover rate and the below-average staffing rating.
Is Sanctuary At Wilmington Place Safe?
Based on CMS inspection data, SANCTUARY AT WILMINGTON PLACE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Ohio. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Sanctuary At Wilmington Place Stick Around?
Staff turnover at SANCTUARY AT WILMINGTON PLACE is high. At 79%, the facility is 33 percentage points above the Ohio average of 46%. Registered Nurse turnover is particularly concerning at 71%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Sanctuary At Wilmington Place Ever Fined?
SANCTUARY AT WILMINGTON PLACE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Sanctuary At Wilmington Place on Any Federal Watch List?
SANCTUARY AT WILMINGTON PLACE 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.